HOW TO INTRODUCE ART IN HEALTH IN A SCIENTIFIC EPISTEMOLOGICAL ENVIRONMENT?

The discussion entitled ‘Psychiatry as a science: on what epistemological bases does its practice stand?’ proposed by Abramov and Mourão Júnior (2016) in the section ‘Debates’ of the journal Psicologia em Estudo is treacherous. Whether we agree with the authors or not, we will not get where they want to go by taking the path they have chosen to take us there. Thus, it may seem that it does not make much sense to carry on a discussion about the proposed topic. However, it seems to me that it can be enlightening by allowing unnecessary detours to be avoided. In addition, I fully agree with the purpose of the trackproposed by those authors.

I would like to simplify the discussion by formally dividing it into two parts: an epistemological and an ethical part- following what seems to me to be the intention of the authors.

The question of the empirical basis

The authors present the epistemological problem of the constitution of the scientificity of psychiatry through a realistic point of view. This is already expressed in the first sentence of the text in which they affirm that "[…] observing nature and drawing conclusions about its reality is the goal of science" (Abramovic & Mourão Júnior, 2016, p. 551). In this realistic version, observation is the first step towards creation of scientific knowledge. Observation would be responsible for the later construction of the working models of the natural world. In this case, the function of the empirical basis would be to sustain the building of scientific knowledge, deriving from it by some version of inductive reasoning. Realism consists in believing that the empirical basis would provide us with the real elements of nature, duly translated into observational terms. Thus, the connection between reality and knowledge would be guaranteed.

After taking this path - which seems to me wrong, as I will try to explain later - the authors recognize that the empirical procedures lead to a "[…] circular reasoning" (Abramovic & Mourão Júnior, 2016, p. 552). The issue of circularity becomes evident if we consider that the concept of ‘normality’, necessary to psychiatry and psychology, must be derived from the empirical basis. Based on this concept, distinctions are made on the same empirical basis when the normal cases are separated from the pathological cases - closing a course on itself. The conclusion of the authors seems to me to be correct: given their realistic starting point about knowledge, the conclusion about the presence of a vicious circle in the empirical construction of scientific concepts makes perfect sense. However, it seems to me that the realistic path taken by them is burdensome and misleading.

Although there is a widely spread belief that scientific knowledge is based on observation, this does not correspond to the practice of the work of producing science. This belief is a version of the Baconian model of scientific knowledge production (Bacon, 1979). Due to its dependence on inductive logic, this model was indirectly criticized by Hume (1979) in his analysis of human knowledge. An adequate solution that allowed to preserve a function for the empirical basis in scientific knowledge and to circumvent the fragility of induction was later developed by Popper (1972). The problem is that this solution led precisely to the abandonment of realism, defended by the authors. Let us look at this in detail.

The Baconian model (Bacon, 1979) corresponds to the authors' understanding of the process of producing scientific knowledge. Such knowledge would begin by observing nature, going through the systematization and classification of the observed facts, the later inductive reasoning that would generate general laws from them and would end with a verification of the validity of those laws to the empirical world, from where they would have emerged.

The core of Hume's (1979) critique is as follows: an empirical basis, no matter how broad it may be, always consists of statements describing particular cases. There is no logical way to pass validly from any particular statements to general laws. Induction is not a valid reasoning because it introduces a dimension that is missing on the empirical basis: the dimension of the future, which is not observable, but is included in any general law. This led to the need to abandon induction as a procedure to generate valid knowledge - producing a strong skeptical disposition.

Popper (1972) circumvented this difficulty by sacrificing realism. For him, scientific knowledge is not initiated with observation, but with the proposition of a theory, however simple it may be. In fact, every scientist would have since the beginning some kind of theoretical expectation. It would be the first step towards generating new knowledge. This obviously requires re-dimensioning the role of the empirical basis. An example of the changes promoted by this view in cognitive psychology can be found in the discussion of the problem of functional dissociation between different memory systems (Silveira, Janczura & Stein, 2012). Then, for Popper, science begins with the proposition of a theory composed of general laws. These laws, for their general nature, allow ‘deductive’ derivations of particular predictions. These predictions are then confronted with the empirical basis to see whe ther they can be accepted or not. The role of the empirical basis is to provide tests for particular statements derived from general laws, but not ‘to substantiate’ or not general statements. Therefore, the empirical basis would provide a test method for scientific laws mediated by a process of logical deduction.

The loss of the realist reference becomes inevitable inasmuch as there is no guarantee in the Popperian model that there is continuity between external reality and scientific knowledge - as in the Baconian model of Abramov and Mourão Júnior (2016). You notice how the Popperian perspective provides us with a version of production of scientific knowledge that undoes the logical circularity which, according to those authors, would contaminate all empiricism. Moreover, it does not make sense for Popper to attempt to describe the origin of a scientist's theoretical expectations because this is something subjective in nature. Science would differ from art by the later process of testing its theories. Such tests are necessary for the recognition of a theory as valid - but not true. This Popperian solution allows circumventing the circularity that the authors seem to consider as inherent in all empirical science.

This apparent oversight of the possibility of an empirical science devoid of circularity, contained in the arguments of Abramov and Mourão Júnior (2016), seems to be due the fact that other concern calls their attention. It is about a supposed reductionist aspect of scientific knowledge. This aspect can be perceived when they state that "[…] within an world that is ontologically much more complex than isolated physical systems, the empirical method of scientifically knowing things shows even more its gross limitations" (Abramov & Mourão Júnior, 2016, p. 551). Shortly thereafter, this reductionism reveals a political face: "We should consider an immeasurable moral aggression the pretension of reducing any man to an object intelligible to science" (Abramov & Mourão Júnior, 2016, p. 555). At this point, it seems to me that the authors' realistic beliefs promote the greatest damage.

The notion that human knowledge consists of a kind of reduction or simplification of an unknown real universe makes no sense. If we have, on the one hand, an unknown nature - as realism claims - how could we know that our knowledge amounts to a reduction in relation to it? If it is indeed ‘unknown’, we cannot compare it to anything we know. So it makes no sense to say that what we already know is more, equal, or less than what we do not know -the nature. If there is indeed an unknown external nature, we have no idea what it is, and we cannot compare it with the knowledge we actually have. What we can compare is a part of what we know with another part of what we know.

Of course we can fantasize that the unknown nature is much more complex than the current scientific knowledge. But this is as useful as fantasizing that it is exactly identical to the knowledge we have. Or it is as useful as postulating that it is much inferior than the content of science.

Apparently, Abramov and Mourão Júnior (2016) furtively called on some version of the theory of complex systems (Von Bertalanffy, 1968), but I do not think it is relevant to discuss this here, since this partnership is not explicitly mentioned in the text. It seems to me more reasonable to think that they were led to defend the reductionist thesis because they did not conceive of alternatives to realism in the production of scientific knowledge. Popper's (1972) theses clearly demonstrate that scientific knowledge without realism is possible. More than that, they show that ‘we can have empiricist scientific knowledge without realism’. In order to obtain this result, the only thing we have to do is to minimize our expectations with respect to the thesis that scientific knowledge corresponds or connects in a special way with an unknown reality.

The question of art

While I believe that the realistic track taken by Abramov and Mourão Júnior does not facilitate access to a more artistic perspective for psychological and psychiatric practices, I agree that this goal is very desirable. I even fear that the realism they adopt works as an obstacle to building a more appropriate critique to current scientific practices. An indication of this difficulty is the authors' ambiguity regarding the latter.

On the one hand, they make assertions of a distinctly moral character in which they suggest a change of direction in those practices: "We should consider [...]" and "There will be a paradigm shift [...]" (Abramov & Mourão Júnior, 2016, p. 555). All this seems to suggest the need for epistemological rupture, for abandonment of an old bankrupt system, to give place to something entirely new. There is even a certain voluntarism here because this reversal is based only on verbs of intention such as ‘duty’ and ‘to have to’. On the other hand, curiously, in the last sentence of the text, there is an assertion that sounds contradictory when the authors conclude that "[…] both psychiatry and psychology must be recognized (what?) as art, without dispensing the tool that science - despite its many limitations - may offer them" (Abramov & Mourão Júnior, 2016, p. 555). With this outcome, it seems that the text goes back to its pretensions, adopting an introductory character toward the problem discussed. Insofar as the rupture with the old reductionist mechanism is criticized by the authors, this may have preserved part of its ‘tools’, without knowing what that might mean exactly. Therefore, it seems that those epistemological foundations promised in the title are not maintained; they rather remain as mere promises to be made in a more promising future.

On the whole, it seems that the authors adopt a praiseworthy political intention to change the course of psychological and psychiatric practices towards a greater attention to human beings who, in the present model, are mere ‘objects’ of these practices. I think that this is the central point of the text, despite its realistic bases and a sort of confusion about what must be done and what must be discarded. I would like to say something that might help to promote the purpose desired by the authors, but in different terms.

In the first place, I would suggest to those who are interested in promoting such changes, in the direction advocated by Abramov and Mourão Júnior (2016), that they abandon the realistic point of view of knowledge. Such point of view only burdens the discussion and gives it that moralizing tone, at some point, indicating the need for an ethical transformation of the scientist - without being able to present the necessary epistemological changes in the internal practice of science itself. I think that is exactly where we arrive when they refer to the preservation of the ‘tools’ of science. It seems that everything comes down to defending the maintenance of the current scientific model, plus a well-intentioned dose of humanism or moral consideration for the human being. That is, after all, we are limited to preaching the need to promote a moral change in scientists. Priests and pastors have always done this better than us, scientists and philosophers.

We need to propose changes in the practices and tools that have been used because they are precisely those that incorporate the guiding values that we want to change. These scientific tools are not innocuous and there is no neutral knowledge. Preserving such tools means running the risk of being stabbed in the back sooner or later. In the case of Abramov and Mourão Júnior (2016), I believe that this stab at the back is equivalent to limiting the proposed changes to the sphere of morality, preserving the traditional epistemological scientific apparatus.

The basic instruments of scientific knowledge are universality, concepts and laws. In this case, ‘the purpose of knowledge is to seek laws’ that make predictions and act upon the world. Thus, it does not make sense to defend that we centralize the health practices in an artistic - thus individualing - attention preserving the universal devices. This is because the individual is particular, and the traditional scientific device is universal. What is sought is an artistic consideration of the individual or a particular point of view about what is particular. This obviously cannot be achieved by means of concepts and laws. Art cannot be attained through theories.

Thus, the art sought to be implemented in psychiatric and psychological practices cannot be limited to the traditional scope it occupies today, in a scientific social environment. Indeed, art is nowadays confined to a purely subjective and internal dimension, opposed to the objective universe of concepts and theories. Adopting this position would be the same as accepting our inability to change the given conditions that put the aesthetic activity itself in a secondary plane. Here again, there is the risk of being stabbed in the back.

I mean that we will not go one step further by stating that it is necessary to change the current model of production of knowledge towards an aesthetic position and reducing that change to the moral realm. We have to take into account that the current model of production of science is industrial since its origin (Silveira, 2013, 2014). It did not become what it is accidentally, because of some moral slip of the scientists. Then it cannot be changed through a mere moral reform. The instrumental part of science cannot be preserved, because it automatically refers every artistic disposition to the ineffectual plan of good subjective intentions - a dimension which art already comfortably occupies in societies where science and technology predominate.

Practices can be altered in an authentic aesthetic direction if we are able to propose models that are not based on that universal instrumentality I referred to above. Abramov and Mourão Júnior (2016) use the example of diabetes to illustrate the difficulties of the functioning of empirical realism. Let us return to this example, also from a different perspective.

If the purpose is to adopt an effectively artistic point of view, the relevant scientific question cannot be the characterization of a universal concept of diabetes. The aesthetic perspective must begin by rejecting this industrial and typical purpose of conventional science. Thus, its goal could be more modestly to restore the patient's health condition, however, provided it is understood that there is no single universal meaning for ‘health’. It would merely be a reference to be filled by the existential content of the patient himself. The relevant empirical scientific question would no longer be to identify a set of symptoms under an already known concept of diabetes. The central point would be to find out what causes discomfort to the patient, according to his own perspective. Sachs (1995, 1997) already showed how some patients can only live well with their own pathologies. This means that there is not necessarily a problem in having pathologies, unless this causes trouble to the patient. With this, the traditional procedure of identifying, first and foremost, what pathology the patient possesses is left aside - although there is so much talk about it in health.

On the contrary, the determining point of a ‘therapeutic aesthetic’ is the individual discomfort expressed by the patients. Obviously this leads to the elimination of standardized technical procedures in traditional clinical practice. It becomes necessary to adopt an artistic pattern of action insofar as the fundamental goal is to reestablish the existential balance of the patient. This is done according to specific needs and moral and cognitive parameters of patients - and not according to a manual of universal pathologies, only illustrated by the particular case of a patient.

In the case of diabetes, this means that there is nothing like ‘diabetes’. Each set of symptoms that in the traditional model was subordinated to a general diagnosis - diabetes - comes to be understood as existential adaptations of the patient. Likewise, there will be no single treatment for these diverse sets of symptoms, but rather attempts to re-establish an individual balance within individual variables. It may even be the case that symptoms related to diabetes do not constitute a source of suffering for the patients. Therefore, they will be considered as integral parts of a particular balanced existence and cease to be relevant.

So it is not a matter of recovering a supposed universal state of normality, but of recovering a new balance of the patient according to his particular way of being. The therapeutic art means to identify the needs of the patients and adjust their existence to them. As can be seen, it is not possible to reconcile this artistic activity with the rational procedures of science which always seek to subsume the multiple into the universal rule. If one intends to approximate the psychiatric and psychological practices to art, the processes of subsumption, typical of instrumental reason, will have to be abandoned.

To escape from the merely hypothetical plan, let me add that this type of artistic approach to health care is already practiced. The version of Traditional Chinese Medicine adapted to the Western world by Neijing School (http://www.escuelaneijing.org/en/) adopts exactly this perspective. This initiative does not know the distinction between epistemological and moral problems, thus avoiding the difficulties generated by the growing industrialization to which contemporary science seems destined (Silveira & Worm, 2013).

For the Neijing School, the care provided by the healer - that is the term used - the patient is not structured as a hierarchical relation of subsumption of the particular by the universal, because there are no hierarchies in artistic procedures. This is best described as a "[…] meeting of two failed artists" (Corral, 2006, p. 408). As a humble loser, the healer knows nothing about the patient at first. And he does not even know how to reestablish the patient's existential failure - the other failed artist. I emphasize the presence of a posture of ignorance and humility, without which there is no artistic activity possible here. It is obvious that it cannot be adopted without proper ‘epistemological experience’ of this same ignorance. Hence, it does not consist in a mere moral disposition of the healer.

This set of moral and epistemological disposition illustrating the possibility of an authentic artistic activity of health care cannot be obtained through a rearrangement of the set of civilizational values that led to the emergence of contemporary science. It will not be possible to produce this kind of change by reproducing that presumption arising from the prior possession of universal laws on the particular functioning of nature. Moral additions made to technical training will also not benefit the promotion of this change.

Referências

• Abramov, D., & Mourão Júnior, C. (2016). A psiquiatria enquanto ciência: sobre que bases epistemológicas sua prática se sustenta? Psicologia em Estudo, 21(4), 551-556.
• Bacon, F. (1979). Novum organum: ou verdadeiras indicações acerca da interpretação da natureza São Paulo, SP: Abril Cultural.
• Corral, J. (2006). Fundamentos da medicina tradicional oriental São Paulo, SP: Rocca.
• Hume, D. (1979). Investigação sobre o conhecimento humano São Paulo, SP: Abril Cultural.
• Popper, K. (1972). A lógica da investigação científica São Paulo, SP: Cultrix.
• Sacks, O. (1995). Um antropólogo em Marte São Paulo, SP: Companhia das Letras.
• Sacks, O. (1997). O homem que confundiu sua mulher com um chapéu e outras histórias clínicas São Paulo, SP: Companhia das Letras.
• Silveira, R. (2014). Ciência sem cultura. Paralaje, 11, 172-185.
• Silveira, R. (2013). A industrialização da verdade. Redescrições, 4(2), 46-67.
• Silveira, R., Janczura, G., & Stein, L. (2012). O que está errado com a dissociação funcional? Ciências & Cognição, 17(2), 40-50.
• Silveira, R., & Worm, M. (2013). Projeto político-pedagógico para a criação do Curso Superior de Graduação Tecnológica em Medicina Tradicional Chinesa Manuscrito não publicado.
• Von Bertalanffy, L. (1968). General system theory New York, NY: George Brazillier.

Publication Dates

• Publication in this collection
  08 Apr 2019
• Date of issue
  2019

History

• Received
  11 Jan 2017
• Accepted
  24 May 2018