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This section contains the book Philosophy of Physiological Psychology, written by Dr. Refinetti in 1992.
CHAPTER 8:
Scientific Attitude and Clinical Attitude

1) Description of the obstacle

The major issue to be discussed in this Chapter is the relation between basic research and applied knowledge. In particular, it will be argued that clinical attitude is the greatest enemy of scientific attitude. Consequently, the worldview of clinical psychology and clinical neurology is a major epistemological obstacle to the advancement of physiological psychology. As the reader should be able to predict by now, this does not mean that clinical work is not useful or effective. At least in immediate terms, clinical work is certainly more important for the average citizen than basic research. The point to be made is that clinical work requires an intellectual attitude (clinical pragmatism) that is not conducive to good scientific work. Certainly, in a book about clinical psychology, it would be equally appropriate to say that scientific attitude is an obstacle to the acquisition of clinical attitude. Also, there is no reason why a single person cannot divide his/her time between the two attitudes. At least in principle, this should be the case for those who hold double graduate degrees (MD and PhD, or PsyD and PhD).

What is the scientific attitude? People who are moved by pure, ideal principles are hard to find, and I have finally come to agree with Professor Harry Carlisle, my advisor in graduate school, that tact and diplomacy are just as important for a scientist as good research methods and extensive knowledge of relevant literature. But it is certainly possible to identify the abstract concept of scientific attitude that is shared in diverse concrete forms by most scientists. For example, Merton's (1942) description of four basic elements that make up the ethos of science (namely: universalism, communism, disinterestedness, and organized skepticism) was mentioned in the Introduction. Although not in a very systematic way, Grinnell (1987) described a number of other elements of the scientific attitude. Still many other elements need to be identified before we can obtain a comprehensive description of scientific attitude. An element that I consider especially important, probably because it clearly distinguishes science from clinical practice, is the irreverence for applicability, or non-pragmatism.

Let me start with four literal citations:

The struggle for understanding is one of the most characteristic features of our species; that is why man is called Homo sapiens. The satisfaction of this urge is our destiny. (Selye 1976 [p. xviii])

A great majority of scientists will agree that [...] they are motivated by a compelling desire to search for truth simply as an end in itself, regardless of whether the ultimate result proves useful to mankind or disconcertingly destructive. The primary purpose of science has little to do with weapons or washing machines; it is just to know and to understand. (Garbuny 1963 [p.3])

Once a scientist experiences the exhilaration of discovery and the satisfaction of carrying through a really tricky experiment, [...] he is hooked and no other kind of life will do. (Medawar 1979 [p. 7])

Properly speaking, the artist, the writer, and the scientist should be moved by such an irresistible impulse to create that, even if they were not being paid for their work, they would be willing to pay to get the chance to do it. (Wiener 1954 [p. 133])

Yes, a major component of scientific attitude is love for science, the impulse to pursue knowledge as an end in itself. Otherwise, why would any one study the concentration of arsenic in 140-year-old tufts of Napoleon's hair (Smith et al 1962), or the behavior of beetles that feed exclusively on elephant manure (Heirich & Bartholomew 1979), or the characteristics of a distant celestial body which seems to project matter in two opposite directions (Margon 1980)?

When confronted with the fact that the neutral theory of molecular evolution is not biologically important (because most mutations do not have phenotypic expressions that could be subjected to selection), Motoo Kimura responded that the neutral theory is an elegant biological theory supported by empirical data and that this is all that matters (Kimura 1979). In his Nobel Prize lecture, Pavlov made clear his opinion that, although the precise knowledge of whole physiological systems is the ultimate goal of physiological sciences, current research can only provide a provisional accumulation of bits of knowledge (Pavlov 1957 [p.129]). This means that, even though medical application may be the goal of most biological research, physiologists can only hope to obtain satisfaction in the gradual accumulation of knowledge. Indeed, with the current level of specialization in biological research and current state of knowledge, no biologist or physiologist can realistically expect to understand any major function in the 30 or 40 years of his/her career. Thus, the actual (rather than the idealized) goal of any individual scientist is indeed to understand the metabolic processes of a small group of cells in the retina of an ant, or the electrolyte composition of neurons in the thalamus of the domestic mouse. Because research must be funded, and because society is much more willing to fund research that can bring practical benefits, scientists are constantly reminding the public (as well as themselves) that, for instance, the study of the processes of cell division in a tissue culture derived from raccoon liver may very well lead to the cure of cancer. This, however, is the public-relations side of the scientist. The scientist as a researcher has a very different view of the world.

It is tempting to say that true scientists do science for science sake, and that concern with funding is less noble. On one hand, this is true because our cultural tradition praises those who place their intellectual cause above financial considerations. On the other hand, there are many scientists whose main concern in life is to obtain research funds. These supposedly "impure" scientists are actually the big names in science: they are the heads of major laboratories and the full professors in large universities. To deny the existence of these people would be utterly foolish. Rather, it is necessary to acknowledge that the word scientist applies to at least two types of people. The scientist I have been talking about in this book is the one involved in research. I am ignoring entirely the other type of scientist, and an analysis of how funding for scientific research is obtained is entirely beyond the scope of this book. Scientists who obtain research funds but rarely read the scientific literature and rarely walk into the laboratory may be essential for the existence of research laboratories. But it is the intellectual and practical achievements of research scientists that distinguish science from other areas of human activity. It is in this sense that "small science is good science" (Alberts 1985). The administrative scientist is necessary for science to stay alive; the research scientist is necessary for science to flourish and have a life of its own.

Naturally, a few honorable people manage to age gracefully and become administrative scientists without abandoning laboratory work. As an actual example, I would like to cite Professor Steven Horvath, in whose laboratory at the University of California I had the pleasure to work during the year of 1988. At that time, Dr. Horvath was well into his 70's but I often found him not only conducting experiments but also volunteering as experimental subject in exercise physiology studies.

It is only fair to have a quick look at the other side of the story. It is true that from the perspective of philosophy of science (or of intellectual analysis in general) the administrative scientist is less of a scientist than the research scientist. However, from a political perspective the research scientist is not more than a puppet, or at the most a naive person. The real world, the proverb says, belongs to the administrators. More than that, the whole idea of rigorous intellectual work loses a lot of its meaningfulness when seen in a political perspective. The intellectual approach of this book, for instance, could be said to be extremely conservative because it revolves around the conservation of the scientific status quo. From the intellectual perspective itself, the defense of the status quo developed in this book is a mere consequence of the effort to produce an objective analysis of science by allowing science itself, rather than extraneous speculations, to say what is right and what is wrong about knowledge. But, from a political perspective, the book does defend the status quo. The political perspective causes the intellectual argument to seem foolish. In other words, it is possible to exit the intellectual perspective and look at it from a different perspective that makes it seem naive and frivolous. Maybe Plato (1888) was wrong when he argued that a good politician must be a very knowledgeable person. Maybe good politics require a limited amount of knowledge.

So, scientific attitude implies non-pragmatism. It is true that James Watson (1968) told us all that opportunism may be much more important than hard work for accomplishing a discovery worthy of a Nobel Prize. Similarly, Frederick Schram (1979) told us that politics may supplant scientific curiosity in many occasions. But both books also showed that the scientist sees his quest for knowledge as his personal fight for life. As Max Weber (1963) pointed out, science is a vocation. And, as Cuvillier (1935) said in a naive but accurate form, the goal of science is to obtain the truth. Clinical attitude, however, is quite different. Irrespective of his own theoretical preferences, the clinician must place the welfare of his patient above his loyalty to his favorite theory or to the abstract truth (Azrin 1977, Baer et al 1968, Maher 1970). A psychiatrist described well the contrasting objectives of the clinician and the scientist:

The latter are to increase knowledge. The scientist does not work in the service of the individual. His curiosity motivates him, although he may believe he works in the service of humanity. The physician, on the other hand, works to serve the individual first and last. For him knowledge is not an end in itself; nor is he motivated primarily to scholarship. (Hill 1978 [p.101])

The quotation has a tint of resentment against science, but we may ignore that. The point was clearly made that clinical attitude is anti-intellectually pragmatic, whereas scientific attitude is anti-pragmatically intellectual. Obviously, care should be taken not to make erroneous inferences out of these simple facts. Regarding the scientist's attitude, it must be remembered that a number of scientists, especially those conducting research in human subjects, have strong concerns about the applicability of their research. In a few cases (e.g., the case of an epidemiologist studying AIDS in the early 1990's), the research does have the potential for immediate application. However, even when an immediate application is unlikely, some scientists may believe that the main goal of their work is immediate medical application. To add more complexity, there are those cases where the possibility of application has not been fully established but seems very likely. Thus, the study of the processes by which embryonic or sectioned axons find their way to the neurons they synapse with (Cowan 1979, Horch 1979, Levi-Montalcini & Calissano 1979) may very soon provide the physician with the means to treat patients who had a nerve severed or crashed in an accident. Finally, all research has a potential for applicability in the long run, and this is probably the reason why society invests money in scientific research. Basic research is similar to automobile insurance in many respects. If at the end of your life you have never had an accident, then all the money you paid to the insurance company was lost. But, all along your life you could not know whether you would be involved in an accident or not. You gambled. Had you been involved in an accident and not had insurance coverage, you would regret dearly now. Similarly, we may not know when the knowledge produced by basic research will be helpful, but we cannot afford to be unprepared for the unpredictable. The non-pragmatism of science is our life insurance policy.

2) Examples of the obstacle

The most important consequence of clinical pragmatism is that the clinician must have no loyalty to science. In his/her attempts to heal the patient, he/she will do anything. This means that the clinician will intentionally disrespect the specificity of a number of sciences. Common sense, spiritualism, sociologism, psychophysical complementarism, and anything else that may help the patient is fair game. Therefore, clinical attitude is made of various obstacles to science in general and to psychology and behavioral neuroscience in particular.

The diversity of obstacles included in the clinical attitude can be exemplified by Freeman's (1978) inclusion of sociological arguments in the evaluation of psychological problems, by Haveliwala et al's (1979) inclusion of common sense arguments in psychotherapeutic considerations, by Azrin's (1977) corruption of operant behaviorism in order to obtain faster clinical results, and especially by the explicit defense, by several authors (Franks & Brady 1970 [p.1], Lazarus 1976 [p.3], Rogers 1964 [p.120]), of the inclusion of any conceivable idea into the "toolbox" of the clinical psychologist.

A common argument in defense of eclectic approaches is that they improve treatment efficacy. This allegedly implies that pure scientists have a biased view of the world and that an eclectic approach provides a more objective evaluation of things. In actuality, it must be recognized that the improved results obtained with eclectic approaches constitute a trade-off between full understanding and immediate practical results. By improving the chances of a cure, the eclectic approach reduces the chances of a scientific understanding of the phenomena involved. In other words, the eclectic approach is not better; it just has different priorities. But, do eclectic approaches really improve treatment efficacy? Clinical psychologists have always assumed that their work produces positive results. Does it really?

The first thing to be noticed about evaluations of psychotherapy outcome is that only a small fraction of people exhibiting deviant behaviors go through psychotherapy (Bandura 1969). Thus, most cases of "anti-social personality" (i.e., psychotics, criminals, juvenile delinquents, etc) are isolated in special institutions and do not undergo psychotherapy (i.e., they receive other types of treatment or no treatment at all). Thirty to sixty percent of those who consult a psychotherapist and are accepted for treatment stop coming back before the therapist thinks they should do so. Of those who stay, about two thirds are considered to show improvement (Bandura 1969). Thus, out of 100 people with deviant behaviors, only 40 undergo psychotherapy, 20 remain under treatment long enough, and 14 show improvement.

Most of us would not call a 14/100 ratio a success. But we would not call it a failure either. After all, it is not the therapist's fault that patients are not sent in or do not wish to stay. What about the 2/3 improvement ratio? Well, this ratio may not be a success either. Since many people who are institutionalized do not undergo therapy, there is a natural control group against which to evaluate the efficacy of psychotherapeutical treatment. In 1952, H. J. Eysenck compared a group of adult neurotic patients undergoing psychotherapy with a similar group of patients not exposed to psychotherapy. His conclusion was straightforward: 2/3 of a group of adult neurotic patients will show some improvement within two years after the beginning of the illness irrespective of whether they underwent psychotherapy or not (Eysenck 1952). A few years later, Levitt (1957) conducted a similar study on children and reached a similar conclusion. Maybe not surprisingly, the community of psychotherapists did not pay much attention to these studies (Astin 1961). How is the situation today? Not too good (Parloff 1984). Some therapists prefer to investigate the constitutional elements of psychotherapy rather than evaluating its efficacy (Appelbaum 1975, Frank 1979, Gomes-Schwartz et al 1978). Others report positive results in studies of psychotherapy outcome (Mintz et al 1979, Smith & Glass 1977). Still others propose that the criteria for evaluation be changed (Adams 1978). Finally, even studies of how therapists react to outcome studies are being conducted (Cohen 1979). Although all of this may eventually lead to a better understanding of the psychotherapeutic process, there is currently no convincing evidence that psychotherapy does what it claims to do. Consequently, it cannot be argued that eclectic approaches improve therapeutic efficacy. Eclecticism is not only an obstacle to physiological psychology; it also fails to prove itself as a therapeutic advancement.

 
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