Monday, May 30, 2016

Rhetoric and Jargon in Health Care Policy, Part 2: "Evidence Based"

These days we often hear about how a new treatment, or program, or therapy style, is "evidence based."  This gives the listener an impression that the new treatment must be superior in some way.

It is another language construct which has become much more common, especially in mental health care discussions.  Recently, its prevalence has tripled in written language, with a steep increase beginning in about 1993, according to the Google NGram viewer.

 But was does "evidence based" really mean?

We often hear, for example, that cognitive-behavioural therapy (CBT) is "evidence based."  The implication of this statement is that other forms of therapy must not be "evidence based."

It should go without saying that most everything is "evidence based":  

An individual's personal account of their experience is a form of evidence.

A randomized controlled prospective trial of therapy supplies another form of evidence.

An opinion from an expert, or from a mystic, or from a random person on a bus, or from a charlatan, is another  form of evidence.

Ironically, the introduction of the phrase "evidence based" may stifle debate and free thinking about a matter.  It implies that the issue it is describing has already been decided upon.

In psychiatry, the phrase "evidence based" is typically used in the area of CBT research, and in health care policy.  But this can bias opinion away from other therapeutic modalities whose practitioners tend not to advertise themselves with this type of language.

I believe that gathering evidence from prospective, randomized, controlled clinical studies is vitally important--so important, in fact, that we must allow such evidence to cause established opinions about care to actually change.   There are many cautionary tales in medical history, in which good evidence about something new was dismissed by practitioners who were resistant to changing the style of practice they had grown up with.

But in mental health care, the evolving evidence is often much less robust than it seems.  Most studies are of very short duration.   Short-term or superficial care approaches may lead to various symptomatic improvements for many people...but long-term data is often not present.   Also, a great deal of evidence supports the efficiency of  treatments which work for 60-70% of people, but does not support useful options of how to help the other 30-40%.  

Many people may look back and value a short-term course of therapy in some way, but what they really found most valuable and life-changing was something quite different, such as having a dedicated caregiver over a period of many years who didn't practice using modern "evidence-based" methods at all...

It is good to think carefully about evidence, and to be prepared to change our practice accordingly.    But the phrase "evidence based" is often just a slogan, a form of jargon, and a construct which can lead to unwelcome biases in thinking.  Such cognitive short-cuts can often be very efficient, in order to decide on an important matter quickly, but such short-cuts should never be used to make large policy changes in a system.


Monday, May 2, 2016

Rhetoric and Jargon in Health Care Policy, Part One: "Stakeholders"

Jargon bothers me.  It reduces the enjoyment and engagement we have with languageIt can be a barrier for others to even understand what is being said.  

The term "stakeholder" is part of contemporary jargon in the area of policy development and corporate planning.  According to the Google NGram viewer, this word was very rarely used before 1975.  Since 1975, its frequency of use in printed language has increased by a factor of 10 000!  The words "stakeholder" or "stakeholders" surpassed the prevalence of the word "honesty" in written language as of the year 2000, and since then the prevalence has almost doubled again!  

Before 1975 "stakeholder" was primarily used as part of legal jargon, including one definition as follows: 

"A stakeholder is a person who is or may be exposed to multiple liability as the result of adverse claims."  
(McKinney, W. M. (1918). McKinney's Consolidated Laws of New York Annotated. West Publishing Company.)

Since 1975, the meaning has evolved to:
"a person or company with a concern or financial interest in ensuring the success of an organization or business"   (Oxford English Dictionary) 
The etymology of the word "stake," relates not to its meaning as a sharp wooden stick, but rather to another meaning, dating back to 1540,  as "the money risked on a game of dice."  (Oxford English Dictionary) 

The honourable spirit of the word "stakeholder" has to do with respecting different groups, positions, and points of view while discussing an issue in an organization.  It may invite a shared view of complex systemic matters, as though all the different interested individuals figuratively have "money risked on a game of dice."   It invites group decision making, rather than a dictatorial approach.

My complaint about this word has to do with its reflexive use as part of jargon.  There are connotations of a group of people gathered around in a betting game  (which is literally where the word originates).   There is an image of wealthy property-holders (with "stakes" in the land) debating about real estate dealings.   Another unintended connotation is of a group of people holding sharp sticks, waiting to confront a vampire! 

Finally, I wish that people in a discussion could simply be referred to as people, or by name, rather than as "stakeholders." 

I believe that the honourable spirit of respect, intended by using the word “stakeholder,” is vitally important.  But sometimes jargon brings us farther away, rather than closer, to this honourable spirit.  Many policy discussions can be so laden with this, as to be content-free, muddled doublespeak.

I invite us all to express ourselves in an articulate, engaging manner, while letting go of any need to use jargon.   Jargon can be a divisive tactic in language and debate:  many listeners become inured to it through repetition.  The jargon becomes a short-cut to be persuasive, while not leading the listener with any new thought.  It becomes "filler" in a dialog, which can distance and bore the audience.  This type of rhetoric can fool an uneducated audience into believing that the speaker is bestowing more wisdom than is actually the case.  It can also have a suppressive effect on a dissenting voice, therefore stultifying debate and free thinking. 

In cognitive therapy, we see that our minds can create various types of "inner jargon," which can perpetuate anxious or depressive states.  While cognitive therapeutic theory is laden with its own jargon, one healthy principle it encourages is to practice awareness of our "inner jargon," to "talk back" to it, and to create new, imaginative, constructive, mindful, and reasoned inner dialog or self-talk. 

I believe that cognitive therapy doesn't tend to encourage one thing enough:  to practice expressing our thoughts, or forming new inner dialogue, in a way which is rhetorically beautiful.  

In cognitive therapy, we are encouraged always to garner the courage to offer a dissenting voice!  In the case of cognitive therapy for depression, we must bravely speak back, in our thoughts, to a storm of negative, pessimistic, self-critical thinking. Let us make the "speaking back" full of eloquence, poetry, and beauty.  Let us step away from using jargon or other forms of empty talk. 

We are "stakeholders" of our own minds!   Or, different points of view held in the mind are all "stakeholders" of self.   But perhaps we can let go of the "stakes" and simply work with ideas, without using jargon, in a frank, articulate, compassionate dialogue.