Before we start, you deserve a warning. I shall not be referring to the published results of any empirical study to defend what I am about to say. Nor shall I be ‘playing Simon Says’. Everything I say is based on evidence, but you may find that my notion of evidence differs from your own. That is, after all, the purpose of communication – to bridge a difference.
Certainty has always bothered me, not least because it narrows the range of possibilities. Possibility is, in my view, the chief thing that draws us forwards in life. A probability of less than one per cent can be enough to kindle hope. In my area of work – child and adolescent mental health – I have come to regard the position of uncertainty as both more secure and more fertile than certainty. The paradox inherent in this position is not lost on me. If there is one thing I am certain of, it is the importance and inevitability of uncertainty.
It is certainty, though, that is constantly demanded of us. In its most reductive form the demand is for dichotomous clarity with stability across time – in other words, categorical inflexibility. I suspect that each of us would prefer a solid base on which to indulge our own flexibility; I want certainty from you, and freedom for me. Accepting the right of another person to their own flexibility, thereby creating uncertainty for me, is an ideological choice.
But, in expecting of our environment and circumstances categorical and inflexible certainty, we appear to be forgetting what we were taught by quantum physics and the Heisenberg Uncertainty Principle. It is simply the case that most things we cannot know for certain and if we impose certainty on them, through the exercise of power, we alter them. News anchors are becoming tedious in their demand for answers along black-or-white lines. I wonder if some of the anger levelled against experts around the time of the UK European Union referendum might have been because genuine experts so often complicate matters, rather than simplify them.
Granted, a degree of certainty is needed at times, but a degree of certainty is all we can reliably get. Absolute certainty is a myth, and even relative uncertainty is expected more frequently, and in a wider range of situations, than is either useful or justified.
This demand for certainty is evidence of a regression on our part. We might expect an adult to accept that ‘I shall get back in time for dinner’ means ‘I will do my best, given the vicissitudes of weather, traffic conditions, and the possibility of my own demise, to get back in time for dinner’, but it would be an idiotic or sadistic parent who gave this as an answer to their anxious child’s questioning. Children need and deserve actual uncertainty to be dressed up for them and presented as certainty. Adults should not but often do. Religious faith is frequently depicted as infantile by those of different persuasions, but it could be argued that it is actuality a quality of maturity that is demonstrated by the ability to accept that things will work out, ‘god willing’ – in other words, ‘maybe’. So, in an insecure world, we regress and long for certainty. The powerful and the angry demand it of others; the anxious ask for it or seek it.
If religious faith has fallen out of fashion, so has the notion of authority. In His Dark Materials, Philip Pullman renames god ‘the authority’. We have, as Robert Bly put it, become a ‘sibling society‘. We no longer accept authority at face value. We scrutinise it. So we should. Authorities draw on the evidence at their disposal to make their own judgements. Judgement, though, is an expression of power and in this society of siblings we demand to see the working. In our search for certainty it is evidence, and not authority, that has become the thing that we turn to.
To use a legal analogy, our emotional grasp of evidence and the standard of proof constantly slips from the ‘balance of probabilities’ employed in the civil court to the criminal law concept of ‘beyond all possible doubt’.
The legal analogy is itself telling. In the process of scrutinising the evidence submitted to the court we accept the fiction that it is ‘the truth, whole truth and nothing but truth’, forgetting that it was initially mostly subjective in its nature, rendered quasi-objective through the process of the swearing an oath. We use a deity – or an ethical ideal – to endorse a promise which, in turn, alchemically renders subjective observations – human and frail – into the gold nuggets of ‘fact’.
Science does something rather similar in its use of figures and statistics. It creates a ritualistic and arcane process that renders the ambiguity and complexity of life into categorical and numerical outputs. The whole point of the chi-square test and much of the rest of statistics, it seems to me, is to transform the scalar, the changeable, and the probabilistic, to the apparently fixed and categorical. I say ‘apparently’ because the output invariably remains probabilistic, the most frequent conclusion is that ‘more research is needed’, and replication turns out to be more problematic than we at first hoped.
Humans, of course, are immensely sophisticated processing machines and are capable, in a split second, of computing multiple data and subtle probabilities to produce, if necessary, a dichotomous output. But we tend to dismiss this, calling it ‘subjective’. Instead we take a tiny proportion of the visible data and put it through a vastly inferior computation to produce an output that, paradoxically, we trust more – not because it is better, but because it is simpler, and because we believe that we have controlled the steps of the process.
We symbolise the real contingencies of life using words and numbers which are amenable to manipulation. By owning and controlling the manipulation of these symbols we believe that we have control over the contingencies themselves.
Granted, to some extent, we have. There is no doubt that we have gained control over aspects of the physical environment. But the system in which we live is so vastly complex that we have no control over the ramifications of the power we have exerted and, ultimately, we have not reduced the level of uncertainty in which we live at all.
We are likely to tolerate an expert if he or she can produce clear categorical, and preferably dichotomous, output. When they do, we respond like one of two kinds of child: We either accept the output at face value, satisfied that this has settled all our doubts, or we demand access to the process and criticise it. One is the child who, knowing that hiding her eyes does not make the feared object go away, nevertheless does so. The other is the child who, worried that his parent is insufficiently powerful to contain the excesses of his exploration, appetite, or refusal, embarks on a destructive testing of this parent’s power.
These could be seen, respectively, as ‘internalising’ and ‘externalising’ responses to the intolerable fact that we can’t have it all as solid as we want it. The scientific expert is driven by two pressures: an internal pressure to favour a transparent process, and an external pressure to produce simplistic output.
While the experts prefer a computer and an algorithm over a human because, to them, the former are more transparent and therefore open to scrutiny and if necessary manipulation, the public prefers computers and algorithms because they are, to them, more complex and arcane. Of course here I am guilty, myself, of over-simplification. Not only can people not be cleanly divided into scientific experts and ‘the public’, but our attitude is one of ambivalence. We (the public) prefer a simple and enjoyable life and so want to hand over to the expert the power to make judgements on our behalf. Yet we want these judgements to be reliable and we find we are suspicious of the expert’s motives and/or credentials. We demand to know and understand the process that the experts are using so that we can make our own judgements about the judgements they have made. In so doing we have dethroned the experts and defeated out own purpose.
To summarise so far: We want to feel safe. We think that certainty is what is needed to achieve this. We no longer trust authority per se, or expert opinion that is not reductive and/or transparent in the extreme. Yet we are deeply confused about this: “If I understand it, then it is not powerful enough to be relied upon. But how can I trust it if I don’t understand it?”
Meanwhile, scientists know that they cannot trust subjective opinion or the experience of an individual as a route to the sort of output that is demanded of them by the public or that satisfies their own need for manipulability.
The clinical analogy is addiction. We crave the impossible. When fed an approximation we are temporarily satisfied, only to feel the pangs of craving return more powerfully than before.
What is the answer?
A step back is needed. Not least, at this point, because I need to appease a scientific audience. As well as being a creative (therapeutic) artist within the clinical relationship, I was brought up, and remain, a scientist of sorts. I do understand the importance and relevance, as well as the limitations, of the empirical method. It is just that I believe that we have to treat it, not as an all-powerful saviour, but as a useful resource. We have to move away from our regressed positions and relationships as (to use the Karpman Drama Triangle) victims, persecutors, and rescuers, and practise a more mature outlook.
In chapter 3 of Being With and Saying Goodbye I drew a distinction between evidence in its broadest sense – inclusive of the subjective and qualitative – and the addictive, dichotomous, narrow, mechanistic brand of ‘evidence’ which I placed in inverted commas, and which I have been talking about here. I suppose I thought of “evidence” as a sort of manufactured opioid, and I listed its side effects:
- The fuelling of the addictive relationship with an elusive and illusory certainty
- The marginalisation of instinct, trust, compassion, and hope
- The rendering of people into countable units, commodifying interpersonal relationships and infiltrating them with a utilitarian ethic
- The impoverishment of our notion of both evidence and treatment.
Being With and Saying Goodbye was written from within a therapeutic context and for a professional audience, but my conclusions are adaptable to a more personal and universal context and I offer them here.
We need to practice our tolerance of uncertainty. What will enable us to do this, I suggest, is less instrumental doing to, and more being with, each other, our circumstances, and the environment. This means that we:
- Patiently allow ourselves continuity of contact with each other and our environment over time, so that we can…
- Inform and refine our interactions with each other and our environment through an iterative process of relatively direct observation and feedback.
- Rely less on all-or-nothing statements and predictions, and become more receptive to our internal cues as well as to both conscious and subliminal feedback from each other and our environment on a moment-to-moment basis and evolving throughout the course of our lives.
- Practice the sensitive gathering and use of a kind of evidence that is rich, personalised, and lacking in dangerous side effects.
- Acknowledge the insecurity intrinsic to life, valuing what we have now instead of desperately trying to preserve it in perpetuity.
To be completely clear, I do not advocate total abstinence. We do have to make decisions.These are not certainties, nor are they based on certainties.They are simply decisions based on evidence. We would be idiots to neglect empirical evidence, but we must remain a) alert to the harms it can do when relied upon to excess and, b) open to all the other kinds of evidence, not despite, but because of, their partnership with uncertainty.
Andrew West, MD is a child and adolescent psychiatrist. He tweets @afwesty
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