Reversing the Order: Situating psychotherapy within the medical model

by Nigel Mulligan

Introduction

Most psychotherapy models are fundamentally psycho-social treatments entailing a verbal exchange between two or more people. A general aim of psychotherapy is that it reduces mental distress and improves a person’s mental health (Roth and Fonagy, 2005). It has been shown to be helpful in relieving symptoms and improving the person’s overall well-being (Corsini, 2005). But in the medical system, it is not always the first utilised mental health intervention for such medical ‘disorders’ as depression, anxiety or schizophrenia. The medical model has its own linguistic conceptual diagnostic ordering (Szasz, 2007). The psychiatrist and psychoanalyst, Ronald D. Laing (1971) defined the medical model as a set of procedures that usually includes a complaint, physical examination, diagnosis and prognosis with and without treatment. Scientific medical advancements in mental health have contributed to a surge in psychopharmacological treatments. Despite some of these apparent breakthroughs, the culture of psychopharmacology is part of a wider dominant discourse of psychiatric medicine that is involved in defining, diagnosing and medically treating a number of mental issues. The certainty of the pharmaco-centric practices comes from bio-chemically based medical theories that assert that aetiology of most psychiatric ‘disorders’ are caused by biological ‘organic’ complications. In the medical model, mental ‘disorders’ are usually seen as diseases of the ‘body’ as opposed to subjective illness of the ‘mind’.

A possible challenge for not only humanistic and integrative psychotherapists, but for all therapies in the overarching medical system, is to keep their sights on the subjectivity of the client. Although psychotherapy models have their own theories and conceptualisations of what distresses and what best treats human beings, this article will explore how some psychotherapies have become complicit in such linguistic ordering of and ‘curing’ of mental distress. It might appear that psychotherapy in general is undermined by some diagnoses, prescriptions and taking of psychopharmacological drugs but I propose it as a challenge for the current role and future praxis of humanistic and integrative psychotherapy to continue to re-prioritise the potential of the human being in the medical model; to re-emphasise the subjective story behind the diagnosis and medication. Not to totally discard the medical definitions, but to see it as part of a dense symbolic system that represents a deeper, unspoken aspect of the client’s human condition; a condition that needs a language that is rooted in the client, anchored in subjective meaning and expressed through the therapeutic relationship (Clarkson, 2003).

Psychotherapy: An impossible profession in the medical discourse?

The practice of psychotherapy has its roots in the 19th century. It is widely acknowledged that Joseph Breuer and Sigmund Freud gave birth to ideas that were to form the embryonic stages of psychoanalysis. Sigmund Freud was very much aware of the mind-body dialectic when working as a neurologist, but he bravely propelled his theories of talking therapy into the scientific world of psychiatry. ‘Freud the neurologist was being overtaken by Freud the psychologist’ (Strachey, 1957: 163). Freud said that there was a mind and a brain but one is not accurately translatable into the workings of the other (Hinshelwood, 1989). Freud wrote intensively to develop his ideas of how unconscious ‘drives’ manifest in symptomatic behaviour (Loose, 2002). Freud observed that symptoms can sometimes substitute for remembering repressed thoughts and feelings. Symptoms, at some level are an attempt to heal psychical disturbance (Verhaeghe, 1995). If symptoms cannot be produced, there is possibility that psychopathological behavior can occur. A central thesis of Freud is that since we are very young, we repress our instincts of love, hate and a powerful, overwhelming libido ‘drive’ toward early parental figures and siblings. Freud referred to this as the ‘Oedipus complex’ (Freud, 1912). Freud claimed that this ‘repression’ later creates what he termed ‘transferences’. In his paper, Remembering, repeating, and working-through, Freud (1914) stressed that what the client does not remember will be repeated in the transference with the therapist. Sigmund Freud himself offers sympathy to the therapist, stating that psychotherapy may be one of those ‘impossible professions in which one can be sure beforehand of achieving unsatisfying results’ (Freud, 1937: 377). Freud is most likely alluding to how clients may unconsciously fear the removal of their symptom and can become resistant to change.

The 19th and early 20th century is not only poised for the development of psychoanalytical explorations but in a different, and yet at times overlapping, trajectory was the burgeoning development of phenomenology. Some phenomenologist writers offered a grounding philosophical orientation for the humanistic therapies such as Existential, Dasein-analysis and the Person Centred Therapies. Martin Heidegger, in particular further developed Edmund Husserl’s phenomenology with a hermeneutic flavour and declared that knowledge and our ability to know is shaped by our ‘ontological Being’. His work offered profound reflections on how we come to know through ‘shared understandings with others’ (Heidegger, 1962). Heidegger referred to this as ‘Daesin’ or ‘Being-with-others’. He maintained that meaning emerges through language, is shared through language, but also fails in language (Richardson, 2003). The Swiss psychiatrist, Ludwig Binswanger was very much inspired by Heidegger’s magnum opus Being and Time and later came to be known as the ‘Heideggerian psychiatrist and psychoanalyst’ (Frie, 2003: 142). Heidegger did not have much time for psychoanalysis (Richardson, 2003), but Binswanger entered into a long-lasting correspondence with Sigmund Freud. Although he highly respected Freud, he was critical of his early proto- physiological terminology such as the mechanistic elements of his ‘drives theory’ (Frie, 2003). Binswanger emphasised a person’s life-world experience rather than reducing a person to intrapsychic drives or labelling them under a mental apparatus. He referred to the human as not merely an isolated subject but a subject that always exists in relation to others. Binswanger claimed that a client’s mode of relating could provide a wealth of information about the person (Frie, 2003). He aimed to understand more about the intersubjective nature of the human being. Binswanger’s conceptions of human experiences promoted a new way to interpret the styles of existence that would otherwise be reduced to psychopathology (Smyth, 2011).

The terms ‘psychosis’ and ‘schizophrenia’ have been framed through a biological lens going back to the time of the famous psychiatrist Eugene Blueler (1924) where he proposed a casual theory of heredity and brain pre- disposition. Although Freud challenged this by privileging subjective causes before biological predisposition (Dalzell, 2011), but it was Binswanger that was critical of how the human condition was rationalised through the psychiatric discourse into ‘causes’, ‘disorders’ and biomedical ‘cures’. For Binswanger, psychosis was closely associated with the French Freudian psychiatrist Jacques Lacan’s concept of the ‘Real’ where he claimed the psychotic experience is characterised by the loss of meaningful speech (Lacan, 1977). Working with psychosis or schizophrenia can be significantly more challenging for psychotherapists. Unlike neurosis, clients who have the hallmarks of a psychotic structure have symptoms of experiencing delusions and hallucinations. They hear messages and voices and believe that they are coming from outside their mind; they lie outside the social domain in the Real (Richardson, 2003). Some psychoanalytical theories maintain that delusions are an attempt to make sense out of the return of what was ‘repressed’ or what was earlier ‘foreclosed’. It is their own personal solution to their Oedipus complex (Verhaeghe, 1995). But the significant difference in Binswanger’s understanding of psychosis was that he claimed that there is meaning to be found everywhere and in everything, even beyond verbal language in bodily expressions. What Binswanger was against was the objectification of a client by putting a label of ‘psychotic’ on someone, before there is any attempt to understand what meaning the client beholds. It was the language that defines and structures the psychosis, rather than the reverse dominant psychiatric presupposition. Was Binswanger suggesting that it is the psychiatric language which is ‘psychotic’ and the medical system that is fundamentally dis-ordered? Binswanger promoted symbolic representation in whatever form of the client’s life-world experience that could be expressed. As psychotherapists from the humanistic tradition, our therapeutic endeavour is to challenge the medical dis-order and to search for the personal meaning of the client. Thus, the objective of therapy is to sublimate symptoms through the many guises of language. But is that objective practically impossible in a dense symbolic system in a ‘structured’ medical world?

In search of meaning within symptoms

Similar to Freud, the humanistic and integrative psychotherapist is situated between the ‘subjective-biographical’ stories of the client against the ‘objective-biological’ categorisation, categorisations that ultimately fail to represent true human experiences. They fail on many fronts. Further to the impact of a naming of a mental health diagnoses, another significant factor that adds to the symbolic exchange is the prescription and taking of psychopharmacological drugs by clients. Clients will invariably react differently to diagnoses and mental health labels, but the various prescribed drugs add another dimension. Some of these drugs act on the central nervous system where they are designed to act on naturally occurring chemicals in the brain (Catell, 2004). Some psycho-pharmacological treatments not only have adverse psychological and physical side effects, but can be over relied on and addictive (Catell, 2004; Cuttcliffe and Lakeman, 2010). Further to this, they can carry significant meanings for both clients and psychotherapists (Karp, 2006; Kirsch, 2009).

An example of common symptoms associated with taking anti-depressant medication, most notably ‘selective serotonin re-uptake inhibitors’ (SSRIs), is the report that the effect of these tablets can numb key emotional aspects of personality (Karp, 2006). Other reports claim that they reduce pleasure; decrease sexual desire and can cause suicide ideation (Whitaker, 2010). Ironically, these are severe side-effect symptoms that are arguably worse than the client’s initial illness before their original complaint to the doctor. Despite some ambiguities in the effect of drugs, there is evidence to suggest a combination of psychotherapy and psychopharmacological drugs is useful in major depression, anxiety states and schizophrenia (Hollon et al., 2002). Also, Corsini (2005: 488) stated that ‘drugs may facilitate psychotherapeutic work by improving cognitive functioning, enhancing memory, promoting abreaction, or contributing to a sense of confidence and enhanced optimism’. Dr. Peter Kramer (2005) believes that at a particular point of a person’s illness, they may need pharmaceutical intervention until they can re-gather their strengths. Medication can allow somebody to be able to sit in the therapeutic space.

Despite this, combining psychotherapy and pharmacotherapy can certainly provide clinical challenges for psychotherapists. For example, psychopharmacological drugs may reduce a client’s motivation to work in therapy or they can even prematurely discontinue therapy. Other clients may regard prescribed drugs ‘as a crutch’ or an ‘admission that they have failed to develop the necessary insight to work through their problems’ (Corsini, 2005: 488). Not only this, but there is an argument that certain psychopharmacological drugs can de-motivate a client’s desire in therapy and reduce symptom formation. If no symptom can form or develop, or previous symptoms wither away, Paul Verhaeghe (2008) suggests that it can be left in the body and possibly cultivate in extreme forms such as panic disorder, chronic anxiety and can even cause severe depression to develop. This, Verhaeghe (2008) maintains, requires a therapeutic attempt to produce a symptom that can be explored through words. In therapeutic reality there are times when one might feel that a client’s capability to explore significant symptomatology may prove too challenging, regardless of being on medication or not. Indeed, there may be many factors that inhibit a client from emotionally processing their experience and reduce the chance of a client getting fuller meaning from the symptomatic illness, but it should not preclude the psychotherapist from continuing to search for meaning with the client.

Can psychotherapy be part of the problem?

For the integrative psychotherapist, the therapeutic orientation adopted can depend to a large measure not only on client personality, behaviour and the symptoms that are presented, but it can ultimately depend on a client’s capability to engage in therapy. Some clients will manage expanded self- understanding and some clients will only want some more practical help to manage situations through modified behaviour. Cognitive behavioural therapy can come out favourably in certain research trials for reducing symptoms significantly more than other therapies (Roth and Fonagy, 2005). This is arguably due to its problem-focused, time-limited measurable protocols. What often escapes researchers is the argument that suggests that short-term therapy, such as CBT, can initiate symptomatic change at a surface level, but symptoms may reappear again or show as something else. Short- term therapy perhaps equates to short-term change. Psychotherapies such as CBT have often used the term ‘guidelines’ or ‘methods’ when describing recommendations for clinical practice but Roth and Fonagy (2005) have questioned the ‘protocol-driven’ or the step-by-step guide to working with a client, referring to certain approaches ‘manualising’ the therapeutic process. Psychotherapy can fall complicit by using the language of science to try to ‘structure the procedure’ and make the client fit its model and technique. The luring temptation is that the medical model offers a ‘certainty’ of cause and cure. Of course, this is the illusion of ‘certainty’. This illusion is the language-trap of the medical model that undermines the humanness of a person and the personal potential for growth and healing.

Sitting with uncertainty

Karp (2006: 141) claimed that ‘it is not so much about the therapist’s training but the patient’s belief in the therapist’ and the particular ‘symbolic system on which the therapy system is based’. A central theme through this article echoes Karp’s emphasis on the symbolic system. By developing a relational dialogue, other key factors can be identified and treated in the therapeutic relationship. The psychotherapist has an opportunity, with the client, to distinguish between the ‘body, illness, pain’ (Karp, 2006) and also to work through possible key relational transferences. This is what Verhaeghe (2008: 309) claims that an eventual aim would be to encourage ‘subject amplification’ and an exploration of any possible childhood diseases and parental reaction toward them. By enquiring how the client interprets and relates to their illness is core to the therapy. The therapeutic treatment is about the asking what their ‘diagnoses’ means to them, while also having a conversation about the meaning they attribute to taking medication and how they interpret the symbolic message of prescription. These questions all aim to recapture the experience of the client as a primary source of information, rather than the reverse set-up. It might be the psychotherapist’s role to help the client reflect into what Binswanger referred to as the heart of the client’s human condition, the subjective meaning of what it means to be human. Having a diagnosis without the client’s meaningful story is like having a frame without the picture. And there is no comparison for a client sitting in a space and being listened to than the ‘certainty of sickness’ message that all prescribed medication is packaged in. The psychotherapeutic space is a space that not only deconstructs the many messages of medicine, but it can be a space to share and come to accept common human ‘uncertainty’.

Conclusion

As humanistic psychotherapists, we realise the task ahead is to continue to situate the subjectivity of the client as an anchor point in a medically diagnostic world, a world that linguistically objectifies the human experience. Psychotherapy is always at risk of becoming part of the problem. First and foremost, there needs to be a strong emphasis on the importance of the clients own subjective experience before any linguistic ordering and biological language reinforcing diagnostic interpretations are administered. For psychotherapists, it would be beneficial to explore not only the meaning of medication, but essentially to deconstruct with the client their experiences of the ‘certainty’ of their ‘diagnoses’ and illnesses and tentatively explore their own symptoms. By reversing the order of priority, we see the client as a potential resource in their own healing and finding of their own solutions.

Psychotherapists need to offer an openness and transparency in the client’s life, illness and medication – where one’s shifting position constantly requires one to situate oneself in a ‘not-so-certain’ position; where underlying theories not only hold different casual possibilities but by allowing for the unexpected, it can leave a space for the unknown, for possibility, for hidden meaning to emerge. Central to this is for psychotherapists to critically engage in the failed language of dominant medical discourse and to always try to re-order and re-prioritise the subjective world of their client in their search to achieve personal meaning to their suffering.

Nigel Mulligan (B.A. in Theology and Psychology, M.A. Culture and Sociology, MSc in Psychotherapy) has over 10 years’ experience working in the field of mental health and substance addiction. Nigel is a candidate on the Doctorate of Psychotherapy programme in the School of Nursing and Human Science, Dublin City University. He is currently carrying out research on Psychotherapy and Anti-depressant medication.

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