by Mary Peyton
In spite of the fact that it is clearly recognised that psychotherapy is a valuable and effective resource for individuals with mental health problems (Budd & Hughes, 2009; Cooper, 2008; Howard et al., 1994; Lutz, 2003; Prochaska & Norcross, 2013; Seligman, 1995) the relationship between psychotherapy and psychiatry could best be described as polarised. The nature of this polarisation is multilayered and has an historical context. This well-documented history appeared with particular vociferousness in the middle ages where the popular healers of the time, the ciarlatani (Italian remedy vendors who sold remedies to the poor) were the subject of a passionate crusade by the physicians of the time, in an effort ostensibly to protect the ignorant public. The reality was that physicians themselves had little to offer the sick, with bloodletting, emetics and purgatives comprising their armamentarium. The ciarlatani/charlatans were seen as outsiders, grouped with ‘others’ such as exiles, atheists, prostitutes, midwives, surgeons and apothecaries who got out of line (Eamon, 2009). One might well argue that this particular war did not end with the dawning of the Age of Discovery.
Beginnings of psychiatry
Within the medical profession the specialty of psychiatry had stark and dark beginnings, emerging from the many madhouses that were set up post-industrialisation. People were sent to these institutions for many reasons, often little to do with their mental health, and being female making one particularly vulnerable to this fate. These institutions offered little; sometimes little nurturance for the body, certainly no nurturance for the soul. There are many horrific tales told of the happenings in these places, with doctors barely visiting them or turning a blind eye to the state of the patients or the torture they were subjected to. There were of course exceptions to this, for example Pinel, Pussin and Tute in Europe, and Kirkbride in the United States, who challenged such inhumane treatment.
Scientific advances, along with the serendipitous discovery of new medications in the 1950s, which seemed to help symptoms in patients who had psychotic, depressive and anxiety diagnoses, revolutionised the thinking of the time. Doctors had some sense at last of having something to offer the individual in distress. This was the beginning of modern psychopharmacology and it came on the coat-tails of anaesthesia. A particular anaesthetic agent was noticed to cause the patient to quieten and appear detached and it was thought that this might be helpful for mentally distressed patients. Modern psychopharmacology was born.
Psychiatry still had a way to go, however, in order to be seen as being on a par with other fields of medicine, and it strived for legitimacy. The medical model of disease was adopted and the DSM (Diagnostic and Statistical Manual) came into being. It was hoped with the creation of the DSM that this would allow for a more cohesive approach to mental health problems (Peyton 2016); at least psychiatrists would have a common language to recognise what was meant by a particular diagnosis, and this could facilitate research into approaches to help.
Its raison d’etre was to facilitate dialogue. In reality, the very creation of this categorical model was flawed (Moncrieff 2008; Whitaker, 2010) even if it did offer a sense of validity to psychiatry as a specialty in itself with a scientific basis. Its validity in relation to diagnostic criteria, however, has been thoroughly critiqued by many, including the National Institute of Mental Health, which withdrew its support for the DSM-5 (Frances, 2013; also Frances, 2013, as cited in Kudlow, 2013; Insel, 2013). And, as is widely known, it has morphed into a tome which increasingly pathologises human experience, deciding on what is normal and what is abnormal within our experience of life and death, even down to deciding how long ‘normal’ grieving takes.
Relating to distress
The DSM has been responsible in part for the polarisation that exists. One of the many layers of the polarisation that is currently present lies in the lens through which mental distress is viewed. Psychotherapy locates mental distress in the complexity of what it is to be human; psychiatry looks towards the diagnosis. Perhaps the difference is also captured by the way suffering and healing are thought about, with psychotherapy thinking of suffering (symptoms) symbolically rather than concretely. The symptoms endeavour to bring attention to unconscious conflicts and traumas. The meaning emerges through relating. In psychiatry, for the most part the symptom has no intrinsic value and is there to be gotten rid of. The symptom needs to be silenced; however, this means that the door to understanding the suffering is closed. This difference in approach to the person who is suffering has the significant consequence of determining the approach to treatment, psychotherapy locating the locus of change within the relationship and the individual. The relationship between therapist and client is collaborative and central to understanding and uncovering the meaning of the suffering. Psychiatry on the other hand locates the method of treatment all too often outside the individual, usually through a relationship with a transitional object/soother, the pharmacological intervention.
The biomedical model assumes that difficulties experienced by individuals originate in abnormalities within brain circuits and neurotransmitters. There is a disease of the brain. Treatment, therefore, has to be biological. Consequent to this is the fantasy that the cure can be found in pharmacology, with the pursuit of research focusing its efforts on discovering disease- specific drugs. There is no specific scientific evidence to support this approach (Moncrieff, 2008). What is omitted in this model is the reality of the living complex dynamic structure called the brain which is receiving, processing and transmitting information constantly, and creating meaning from all of this activity; to say nothing of the brain-body symphony that is playing, sometimes discordantly, creating the experiences of life. The social, psychological and behavioural elements of dis ease are discounted (Engel, 1977).
Tragically, the consequences of restricting thinking to the biological model, as has happened during the decades since the 1980s, are that mental health outcomes are increasingly poor with more people receiving disability payments than ever, begging the question as to the curative potential of psychotropic agents (Whitaker, 2010). The biomedical model has served to polarise psychiatry and psychotherapy, omitting context and, therefore, environmental history, including intergenerational and prenatal experiences.
Diagnosis and its challenges
Our clients often have to straddle the two worlds of psychiatry and psychotherapy, while some of those who espouse either model stay entrenched in their own worlds. This has consequences for the client. While psychotherapy eschews diagnosis (Rowan, 2013, 2007) clients may arrive to therapy with a diagnosis or a self-diagnosis. Our response to this can be to ignore it and therefore not explore it, which amounts to an opportunity missed. The story of the diagnosis can reveal much, both in relation to how our clients relate to themselves and their difficulties, the underbelly of their difficulties, and information regarding their relationship with Other.
The question also arises as to how the therapist relates to diagnosis. Is it always a bad thing or does it have anything to offer? Diagnosis as per the DSM categorical model has many faults, not least of which is one of reliability (Spitzer, as cited in Spiegel, 2005). Clients present in many ways, with difficulties that may be developmental in nature and/or traumatic. There is a whole spectrum to human individuals and their experiences and how these might manifest. If we look at diagnosis as descriptive, naming a constellation of symptoms/experiences, I feel that there are diagnoses that are important to be aware of. I would also argue that knowledge of some diagnoses is helpful in relation to what might be experienced in the psychotherapeutic relationship.
Complex post-traumatic stress disorder and dissociative identity disorder, with their attendant chaos for the client, are terms that we need at least to be familiar with. This is in order to offer us some awareness of the territory we are working in. Working with the fragile client with trauma-related structural dissociation of the personality (Nijenhuis et al., 2004), caused by trauma occurring at a young age, will be chaotic for both the therapist and the client unless we can recognise what is happening and offer a framework for integration (van der Hart, 2006).
Another controversial diagnosis, due in part to the unpalatable language used in the label and the stigmatisation of the individual, is Borderline Personality Disorder (DSM-5) or Emotionally Unstable Personality Disorder (ICD 10). This diagnosis was one which caused psychiatrists to throw their hands in the air, dreading seeing the patient and often offering them cocktails of medication that did not help. It has been through the psychotherapeutic lens that individuals who have severe difficulty in regulating their emotional selves have been seen more clearly and with compassion. It has also been through the psychotherapeutic lens that hope has emerged. In psychotherapy, the therapist and client engage in the extremely complex task of attending to emotional regulation, with the therapist attending both to him/herself and also to the client. These fragile clients can leave us reeling unless we have an awareness of the territory, even when we do not use a diagnostic label (Carsky et al., 2012). Again, it is the approach to the individual that is different. Having a notion of the territory, and holding that map lightly so that we have some reference point to stay grounded ourselves, is different to looking for signposts and then defining the territory, and therefore the individual, from them. Knowledge here is used in facilitating relating in the psychotherapeutic relationship and is process-orientated. It should not, and does not, categorically define it.
Areas of commonality
One area where psychotherapy and psychiatry increasingly share a common interest is neuroscience. Psychiatry is currently embracing neuroscience to give validity to the disease model and to support the pharmacotherapy model. This ‘technological paradigm’ (Bracken et al., 2012) is at the heart of the medicalisation of human suffering. The reality is that while there are many changes in brain activity observed on functional MRI (fMRI) studies, there are no specifically identifiable patterns to correlate with specific DSM categories. MRI studies in and of themselves are not neutral experiences for individuals. The individual is in a strange place, with people they do not know, being asked to lie still in a confined and very noisy environment, and the experience of the process itself must be the source of some of the brain activity observed. fMRI interpretation can only be correlative and not causative. Nor can neuroscience, for all it has illustrated in relation to the brain and its activity, explain the complexity of human experiences involved in relationship, meaning-making, belief systems and values. Psychotherapy is also embracing neuroscience, and, not unlike psychiatry, can see it also as giving validity to the psychological relational model (Shore, 2012; Marks-Tarlow, 2012). There are many neuroscientific findings supporting the theoretical models we use in an effort to understand, amongst others, concepts such as attachment, anxiety, stress and trauma. Neuroscience is in its infancy, and at best is a crude measure of brain activity. It is however a place where we share a common language with psychiatry, however psychotherapy offers a different interpretation of neurobiological research, one which opens out possibilities rather than reducing them to a list facilitating diagnosis.
It is here that psychotherapy and the Critical Psychiatry movement have common ground. This movement was established in 1999 by psychiatrists who were dissatisfied by the traditional psychiatric model, with concerns that mirror those of psychotherapists. Some areas of concern within the movement are the…
…problems of psychiatric diagnosis, the problems of evidence based medicine in psychiatry and the relationship between the pharmaceutical industry and psychiatry, …the central role of contexts and meanings in the theory and practice of psychiatry, and the historical and philosophical basis of psychiatric knowledge and practice.
(Thomas, 2017, 2014)
Thomas, like Rowan, makes the point that the experience of the individual gets lost in the current biomedical model, something psychotherapists would have no difficulty concurring with.
As to the question of where psychotherapy meets psychiatry, there are meeting points and flash points which have been touched on here. I would hope that the chasm that exists could change, and there are signs that it is indeed changing, particularly with the increasing recognition of the limitations of psychopharmacological interventions among some psychiatrists and the value of psychotherapy for their patients. This change is vital, with psychotherapy being given its rightful place for the sake of the individual who needs to be heard in all of his/her complexity, depth and uniqueness.
Photograph by Christopher Payne (2009) from Asylum, inside the closed world of state mental hospitals. MIT Press.
Mary Peyton works as a humanistic and integrative psychotherapist in private practice and is an accredited supervisor with IAHIP.
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