Decoupling psychological therapies from the medical model. Adopting an illness model of distress is too high a price to pay for the professionalisation of counselling and psychotherapy. We need to establish a more humane and constructive alternative
From the archive
This article was originally published in the November 2007 issue of Therapy Today
Counselling and psychotherapy, like psychology before them, have historically struggled to establish themselves as academic disciplines, whether unified or separate. Now we find that we live in interesting times as we try to establish a ‘profession’ of counselling and psychotherapy. We discover ourselves seeking cover under the ready-made umbrellas of ‘the psychological therapies’, and association with the authoritative and ancient profession of medicine.
As counselling and psychotherapy negotiate the next, apparently inevitable, step towards regulation as a profession, I suggest that we pause to consider a particular facet of the profession we would like to be bound into. We must remember that our place in the professional firmament has never been guaranteed – we have had to pay our dues. Over the years, counsellors and psychotherapists have struck many, sometimes quite peculiar, poses in order to stand close to the medical profession without causing too much offence.
Regarding the history of psychological therapies, John Shlien1 wrote: ‘“Diagnostics” is an area that was assigned to psychology by psychiatry … In fact, since treatment was so confused and ineffective, diagnosis was the main area of “success”. Psychologists were simply the hired hands in the psychiatric field, and generally all too willing ones …The diagnostics were their security blanket as well as their entering wedge.’
Will we sleepwalk into a professional position where we are required to be the ‘all too willing’... ‘hired hands’ of the psy-complex; ie the collective interests of psychiatry and the pharmaceutical industry?2
Here, I will suspend some of the niceties of academic discourse. Balance and distance are required in order to regulate debate and clarify issues, yet sometimes they serve the opposite purpose – to throw a cloak over the elephant in the corner. Instead, I am going off message. In bald terms, the medical model of mental illness does not work, and in practice it is iatrogenic. If I understand this, then I need not debate whether I should associate with it, adopt it, pander to it or revise it. Unfortunately, it is clear that members of our emerging profession will be required to fall into line behind the psychodiagnosticians and other members of the emperor’s entourage, holding their noses while clucking about his marvellous apparel. At the heart of the issue is a simple question: Do we believe that a frightened, confused or overwhelmed person is ‘ill’ and requires medical treatment? I have met very few members of BACP who do. Neither do the majority of counsellors identify with the medical model in theory or practice.
There are many ways of thinking about mental health. As psycho-practitioners we must decide how to approach the conceptualisation of our day-to-day emotional and psychological experience and functioning. Do we subscribe to a biological, psychological, social, spiritual or existential model, or a combination? Some counselling and psychotherapy approaches have developed idiosyncratic systems of categorisation and psychodiagnosis, which they use to facilitate the matching of treatment options with ‘symptoms’ or lived experience. Other approaches, such as person-centred therapy, reject diagnosis and differential treatment.1 A popular view among theorists and practitioners is to see the spectrum of psychological distress as a bio-psychosocial phenomenon. But such a model begins with and encourages popular emphasis on the bio. This is challenged from various points of view by the likes of Tew et al3 and Read, Mosher and Bentall.4
Counsellors and psychotherapists are neither medically qualified nor spiritual guides; our work is informed by psychological and social theories. Indeed, psychotherapy journals are dominated by psychological, sociological and existential essays. Why, then, do we turn to the medical model – rooted in biological psychiatry – as a compass in professional settings? A need for approval? Insecurity? A wedge to gain a professional foothold?
If our work is founded in psychology, sociology, and philosophy, we should not root our authority in biological psychiatry and the medical model of mental illness. We should reject the illness metaphor of distress. Otherwise, the mind-set of thinking that the people we try to help are ill will insinuate itself into all we see, do, and are with clients. If we think sick, we will see sick and treat sick. If treated sick, people will act sick. If we understand that people yearn to be known and understood – and this is often greater when we are distressed and vulnerable – this equation is heading for a state of dependency on labels of illness for all parties concerned. And we will be inclined to take the easy route by looking no further than those supplied by the medical model system of diagnosis: the American Psychiatric Association’s Diagnostic and statistical manual for mental disorders (DSM) and the International Classification of Diseases.
Changing the metaphor
‘Illness’ is a metaphor for distress, not a fact determined by scientific analysis. It is a representation of reality, not reality itself. It is a way of thinking that is intended to be helpful, and it may have a place in the history of our understanding of madness. According to Wing,5 psychological ‘disorders’ are names for theories, not names for things that exist in nature. They are metaphors for how things look and feel when people are distressed. However, I would argue that these metaphors – like so many illness metaphors – have reached their sell-by date and are no longer fit for purpose. Many4,6-9 question the utility of the metaphor, yet it is still taken as given by the general public and by the majority of practitioners in psychology, psychotherapy and counselling.
‘Illness’ has been used as a metaphor for a lot of things that we no longer think of as illnesses. For example, many of my friends ceased to be ‘ill’ in 1973 when ‘homosexuality’ was taken out of the DSM. The women’s movement struggled, and has (at least in part) succeeded, to remove pregnancy and menstruation from the list of ‘pathologies’ associated with being a woman. Disability is no longer seen as a medical condition per se.10,11 Disabled people, lesbian, gay and bisexual people, men, women, transgendered people, may be different, but they are not ill. Illness metaphors are far from benign. Get on the wrong side of an illness metaphor for distress and you could well end up marginalised, in hospital, treated against your will, or in jail. Severely distressed people are subjected to a range of chronifying ‘treatments’, sometimes against their will. To add to an already grim picture, we find a substantial body of literature documenting the disabling effects of the stigma of a diagnosis of ‘schizophrenia’ or ‘personality disorder’.12
History suggests that it is defeatist to think that the psy-complex is too big, has too many political connections or too much inertia to make change possible. Change is only a matter of timing. The above examples remind us that campaigning to reassign metaphors is not a lost cause. However, these changes came after much suffering, and social action. The psycomplex is similarly unlikely to yield to a different metaphor without a struggle. There are other barriers to metaphor reassignment. Terror, overwhelm and confusion are real; and to be intimidated by such experiences drives many to escape by withdrawing, self-medicating, or even trying to kill themselves. The illness metaphor has also provided (and continues to provide) comfort for many, as did the medicalisation of disability, pregnancy, sexuality, and so on. None of this, however, excuses it from being simply wrong. Distress is not an illness. To insist that distressed people are ill diverts attention from the real causes of distress, and promotes and maintains the careers of everyone employed in the psy-complex – myself included.
Assigning new language to our theories will force change upon thinking and practice in ways that may be uncomfortable or unpalatable. Examples of alternative language forcing different concepts are sprinkled around this article. I personally favour terms such as mild, moderate, severe and enduring psychological distress, in preference to general terms implying illness and disease. I am also a fan of Peter Breggin’s2 sensitive use of terms like overwhelm. But as therapists we need look (or listen) no further than the experiences of our own clients, in their own language, on their own terms. Our clients will have interesting messages for us if we listen, since even public opinion is set against biological explanations for distress. Read and Haslam12 reviewed research in nine countries on ‘mental health literacy’ and public opinion on medical interventions, and found that the public prefers psychosocial explanations and solutions over medical ones.
If our emerging profession is to be worth anything, let it be born in the struggle to establish a more useful, humane and constructive metaphor for human distress. Let us campaign for the de-medicalisation of life, rather than the proliferation of new diagnostic categories for everything from relationships and sex to eating and shopping. Let it be the path for, among other things, transforming us from being, as Madigan13 puts it, ‘patients without knowledge’ to ‘persons with knowledge’.
Evidence that distress is not an illness
The arguments suggesting that distress is not illness are not new. Social and environmental factors are increasingly and persuasively implicated in the aetiology of distress. For example, people who have suffered sexual abuse are three times more likely to receive a diagnosis of schizophrenia, while people who are subject to poverty and ethnic discrimination are three times more likely to receive a diagnosis of psychosis other than schizophrenia. Similarly, childhood neglect and abuse are highly correlated with attention-deficit hyperactivity disorder (ADHD), lower academic achievement, problems with peers at school, earlier age at first admission to psychiatric care, and a higher number of admissions.14
There is little or no evidence of differences in (a) the distribution or use of neurotransmitters (b) brain structures and (c) activity levels, between the brains of people diagnosed with a psychotic condition and people with no diagnosis that cannot be explained equally by changes due to childhood experience. For example, the brains of traumatised children show structural and functional changes similar to those associated with psychotic conditions.4
Breggin,2 Bentall,15 Lynch,16 Moncrieff17, 18 and others have countered the ‘chemical imbalance’ notion of serious and enduring distress (‘psychoses’). There is little scientific evidence of specific biochemical abnormalities associated with particular psychiatric disorders. Although depression is attributed to a deficiency of serotonin or noradrenaline, this has never been confirmed in research. Patients do not have their serotonin levels measured, and there is no data on what ‘normal’ serotonin levels should be. Thus, Peter Breggin2 writes: ‘Dozens of mass-marketed books misinform the public that a “broken brain” or “biochemical imbalance” is responsible for personal unhappiness. Yet the only biochemical imbalances that we can identify with certainty in the brains of psychiatric patients are the ones produced by psychiatric treatment itself.’
Mental illness diagnoses are highly questionable on several grounds. For example, there is no link between symptoms and distress: people can have many symptoms but little distress, and conversely, few symptoms and great distress.19 Also, there is large overlap between diagnostic categories in the DSM, both in their description and their application, leaving its use as an ‘instrument’ both largely invalid and unreliable.20, 21 Moreover, Bentall15 has collected impressive evidence to demonstrate that so called ‘psychotic’ experience falls within the wide range of ordinary experience.
The confines of this article prevent more detailed presentation of the evidence balancing the dominant view that distress is an illness. This is all the more disappointing since the evidence is considerable and well presented, and held by an increasing number of ‘mental health’ professionals. It is also, I believe, largely unknown to counsellors and psychotherapists; the very workers who should be in the mainstream of psychosocial practice rather than propping up the failing medical metaphor.
An alternative approach
An equally plausible alternative to a medical explanation for distress is that the symptoms of so-called mental illness are understandable responses to a noxious environment. The way that we structure our social and economic relations affects our biology and psychology. Just as homeless people die of hypothermia, poverty disadvantages families in numerous ways. Thus Ermisch et al22 have shown that UK children growing up poor are more likely to have lower self-esteem; plan not to marry; believe that health is a matter of luck; play truant; expect to leave school at 16; have lower educational attainment; be unemployed as young adults, and experience psychological distress compared with those who have never experienced poverty.
Models of distress that put psychological, social and existential explanations first are in the ascendant. Moreover, such models obviously put psychological and social interventions before biological treatments, in that talking therapies, relationships, community initiatives, and building social capital are all consistently preferred to drug treatment of questionable value.2,4,15-17,23,24 While it would be illogical to dismiss biological factors altogether, they must take their place in the list of possible factors according to the evidence – and increasingly the evidence favours other factors.4,7,8,15,25-27 If our new profession is to be guided by evidence, then let all evidence be admitted, including the evidence from ‘experts by experience’, ie our clients, a group that increasingly rails against the medical model.
How we therapists think about distress should be guided by events as far away from diagnostic categories and the illness metaphor as it is possible to imagine – the experiences of ordinary people and our efforts to meet and understand them. We will be of more use to our clients if we meet them in the clear air of human encounter, free from the smoke and mirrors of medical metaphors. We must better understand the ordinary contexts of our work, rather than quasi-medical ‘theory’.
We had left Mam at the hospital that morning, looking, even after weeks of illness, not much different from her usual self: weeping and distraught, it’s true, but still plump and pretty, clutching her everlasting handbag and still somehow managing to face the world. As I followed my father down the ward, I wondered why we were bothering: there was no such person here. He stopped at the bed of a sad shrunken woman with wild hair, who cringed back against the pillows. ‘Here’s your Mam,’ he said. The obliteration of her usual self was so utter and complete that to restore her even to an appearance of normality now seemed beyond hope. ‘What have you done to me, Walt?’ she said.28
For those determined to establish the profession of counselling and psychotherapy, plotting a course through contemporary critiques will take empathy, political and social awareness, and an abundance of the quality that we hope will be its hallmark – putting clients first. There are several analyses suggesting that the psychological professions are complicit in the manufacture of madness.29-31 If counselling and psychotherapy are to emerge as professions, we should take this opportunity to establish a distinct set of founding principles separate from the medical profession. We should constitutionally fix ourselves in the domain of psychological, social and existential theories. While critical psychologists and psychiatrists the world over are calling into question the medical model of mental illness, and sociologists are critiquing the medicalisation of everyday life,32,33 we should be not be associating ourselves with such an outdated and damaging system. The time is right to step out on our own.
Pete Sanders retired in 2005 after over 30 years as a therapist, trainer, supervisor and author. He is a member and trustee of the Soteria Network UK.
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