Why the Medical Model Fails in Psychotherapy, Part One: Subjective Experience Matters

[This is part one of two - part two is at the link.]

Have you ever gone to see your doctor about some issue, say a broken ankle, and felt that the doctor was only concerned with the broken ankle, or felt that he barely even noticed there was a body attached to the leg attached to the ankle?

I have, only it was my wrist. I might as well have been invisible because all the doctor could see was my broken wrist, and all he could imagine was surgical intervention to fix it. He dismissed my educated questions and barely acknowledged my presence. Not all doctors are like this, but the production-line nature of modern medicine makes this far more common than is good.

This is the medical model, an approach that is sometimes also known as the illness model. In essence, it is the application of objective medical criteria in treating dis-ease. In many ways, it's an excellent system, except for one thing: In this model, the subjective experience of the individual is largely irrelevant.

This approach has slowly been staking out its claim to mental realm and its illnesses, as well, over the last 40 years. And this is, in my opinion, not a very good thing for counseling and psychotherapy.

Over the last couple of decades, as psychiatrists (medical doctors with some psychology training) have become the dominant force on the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic committees (it is produced, after all, by the American Psychiatric Association), the focus of the DSM has moved increasingly toward the medical model of diagnosis and treatment.

In this view, nearly all mental distress has a biological basis (partial truth) and can be treated with a chemical, if only we can find the right ones (very partial truth). Here is one summary of the medical model in psychology:

The medical model of psychotherapy contains five components. In the medical model, (a) the client presents with a disorder, problem, or complaint; (b) there exists a psychological explanation for the disorder, problem, or complaint; (c) the theoretical conceptualization and knowledge are sufficient to posit a psychological mechanism of change; (d) the therapist administers a set of therapeutic ingredients that are logically derived from the psychological explanation and the mechanism of change; and (e) the benefits of psychotherapy are due, for the most part, to the specific ingredients. The last component, which is often referred to as specificity, is critical to the medical model of psychotherapy and gives primacy to the specific ingredients rather than common or contextual factors. (Wampold, Hyun-nie, & Coleman, 2001, paragraph 4)

In opposition to this model, which reduces the human being to a diagnostic issue, the authors propose a "contextual mode," which offers a more rounded view of the person and the interaction with the therapist:

The contextual model presented by Wampold (2001), which borrows heavily from Frank and Frank (1991), contains four components. The first component is an emotionally charged, confiding relationship with a helping person (i.e., the therapist) in which the client expects the relationship to develop as he or she divulges emotional and psychologically sensitive material. The second component is a therapy process that transpires in a healing context; the client believes that the therapist will provide help and will work in the client's best interest. The third component stipulates that there exists a rationale, conceptual scheme, or myth that provides a plausible explanation for the client's symptoms and is consistent with the client's worldview. The final component of the contextual model involves a procedure or ritual that is consistent with the rationale of the treatment and requires the active participation of both client and therapist. (Wampold, Hyun-nie, & Coleman, 2001, paragraph 5)

After a thorough review of the evidence, and rebuttal of the main medical model's arguments against anything like the conceptual model (for another version of this issue, see the recent LA Times article), the authors conclude in their final paragraph:

We use “old habits die hard” to suggest that the medical model is a habit that should die (or at least be extinguished, if the patient's therapist is a medical model adherent). The empirical support for a medical model of psychotherapy is nonexistent. We contend that it will neither scientifically explain research results nor further the field. The alternative contextual model is scientific and culturally appropriate and will, in the long run, sustain counseling psychology as a field.

This article, as noted below, is from 2001 and there have been some important discoveries since then of biological markers for mental illness, but one thing that is seldom (if ever) addressed is whether the markers cause the illness or whether the illness causes the markers. No one has an answer for this, but the integral model of psychotherapy would suggest it is not either/or but, rather, both/and.

James Hansen (2005) argues that part of the reason that the medical model has been triumphant is the lack of cohesion and cross-support for the alternate, more humanist (and post-modern) perspectives:

There are many reasons for the rise of the medical model, including the discovery of chemical agents that alleviate symptoms (Shorter, 1997), the fact that third-party payers are structured according to a medical perspective (Hansen, 1997), and, perhaps most important, because of the economic benefits of this model for organized psychiatry and the pharmaceutical industry (Leifer, 2001). However, another possible reason, which I am now proposing, for the dominance of the medical model is that theories that emphasize human complexity, notably humanism and postmodernism, do not provide a conceptually unified alternative to theories that blur individual differences through categorization, such as the medical model. That is, there is little dialogue or cross-fertilization between humanistic and postmodern orientations. As isolated perspectives, neither humanism nor postmodernism has the critical mass to challenge the dominant medical model. (p. 4)

Post-modernism, which allows for and includes a variety of perspectives, admits the biological element for some mental illness issues, but also allows for and honors the subjective experience of the client, as well as the interpersonal relationship between the client and the therapist. Many of the therapies based in this perspective (narrative, dialogical, client-centered, and so on) honor the subjective experience of the client and the interpersonal connection between the client and the therapist.

I agree with this stance, but I want to go even a step further in my position.

I abhor the labels in the DSM and the whole objective model of treatment - people are not their disorders. No one is a borderline, or a narcissist (one of the most misused words in our culture), nor are they depressed, anxious, or phobic. We are more than our illnesses - we would never call someone fighting malignant tumor a cancer. Nor would we refer to someone with a fracture femur as broken. So why do we refer to people with mental illness as their illness? [One exception is diabetes, where people identify and are identified as diabetic, partially, I think, because it is a disease that is avoidable (with the exception of type I).]

People pay lip service to this truth, but it gets lost in the working of the medical model approach to ilness. This is dehumanizing at best.

Many of the models of therapy I am most drawn to take a very non-pathologizing view of the individual and the illness. None better reflects that perspective than the Internal Family Systems Therapy (1995) model developed by Richard Schwartz. Here is how he sees it:

To experience the Self, there’s no shortcut around our inner barbarians – those unwelcome parts of ourselves, such as hatred, rage, suicidal despair, fear, addictive need (for drugs, food, sex), racism and other prejudice, greed, as well as the somewhat less heinous feelings of ennui, guilt, depression, anxiety, self-righteousness, and self-loathing. The lesson I’ve repeatedly learned over the years of practice is that we must learn to listen to and ultimately embrace these unwelcome parts. If we can do that, rather than trying to exile them, they transform. And, though it seems counter-intuitive, there’s great relief for therapists in the process of helping clients befriend rather than berate their inner tormentors. I’ve discovered, after painful trial and much error at my clients’ expense, that treating their symptoms and difficulties like varieties of emotional garbage to be eliminated from their systems simply doesn’t work well. Often, the more I’ve joined clients in trying to get rid of their destructive rage and suicidal impulses, the more powerful and resistant these feelings have grown – though they’ve sometimes gone underground to surface at another time, in another way.

In contrast, these same destructive or shameful parts responded far more positively and became less troublesome, when I began treating them as if they had a life of their own, as if they were in effect, real personalities in themselves, with a point of view and a reason for acting as they did. Only when I could approach them in a spirit of humility and a friendly desire to understand them could I begin to understand why they were causing my clients so much trouble. I discovered that if I can help people approach their own worst, most hated feelings and desires with open minds and hearts, these retrograde emotions will be found not only to make sense and have a legitimate purpose in the person’s psychological economy, but also, quite spontaneously, to become more benign.

I’ve seen this happen over and over again. As I help clients begin inner dialogues with the parts of themselves holding horrible, antisocial feelings and get to know why these internal selves express such fury or self-defeating violence, these parts calm down, grow softer, and even show that they also contain something of value. I’ve found, during this work, that there are no purely “bad” aspects of any person. Even the worst impulses and feelings – the urge to drink, the compulsion to cut oneself, the paranoid suspicions, the murderous fantasies – spring from parts of a person that themselves have a story to tell and the capacity to become something positive and helpful to the client’s life. The point of therapy isn’t to get rid of anything, but to help it transform. (2008, paragraphs 29-31)

This is the vision I want to take into practice as a therapist. This is the hope and healing I want to be able to offer my clients.

In part two, I will examine some of the issues with DSM diagnoses, which are not as reliable as people would like to believe.

Go to part two.

References:

Hansen, J. (2005). Postmodernism and Humanism: A Proposed Integration of Perspectives That Value Human Meaning Systems. Journal of Humanistic Counseling, Education & Development, 44(1), 3-15. Retrieved from Education Research Complete database.

Schwartz, R. (1995). Internal family systems therapy. New York: Guilford Press.

Schwartz, R. (2008) The Larger Self. Center for Self-Leadership, http://www.selfleadership.org/about/theLargerSelf.

Wampold, B., Hyun-nie, A., & Coleman, H. (2001). Medical Model as Metaphor: Old Habits Die Hard. Journal of Counseling Psychology, 48(3), 268. Retrieved from Academic Search Complete database.

Tags: Psychology, therapy, medicine, mind, medical model, context model, post-modernism, humanist therapy, Richard Schwartz, Subjective Experience, Internal Family Systems Therapy, DSM, Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association