The radical roots of counselling opposition to medical metaphors and the manufacture of distress

WARNING Unbalanced Presentation

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It is invalid (as any DSM-IV diagnostic category) Evidence is carefully selected and partial Irresponsible Unscientific Example of liberal counter-culture Lacking academic rigour … just like articles and presentations defending the medical model …

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Radical Roots

Rogers’ general approach was radical because it started in entirely the ‘wrong’ place — it started with the client and the primacy of understanding the client’s process.

Rogers’ particular approach was radical because he thought that it was unhelpful to stereotype and categorise the client’s experience: he was set against diagnosis because it was therapeutically damaging.

He thought that it was unhelpful to understand the client’s process as one of ‘sickness’.

He thought it was unhelpful to play the expert, because he believed that it was the client who was the expert in their distress and their healing.

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Radical Roots

It is helpful to be humble and authentic, to listen, understand and accept rather than judge, interpret and categorise. Rogers disagreed with the guilt-ridden edifice of psychoanalysis: people are not ‘bad’. As adult human beings we do not have to be protected from ourselves.

Rogers disagreed with the narrow vision of learning theory: humans are not limited to change by learning.

Human beings grow. We live by growing and are constantly changing and adapting by growing. Clients grow in multi-dimensional ways which are frequently mysterious to the therapist.

Rogers’ Radical Activities

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Recording of therapy sessions Arguing that psychotherapy can be done by ‘lay’ (non-medically qualified) people Educating of therapists Operationalisation of relationships Researching therapy Developing new methodologies Applying research to practice

The Marginalisation of PCT

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Under-represented in psychiatry and clinical psychology Failed to establish itself in the mainstream clinical psychology or psychiatry curriculum. Not simply because of lack of research evidence, but that hasn’t helped Neoliberalism, medicalisation and a quick-fix culture

If demedicalisation is the solution, what is the problem?

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The tendency of things to become commodities … leading to … The medicalisation of life and the self promoting complicity of therapists in this confidence trick … leading to … Iatrogenesis: clinical, social, cultural

The tendency of things to become commodities

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Commodities to satisfy physical needs

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Commodities to satisfy psychological needs

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Psychological needs themselves become commodities to be consumed Essentialisation of distress Essentialisation of treatments

The Medicalisation of Life

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A special form of ‘commodification’ Medicalisation of everyday life:

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Attention Deficit Hyperactivity Disorder (ADHD)

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Social Anxiety Disorder (SAD) Generalised Anxiety Disorder

Life isn’t Perfect Disorder –

Panic Disorder

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Post Traumatic Stress Disorder

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Premenstrual Dysphoric Disorder

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Compulsive Buying Disorder

The Psychological Health Industry

Ivan Illich — Iatrogenesis

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Clinical iatrogenesis is the harm done to patients by medical treatments Social iatrogenesis is the damage done by the unnecessary medicalisation of life (which he called polyphragmasia), and Cultural iatrogenesis is the destruction of culturally traditional ways of dealing with pain, illness and death

The Medicalisation of Distress

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Reproduces cultural milieus that are: Technological Objective Atomised and reductionistic ‘Treatment’ oriented, dosage oriented Correctional: oriented towards repair or reprogramming Normative and prescriptive Seeing patients (and therefore people) as objects Commodified Consumerised

‘polyphragmasia’

the unnecessary medicalisation of life (Illich, 1976)

Few families have no contact with someone who has been through the mental health system. The increasing medicalising of human distress, ably abetted by drug company propaganda, knew no bounds in the latter part of the twentieth century. To market tranquillizers and antidepressants, what used to be called worrying and feeling sad are now ‘anxiety disorders’ and ‘depressive illnesses’. Millions of our children are now on amphetamines to treat their difficulty concentrating and sitting still. Millions of older people sit tranquillized in ‘homes’. Tens of thousands are still having electric shocks applied to their brains to cause convulsions in the name of ‘psychiatric treatment’.

(Read, Mosher and Bentall, Models of Madness, 2004, p. 5)

Social Iatrogenesis

The control of diversity

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‘Homosexuality’ CURED!

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Menstruation, Pregnancy, Premenstrual Dysphoric Disorder Borderline Personality Disorder, Masochistic personality Disorder. (‘Being a woman’) CURED!

(Well, almost!) CURED!

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Learning disability

Cultural Iatrogenesis

Damage done by the medicalisation of traditions and rituals — cultural ways of dealing with

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Birth and infant development Childhood, socialization and learning Adolescence and socialization Relationship formation, maintenance and breakdown Family relationships and problems Emotional pain Death

PCT and the medical model

We regard the medical model as an extremely inappropriate model for dealing with psychological disturbances. The model that makes more sense is a growth model or a developmental model. In other words we see people as having a potential for growth and development, and that that can be released under the right psychological climate. We don’t see them as sick and needing a diagnosis, prescription and a cure. And that is a very fundamental difference with a good many implications.

(Rogers, 1976, BBC Radio Broadcast)

‘Some new challenges to the helping professions’

… [the challenge] to broaden the scope of clinical and other psychologists and perhaps finally the [challenge] to help psychologists become true change agents, not simply remedial appliers of psychic Band-Aids (Rogers, 1980, p. 236. A Way of Being)

Metaphors for distress Vocabulary Authority (in therapy) Privileged professional discourse Person-Centred: Growth Self-defined, described experience of distress Actualisation Diversity Changeable Potentiality Client None above client’s experience Medical Model: Health Sick, ill, damage Imbalance Exogenous Treatment Disability Immutable Deficiency Therapist (In order of power) Psychiatrist Clinical psychologist Psychiatric nurse/ Social worker

Person-Centred: Growth Medical Model: Health Power relations between client and practitioner Acknowledged, informed by dynamics of client as self-directing healer Reinforce personal power of client Nature and process of intervention Holistic Emphasises personal power of client Empathy Accompaniment Description Informed by need for treatment compliance: predisposed to abuse. Reinforce low structural and personal power of patient. Reductionistic Diagnosis Instructional Correctional Reinforce deficiency model Prescription

Nature of distressed person Nature of therapist Privileged frame of reference Change process Person-Centred: Growth Whole person Client/subject Director of healing process Represented by experience Companion Internal Self directed Growth Actualisation Development Medical Model: Health Compartmentalised Patient/object Disenfranchised Represented by symptoms Expert; Physician Technician External Expert directed Repair Reprogramming Cure

Aim of intervention Resources Person-Centred: Growth Fulfilment of potential Medical Model: Health Recover previous state of being (health) Return to homoeostatic balance In a rich facilitative growth orientated milieu the client is able to make use of all possible resources, including the whole person of client Expertise of therapist Psychopharmacology Psychotechnology [Note client’s being is frequently seen as a negative resource, an obstacle]

Demedicalising distress:

Hello … ?

Is there anyone else here?

Service user movement

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European Network of (ex-) Users and Survivors of Psychiatry (ENUSP) www.enusp.org

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Hearing Voices Network (HVN) www.hearing-voices.org

Mad Pride www.madpride.org.uk

Mind Freedom International www.mindfreedom.org

… a system … [that has] … underplayed the social factors that have an important bearing on service users’ lives. They feel a more social understanding of them and their experience would be much preferable … Survivors have long highlighted the broader responses that are helpful for enabling them to break out of the psychiatric ghetto. These include the support of social relationships, loving relationships, meaningful activity and employment, learning opportunities, exercise, recreation, cultural involvement and the development of real self esteem and sense of self-worth.

Peter Beresford

Medication

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Disease-centred model of drug action — psychiatric distress is an ‘illness’ of neurochemical origin which is ‘cured’ by rebalancing the neurochemistry of the brain with drugs which mimic or block neurotransmitters drug-centred model — in which drug action is understood not in terms of cure, but in terms of creating a state of intoxication, the varied effects of which may, for some people, ameliorate their symptoms of distress

Anti-medicalisation does not equal anti-medication (the drugs do work, but how?)

Madness Explained

(a psychological approach to the study of mental distress)

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SoCRATES (Study of Cognitive Realignment Therapy in Early Schizophrenia)

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People with first and second episode psychosis — comparing treatment as usual (TAU), cognitive realignment therapy and ‘supportive counselling’ (client-centred therapy) in three centres.

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Both therapies were significantly better than TAU, and there was no difference between cognitive and supportive counselling.

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All differences between centres and treatment groups due to therapeutic alliance.

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Soteria

Treatments

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… the 24 hour-a-day application of interpersonal phenomenologic interventions by a non-professional staff, usually without neuroleptic drug treatment … the development of a non-intrusive, non-controlling but actively empathic relationship … ‘being with’, ‘standing by attentively’ (Mosher, 1999: 37–8)

Results

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Mosher (1999)

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Calton et al (2008) — residents at Soteria did at least as well as patients who were treated with standard hospital treatment on measurements of ‘symptoms’ and ‘outcomes’

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Additional benefits for Soteria residents. For example, because they were much less likely to be treated with neuroleptics, they were not subject to side effects, withdrawal effects and drug dependency

Things to do …

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(PC) Counselling has a radical tradition In its basic philosophy and theory it is against the medicalisation of distress which favours the medical profession, or any other sort of commodification by the psychological health industry Those person-centred practitioners who are drawn to the radical nature of the approach, take heart. Wherever you think it is appropriate, have the courage to stand up and present your critiques You will not be alone. Work with different groups with the same values against each other — we get to understand each other better; it is more difficult to divide and set us — we have more solidarity, are less isolated and we learn from each other

Things to do …

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We will become less marginalised We will become more responsive to clients’ needs if we support and facilitate the service user movement

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We must get out of our consulting rooms and discover how to ‘broaden the scope of our work’ and become ‘true change agents, not simply remedial appliers of psychic Band Aids’