A Medical Model Conundrum
I wanted to include a description of the medical model in this collection of counseling theories articles because many psychotherapists use it in conjunction with their practice. To be an informed consumer of psychotherapy it's important to understand the implications of its usage.
Whenever a therapist begins the treatment with an assessment to determine a diagnosis they are using a medical model. Taking the medical model to its extreme, the diagnosis will determine the treatment of choice and--more often than not--the use of medications.
"The medical model could best be summarized by the following:
Diagnosis + Prescriptive treatment = Symptom Amelioration."1
In other words, under the medical model, you go to your therapist who determines a diagnosis (PTSD, OCD etc) and then you receive a "prescriptive" treatment for your "illness".
It assumes there are specific treatments for different problems. It does not take in consideration the nature of the relationship between the client and the therapist.
The conundrum of diagnostic labels
Labelling a condition can be helpful. Knowing that one's problems are not unusual, that medical science recognizes one's symptoms, and that "it's not all in your head" can be an enormous relief.
However, an inherent danger with labelling is that we can become what we are labelled with. "I'm OCD" versus "When I'm anxious, I notice I have to check the door several times before I leave home."
The medical model and psychotherapy
The medical model doesn't always suit the arena of psychotherapy. For one, it depends on the how a specific diagnosis is determined.
Having a "diagnosis" isn't like having the flu. Each flu has an identified virus. There's no blood test that determines the presence of a paranoid personality disorder for instance. And, you can't measure the level of anxiety like you measure glucose levels in a diabetic.
With the mumps, you have them or you don't. Similary, with cancer, there's no such thing as "oh, you just have a little bit of cancer." You have cancer or you don't.
Yet, I can feel anxious about speaking in public but, when is my fear called "anxiety"? There's no definitive line that says I now have an anxiety disorder.
Another problem with diagnostic labels.
The determination of what is normal and what is abnormal or "pathological" is vastly different depending on factors such as culture and social norms.
In simple language, how does one distinguish between "pathology" and a normal reaction to life's challenges? For example, when does grief over the loss of a child become clinical depression? Or in France, where it's not uncommon to have a glass of wine with each meal, when does social drinking become alcoholism?
Yet another problem with diagnostic labels.
What makes matters even worse is that experienced clinicians do not make consistent diagnostic assessments.2 One problem is that the interview (to determine a diagnosis) depends to a great degree upon the interviewer-client relationship. (I have spent numerous sessions helping many clients recover from insurance-required diagnostic interviews!)
Managed-care adminstrators demand that therapists arrive quickly at a diagnosis and then proceed upon a course of brief, focused therapy that matches that particlular diagnosis.
Sounds good. Sounds logical and efficient. But it has precious little to do with reality.
Irving Yalom, 2002,
The Gift of Therapy
Several factors influence the outcome of the diagnostic interview:
If the client was uncomfortable with the interviewer, would he or she be as disclosing as needed?
Did the interviewer flood the client by asking triggering questions and thereby inadvertently distort the responses made? For instance, would the client report more details on those things he or she felt were less important and underreport other even more relevant problems?
More generally, consider what questions were asked versus what questions weren't asked. ("Oops, did I forget to mention I have a problem with crack cocaine?")
Were the responses from the interviewee influenced by outside forces? For example, would the outcome of the interview determine the client's entitlement to health benefits?
You can imagine how these factors might affect what was talked about.
My Personal Musings
Most people are really looking for ways to make sense of their problems, bringing all the "non-sense" into states of understanding and meaning-making. (And that's what you hear from folks..."Stuff just doesn't make sense.")
Diagnoses may be helpful...but at the end of the day, you--not your labelled condition--are the one in therapy. Your diagnosis isn't something that has to be gotten "out of you".
Psychotherapy is the process for healing and becoming all you can be. It's about dealing with your stuff and facing your fears. This is where my friend Dr. Carole says, "the rubber hits the road".
Alternatives to diagnostic labelling?
There are few alternatives to diagnostic labelling. And because most health insurance plans require a diagnosis, we probably won't see any large scale changes in the near future.
Fortunately, there are new ways of understanding the nature of mental health being proposed by leaders in the field. One of my favourites is the one metaphorically offered by psychiatrist and author, Dr. Daniel Siegel:
Imagine a flowing river, with rigidity on one side, and on the other bank, chaos. Emotional problems or mental health problems can be classified as being on one side or the other. Occasionally, there is very little to the flow of the river and the banks meet in the middle, causing extreme distress for the individual.
Dr. Siegel as you may know, is the author of the popular books, The Developing Mind and Parenting from the Inside Out. He has recently been on tour with his latest book, The Mindful Brain.
Dr. Siegel's experience and study of mindfulness inspired this descriptive metaphor. He says that his clients' symptoms could typically be seen to fall under rigidity (e.g. obsessive, compulsive, depressive symptoms) or chaos (e.g. mania, anxiety) or moving between both (e.g. bipolar).
His metaphor certainly captures the clinical picture of what we see in our practices in the field of somatic therapy.
In future, I will hopefully be able to elaborate on this emerging subject. Here's a brief introduction:
Reviewed by: Dr. Carole Gaato
1 Sparks, Jacqueline A., Duncan, Barry L., and Miller, Scott D. (2006) PDF format Integrating Psychotherapy and Pharmacotherapy: Myths and the Missing Link.
2 There have been numerous studies reflecting this finding. One large study was mentioned in the above article: Williams, J., Gibbon, M., First, M., Spitzer, R., Davies, M., Borus, J., Howes, M., Kane, J., Pope, H., Rounsaville, B., & Wittchen, H. (1992). The structured clinical interview for DSM-III-R (SCID) II: Multi-site test-re-test reliability. Archives of General Psychiatry, 49, 630-636.
Kendell, R., Jablensky, A. (2003) Distinguishing Between the Validity and Utility of Psychiatric Diagnoses. Am J Psychiatry 160:4-12 [Electronic Version]
"At present there is little evidence that most contemporary psychiatric diagnoses are valid, because they are still defined by syndromes that have not been demonstrated to have natural boundaries."
Siegel, Daniel J., (2007) "Psychotherapy from the Inside Out: The Brain of the Mindful Therapist. Nov. 8-9, 2007, The Justice Institute, Vancouver, BC.
Therapy Lingo Article?
Antonio (Denver, USA)I am a student and I feel that cognitive therapy works in the here and now but I also feel that the past does help in the here and now. That probably sounds strange. But I've found that w/clients that have had trauma in the past it does come back to haunt with some present problems that aggravate it more and make the present even more intense. And I also feel that medication does not always help--its antagonistic.