Transcript Rediscovering our radical roots Person

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 …
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.
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
• 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
• 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?
• The tendency of things to become
commodities … leading to …
• The medicalisation of life and the selfpromoting complicity of therapists in
this confidence trick … leading to …
• Iatrogenesis: clinical, social, cultural
The tendency of things to
become commodities
• Commodities to satisfy physical needs
• Commodities to satisfy psychological
needs
• Psychological needs themselves become
commodities to be consumed
• Essentialisation of distress
• Essentialisation of treatments
The Medicalisation of Life
• A special form of ‘commodification’
• Medicalisation of everyday life:
– Attention Deficit Hyperactivity
Disorder (ADHD)
– Social Anxiety Disorder (SAD)
– Generalised Anxiety Disorder
– Panic Disorder
– Post Traumatic Stress Disorder
– Premenstrual Dysphoric Disorder
– Compulsive Buying Disorder
Life isn’t
Perfect
Disorder
The
Psychological
Health
Industry
Ivan Illich — Iatrogenesis
• 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
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
• ‘Homosexuality’
• Menstruation, Pregnancy,
Premenstrual Dysphoric Disorder
Borderline Personality Disorder,
Masochistic personality Disorder.
(‘Being a woman’)
• Learning disability
CURED!
CURED!
(Well, almost!)
CURED!
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)
Person-Centred:
Growth
Medical Model:
Health
Metaphors for
distress
Self-defined, described
experience of distress
Actualisation
Diversity
Changeable
Sick, ill, damage
Imbalance
Exogenous Treatment
Disability
Immutable
Vocabulary
Potentiality
Deficiency
Authority (in
therapy)
Client
Therapist
Privileged
professional
discourse
None above client’s
experience
(In order of power)
Psychiatrist
Clinical psychologist
Psychiatric nurse/
Social worker
Person-Centred: Growth
Medical Model: Health
Power relations Acknowledged, informed
between client by dynamics of client as
and practitioner self-directing healer
Reinforce personal power
of client
Informed by need for
treatment
compliance:
predisposed to
abuse.
Reinforce low
structural and
personal power of
patient.
Nature and
process of
intervention
Reductionistic
Diagnosis
Instructional
Correctional
Reinforce deficiency
model
Prescription
Holistic
Emphasises personal
power of client
Empathy
Accompaniment
Description
Person-Centred: Growth
Medical Model: Health
Nature of
distressed
person
Whole person
Client/subject
Director of healing
process
Represented by
experience
Compartmentalised
Patient/object
Disenfranchised
Represented by
symptoms
Nature of
therapist
Companion
Expert; Physician
Technician
Privileged
frame of
reference
Internal
External
Change
process
Self directed
Growth
Actualisation
Development
Expert directed
Repair
Reprogramming
Cure
Aim of
intervention
Person-Centred: Growth
Medical Model: Health
Fulfilment of potential
Recover previous
state of being (health)
Return to
homoeostatic balance
Resources
In a rich facilitative growthorientated 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
• European Network of (ex-) Users and
Survivors of Psychiatry (ENUSP)
www.enusp.org
• 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 selfesteem and sense of self-worth.
Peter Beresford
Medication
• 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)
• SoCRATES (Study of Cognitive
Realignment Therapy in Early
Schizophrenia)
– People with first and second episode
psychosis — comparing treatment as usual
(TAU), cognitive realignment therapy and
‘supportive counselling’ (client-centred
therapy) in three centres.
• Both therapies were significantly better than TAU,
and there was no difference between cognitive and
supportive counselling.
• All differences between centres and treatment
groups due to therapeutic alliance.
• Treatments
Soteria
– … 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
– Mosher (1999)
– 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’
– 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 …
• (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 — we get to understand each
other better; it is more difficult to divide and set us
against each other — we have more solidarity, are
less isolated and we learn from each other
Things to do …
• We will become less marginalised
• We will become more responsive to
clients’ needs if we support and
facilitate the service user movement
• 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 BandAids’