3. Implications for therapeutic practice

From the outset, it is important to acknowledge some of the tensions that exist between the biomedical model currently dominating healthcare and the psychological paradigm adopted by therapists working with those in emotional distress.

As stated in the introduction, the growing medicalisation of distress in society reflects the widespread assumption that mental illness exists in the same way as physical illness and can be diagnosed and treated like flu or a virus. The idea that most kinds of psychological distress may be understood as the symptom of an underlying disease process or ‘chemical imbalance’, to be treated with prescribed psychiatric drugs, reflects a disease-centred model of practice in line with the biomedical approach to science, policy and practice currently dominating mental health services. However, it should be recognised that there are exceptions to this and that some diagnostic categories such as ‘personality disorder’ and ‘post-traumatic stress disorder’ will reflect responses to trauma or developmental issues rather than any assumed underlying disease process.

Of course, the prevalence of the biomedical approach does not exclude mental health services advocating better access to psychological therapies, particularly where therapy is assumed to be complementary to the use of psychiatric drugs. However, the majority of psychological therapists hold a framework for understanding emotional pain that conflicts with the prevailing disease-centred model of practice. Therapists from all professional backgrounds draw from paradigms that predominantly emphasise the psychological and psychosocial aspects of experience thought to underpin mental suffering, rather than on models that emphasise notions of deficit, symptomatology and medicalisation. Indeed, there has been a growing professional movement in the psychotherapeutic field away from a disease-centred model of practice and the use of prescribed psychiatric drugs. For example, there have been recent attempts to offer alternative ways of understanding mental distress (e.g. the Power Threat Meaning Framework¹). The BPS², too, has stated that ‘clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses… which do not reflect illnesses so much as normal individual variation… This misses the relational context of problems and the undeniable social causation of many such problems’ (p2). Underpinning these and other critiques lies the call for a ‘paradigm shift’ within mainstream psychiatry³ that takes account of the complex interplay of social, cultural, economic and psychological forces that are thought to result in much mental distress today.

However, the continuing cultural dominance of the biomedical approach means that it is likely to shape the attitudes, beliefs and values of therapists from all psychotherapeutic backgrounds and to pervade their practice in both explicit and implicit ways. Whilst Elkins (2009)⁴ suggests that the ‘medical model’ in the psychological therapies is essentially an analogy: ‘a descriptive schema borrowed from the practice of medicine and superimposed on the practice of psychotherapy’ (pp67–71), it is clear that different psychotherapeutic disciplines will understand, take up and respond to it in different ways. For example, some have argued that the field of applied psychology is significantly permeated by a biomedical perspective⁵, whilst others prefer to adopt a critical position in relation to notions of ‘pathology’, ‘illness’ and ‘disorder’.⁶ Within the different theoretical traditions too there is considerable variation in philosophical stance and attitude, reflective of different tensions and discourses within the field. Although therapists principally draw from psychological paradigms that differ from the biomedical approach, it is clear some psychotherapeutic frameworks actively recruit the ‘medical model’ by analogy, borrowing language and classificatory systems that give rise to an apparent alignment in practice.

In the face of these and other complex debates and professional differences, therapists using this guidance will need to consider carefully the degree to which they think a biomedical perspective currently influences their practice. Clearly there will be considerable differences here, depending on each therapist’s professional background, professional training, work context and personal preference. For example, there will be some therapists whose work setting privileges a biomedical framework, requiring them to use the language of psychiatric classification and to incorporate standardised assessments and manualised ‘clinical’ techniques into their therapeutic work. By contrast, others may work in settings that allow them to reject the language of medicalisation and symptomatology entirely and to focus instead on the therapeutic relationship and client self-determination. There are many possible configurations here and many possible variations in the extent to which therapists feel they can or must adhere to a biomedical perspective. For this reason, it is important for therapists to reflect on the personal and professional ways in which they relate to and engage with the ‘medical model’, as this is likely to influence significantly, if implicitly, their attitude towards people who are taking prescribed drugs, prescribers and the drugs themselves.

How do the main modalities relate to the medical model?

The authority of the medical model means that many therapists consider issues of prescribed psychiatric drugs to be the exclusive remit of doctors, psychiatrists and neurologists. However, the specialist training of therapists means they all subscribe to a conceptual system of mental distress that is primarily psychological rather than biomedical. They are therefore well placed to help their clients in ways that are additional to and distinctive from medication.

The next section offers a brief summary of how the three main therapeutic modalities traditionally position themselves in relation to the biomedical model of practice. It is clear that such a summary cannot be exhaustive, nor can it do justice to the variations that exist within and between theoretical orientations. Rather, it aims to offer a starting-point of reference for therapists who wish to locate their practice on the continuum discussed above.

3.1.1 Humanistic models of training and practice, including person-centred, experiential, existential and Gestalt approaches are concerned with notions of subjective experience, personal meaning and the development of potential, with therapy seen as inherently relational. The client’s potential for actualisation, uniqueness, autonomy and authenticity contrasts with the medical model’s focus on ‘illness’, ‘disorder’ ‘psychopathology’ and its use of standardised assessments, ‘objective’ outcome measures and the specificity of ‘clinical’ techniques. Psychological distress is considered to be the result of thwarted actualisation due to sub-optimal social/environmental conditions. Humanistic therapists seek to develop a therapeutic relationship characterised by authenticity and transparency rather than by hidden agendas or ‘expert’ positions, instead emphasising emotional engagement, collaborative work, responsibility for the self and the client’s freedom to self-direct. The fundamental call for humanistic therapists to ‘be with’ rather than ‘do to’ the client means they do not direct or actively encourage clients to make changes in their lives. Instead, they prefer to support clients in taking responsibility for themselves through a spirit of collaborative, empathic enquiry, exploration and acceptance.

3.1.2 Psychodynamic models of training and practice range from long-term psychoanalytic and relational psychotherapy through to shorter term models such as brief, psychodynamically oriented counselling and Dynamic Interpersonal Therapy (DIT). Whilst there are important differences between the various psychoanalytic schools of thought, all approaches emphasise the centrality of unconscious mechanisms and processes in relationships and tend to focus on the emergence of transferential and countertransferential material within therapy. The client is seen as ‘divided’, and therapeutic work aims to bring unconscious material to the surface, allowing it to be experienced safely and to become available for thought and processing with the therapist. Psychodynamic therapists, like humanistic therapists, tend to reject the ‘expert’ position characteristic of biomedical approaches, although some schools of psychoanalytic thought adhere to diagnostic classifications that are closely linked with medical psychiatry. Most therapists prefer to adopt a ‘neutral’ stance that allows the client to project on to the therapist feelings and fantasies deriving from his or her early relationships. The traditional injunction to keep the therapeutic space free for transferential work means that psychodynamic therapists may vary in their willingness to offer direction or advice to clients, and they are likely to consider carefully the unconscious implications of the therapist’s contact with prescribers or other people involved in the client’s care.

3.1.3 Cognitive-behavioural models of training and practice cover a number of approaches including Beckian cognitive-behavioural therapy (CBT), dialectical behaviour therapy (DBT) and rational-emotive behaviour therapy (REBT) as well as those that would be considered under the heading of ‘third wave’ approaches such as mindfulness-based CBT (MBCBT), compassion-focused therapy (CFT) and acceptance and commitment therapy (ACT). These are all structured, focused approaches emphasising the use of specific techniques and strategies to promote measurable change. Whilst there is some debate about the extent to which its proponents align themselves with the ‘expert’ position characteristic of the biomedical model, the therapist stance endorsed by most CBT practitioners is collaborative, seeking to develop a helpful therapeutic alliance, a shared formulation and therapy goals. Psychoeducation and self-monitoring may be used to help clients identify unhelpful patterns of thought, behaviour and action that are seen as maintaining their current psychological difficulties. This may be followed by therapeutic work aimed at addressing underlying issues such as the impact of trauma. CBT is a common approach within public sector services, where therapists routinely work within a multi-disciplinary team.

In concluding this section, it can be seen that the different perspectives outlined above all carry very different assumptions about the nature of emotional suffering. The biomedical paradigm sees much of mental distress as an unproductive ‘disorder’ or ‘symptom’ that is best removed with the help of prescription psychiatric drugs. Within the humanistic and psychodynamic traditions, however, suffering is conceptualised as having potential value and purpose rather than something that is merely ‘pathological’ or otherwise useless. Therapists from these traditions tend to see emotional distress as a signal that there is something wrong in the individual’s life: suffering represents an opportunity for change and transformation if it can be explored and managed productively. By contrast, in approaches such as cognitive-behavioural therapy, the main focus is on removing symptoms of distress by altering patterns of cognition, emotion and behaviour that are understood to maintain emotional suffering.