Michael Soth - Articles & Papers:

Embracing the paradigm clash between the ‘medical model’ and counselling A Response To James T. Hansen

Soth, M. (2004) Embracing the paradigm clash between the ‘medical model’ and counselling - A Response to James T. Hansen's article ‘Should counselling be considered a healthcare profession ?’, therapy today, Jan. 2008

I was both delighted and dismayed to read James T. Hansen's article "Should counselling be considered a healthcare profession ?" in the October issue of Therapy Today (Vol. 18 No 8).

I was delighted to read his comprehensive questioning and logical deconstruction of the increasing medicalisation and the creeping domination of 'medical model' thinking, in society in general, but specifically in the training, thinking and practice of counsellors. To use postmodernism to take this deconstruction beyond the practical and conscious level and down into the less obvious assumptions implicit in language is in my view a precious and necessary contribution to the debate. I agree with him that counselling cannot whole-heartedly subscribe to the 'medical model' without losing its essence.

These are themes I also feel passionate about which are essential in shaping the future of our profession. Naming aspects of the implicit paradigm clash at stake (subjectivity versus symptomatology, actualisation versus deficiency, relationship versus techniques) and the potentially devastating consequences for the service we offer (and for the psyche- of our clients, not to mention our own) constitutes a valuable clarification of the very real threat which our principles are under. As a practitioner long interested and inspired by holism, I found his challenge of the devious logic by which holism is used to break down the specialisation between medical practitioners for the body on the one hand and psychological practitioners for the mind on the other in order to appropriate and subsume the whole bodymind under the aegis of psychiatry and healthcare eloquent and highly relevant.

And yet, and yet ... I was equally dismayed: having previously addressed the role and function of the 'medical model' within counselling and psychotherapy myself (Soth 1997, 1998, 2005a, 2006b), I found Hansen's contribution - and the high profile it was given in Therapy Today – also a step backwards.

My own suggestion has been for us to deal with the dangers constituted by an exclusive 'medical model' stance by recognising it as an inevitable psychological - rather than purely ideological part of the process. I suggest to deal with by NOT polarising against it, but by embracing it. At the FHCP conference in May 2006, for example, I offered a workshop on "Embracing the paradigm clash between the 'medical model' and counselling".

What does that mean ?

The first step is, of course, to recognise and acknowledge that there is a clash of paradigms, with very real political and economical implications. But it is a clash that also has a psychological dimension and is reflected in some way in each and every client AND in each of us as practitioners. On the whole, as I have suggested, our profession is torn and confused between the paradigms, and I meet that confusion in myself, in colleagues and in supervision. Whilst many practitioners enter the consulting room with quite clear principles of relational engagement, attention to subjectivity and self-actualisation, they often leave with confusion and conflict, having to recognise that they did  get drawn into quasi-medical responses and interactions.

Why does that happen ?

In each particular instance when it does  happen we can investigate this – depending on our theoretical orientation – as collusion, as a failure to empathise or as transferential pressures. The point is: the 'medical model' does  enter our practice through our clients' pre- and mis-conceptions of the counselling process, and we have to relate to that fact. Inasmuch as many people have internalised the very ideas which Hansen challenges, if we want to relate to our clients, we need to also relate to the 'medical model' in them. The 'medical model' does not just reside in psychiatrists who have a vested interest in medicalising emotional and social distress. It resides in varying degrees in each of us in an underlying condition of self-objectification which – in Heidegger's phrase – we 'find ourselves thrown into'. This self-objectification is, in my view, an emotionally and psychologically-rooted existential condition that cannot be dealt with by insight or philosophical exhortation. It is a condition that does rather open the doors to external objectification by 'gods in white coats', and we cannot simply blame the medical profession for this who find themselves struggling with this projection, too (as well as benefitting from it). I have speculated elsewhere on the developmental roots of our inclination to project omnipotence into the medical profession, and I won't try to expand on it here (Soth 1998, 2006a). The point at which we resort to 'medical model' interventions (and even taking a pill can be - such an intervention even if not explicitly administered by anyone but ourselves) is largely defined by what degree of pain – physical, emotional, existential – we find unbearable. That point or pain threshold is not simply biologically given; it is psychologically and socially constructed and amenable to loving 'interactive regulation' (as the neuroscientists call it).

This is a delicate time in terms of situating the counselling profession and that is of course why Hansen's contribution is timely and important. But to state that "the counselling profession is fundamentally rooted in humanistic ideologies that emphasise subjectivity, self-actualisation and the healing potential of the counselling relationship" is in my view at best a partial claim. Don't get me wrong – I do subscribe to these humanistic values and I do think they are essential. But if we deconstruct the 'truth claims' of statements by others (e.g. psychiatrists, scientists), we lay ourselves open to the same charge. I don't think it is fair to subsume all counselling under that quoted statement. On the contrary: it sounds to me that it flies in the face of long-standing polarisations within our profession, and betrays a humanistically-hegemonial desire to subsume everybody under his  paradigm. Many counsellors from outside the humanistic tradition would at best go along if not take issue with that statement. Who – they would be entitled to ask – is James Hansen to postulate what ideology I am fundamentally rooted in ?

It seems to me that these claims constitute a partial, biased position which ignores the established polarisations within the field, and Foucault would rightly jump up and down and point at the power implications of anybody overriding the apparent self-stated convictions of a good proportion of counsellors under a unifying banner carried by James Hansen. Although my roots are indeed in the humanistic tradition and I will fight tooth and nail to defend them, I have to say: "no, not everybody agrees to a fundamentally humanistic ideology".

In my view the 'medical model' has been ambiguously pervasive since the origins of our profession in the late 19th century - what I have somewhat tongue-in-cheek called the 'birth trauma' of the profession in the dualistic, positivist zeitgeist  of the late 19 century (Soth 2005b). Freud took the 'medical model' nature of psychoanalysis for granted and situated it as 'treatment', although he remained profoundly ambivalent about it throughout his professional life. I would say that he was as ambiguously conflicted between subscribing to it and refuting it as the average counsellor is today. My reading of the historical development is that behaviourism was a reaction against psychoanalysis and the humanistic revolution was a protest against both of them.

My argument would be that the humanistic reaction – as necessary and precious as it was (perish the thought where we'd be without it!) – has remained to some extent precisely that: reactive. As we know from any psychological process: a reactive protest often does not lead to 'working-through'. However valid the protest may be in and of itself, it can rationalise an emotional stuckness in what can become as dogmatic a position as the one we're protesting against . This is my basic misgiving about the article: in one definitional sleight of hand Hansen places counselling into what I have called an anti-'medical model' position. I strongly believe that "re-seating" counselling – to use Hansen's phrase – in such a position will in the end be to the detriment of our profession.

Why do I believe a humanistically-inspired anti-'medical model' position to be detrimental ?

By perpetuating the polarisation and paradigm clash (which on a philosophical level is valid and true enough) we get stuck on the level of beliefs and ideology rather than bringing psychological awareness to it. As counsellors we know  how to work with splits and polarisations. We know  how to work with the emotional underbelly of belief, ideology and rationalisation. We know that insight and philosophical exhortation are not enough to change outlook and behaviour. Paradigm clashes are also an emotional issue. It's not enough to counter ideology with a counter-ideology.

For us to stay in the anti-'medical model' position deprives other helping and medical professions of our psychological and relational awareness. But more importantly, it also deprives our  profession and our work: the anti-'medical model' position glosses over some of the essential dilemmas inherent in our practice and ignores some of its phenomenology.

The main problem with Hansen's stated position is that the majority of clients – unless they have already had some involvement with counselling and its values – do not  share his perception of the work. Most clients – depending on their pain threshold as suggested above - DO have 'medical model' expectations of the counsellor. In fact, unless it was for some kind of quasi-medical treatment, they would be seriously questioning what they are paying us for. Many clients can just about understand why we might refrain from giving plain advice. But most of them expect that our treatment will have- a symptom-reducing effect – "otherwise," many of them will say, "what's the point of coming to counselling ?"

If clients already shared our humanistic beliefs when they first come to us, and already understood and agreed with us about the values informing our practice, many of them would already be in a different place inside themselves. They would already  understand their 'symptoms' in emotional-psychological terms and be more interested in them rather than trying to get rid of them. They might already  be operating from within a capacity for self-actualisation and self-acceptance. If they were capable of taking a humanistic stance in reflecting on their issues, their problems would already acquire a much more managable complexion, to the point where many might not even need counselling

The opposite, however, is true: because of a process of internal self-objectification, and the absence of self-acceptance and self-love plus a medicalisation of how they relate to themselves and their pain, many clients DO subscribe to medical model thinking and expect us to be 'doctors for the feelings and the mind'. Their beliefs about counselling reflect their view of themselves and the world which in turn necessarily reflect their inner experience. Even before clients come to counselling, they 'treat' themselves in objectifying, unloving ways (reaching all the way to self-hatred, self-destruction, self-harm). Large areas of their inner experience, therefore, do not resonate with humanistic values.

In my view it is the recognition of this self-destructive and self-objectifying starting point as a given of the client's inner experience which constitutes an essential dilemma for the counsellor, especially the humanistic counsellor. One of our crucial principles is to meet the client 'where they are'. We precisely do not  want to require clients to subscribe to 'our humanistic values' (or any others) up-front – that would imply conditional acceptance which is against Hansen's stated values. So, if that is part of what they bring, we need to accept the client's self-medicalisation and their 'medical model' expectations of the counsellor. This is not only a question of meta-psychological frameworks or philosophy, it's a question of the dilemmas of practice. These cannot be resolved by ideology - 'medical model' or  anti-'medical model'.

To my mind, as a practitioner I am required to enter such dilemmas over and over again through the idiosyncracies and particularities of each client's psyche . I want to engage relationally in these conflicts rather than hanging onto my cherished therapeutic position and philosophical beliefs which are always more pure and straightforward than the ambiguities of love and human relating.

My problem, therefore, is not only the 'medical model', but also any 'absolutist' challenge of it which abandons psychological complexity and the parallels between outer and inner realities. As counsellors we can offer a psychological process of working-through or transformation, in addition to economical, sociological and political perspectives (which are equally valid in their respective domains, recognising and engaging in maybe necessary power struggles). This is the perspective I find lacking in Hansen's contribution. I know it's only meant as a thought experiment, but how does a commitment to a postmodernist deconstruction of power relations sit with the Orwellian Big Brother flavour of his thought experiment (having a guardian sit in every consulting room to police the use of 'medical model' terms) ?

I have suggested previously that the transcendence of the doctor-patient dualism (which is the core of the 'medical model') cannot be achieved through an anti-'medical model' which merely polarises against it. On an emotional level, both  positions can be used defensively. For me, the hallmark of a 21st century psychology is that these positions can be held in a paradoxical embrace which recognises the validity of both at the same time.

I have summarised the historical development from the dualism of the late 19th century through its 20th century deconstruction and eventual confusion, potentially leading to a 21st century position of paradox in the following diagram:

Recognising how the paradigm clash between the 'medical model' and humanism, between 'counselling as treatment' and 'counselling as relationship' enters our consulting room and is present within  the work (rather than just besieging us from outside) can ultimately make our work richer and more effective. Through embracing conflict, ambiguity and paradox as pervasive and necessary ingredients in psychological work, we may be able ground and re-seat ourselves more thoroughly than throuh legislating ideological 'clarity'. We may then be able to not only effectively support and help a psychologically and holistically ailing medical profession, but also more effectively resist the medical model's unsubstantiated claims at domination.

References:

Soth, M. (1997) Collective Mothering and the Medical Model - A response to Emmy van Deurzen-Smith's paper "The Future of Psychotherapy", European Journal of Psychotherapy 1997

Soth, M. (1998) Collective Mothering and the Medical Model, AChP Newsletter 1998

Soth, M. (2005a) Counselling: the 'Relating Cure', Healthcare Counselling & Psychotherapy Journal, October 2005, Vol 5 No 4

Soth, M. (2005b) Body Psychotherapy today - an integral-relational approach, Therapy Today, November 2005, Vol 16 No 9

Soth, M. (2006a) "What therapeutic hope for a subjective mind in an objectified body? " - in: Journal for Body, Movement and Dance in Psychotherapy Volumes 1 and 2 (June & September 2006)

Soth, M. (2006b) How 'the wound' enters the room and the relationship, Therapy Today, December 2006