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Caroline McDougall, Academic Reflections

The Medical Model, Mental Illness and Therapy

With over 400 possible ways to be considered abnormal, the worldwide web of pathology-orientated psychologists rarely have difficulty plotting the person’s entire life story within the text of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (the DSM-IV) (Caplan, 1995, p152). Duncan et al (2004, p24) describe diagnosis as a flawed extension of the medical model, and refer to the DSM-1V as the professional digest of human disasters.

The current trend of intervention for people experiencing chronic symptoms of depression and anxiety focuses on assessment, diagnosis and drug intervention, a fundamentalist script whereby vulnerable people follow the orders of ‘experts’ who label them. This script does not by definition embrace the many forces of humanness which shape problems, such as loneliness, poverty, loss of love, ill health, community disenfranchisement, frustrated hopes and ambitions, cultural oppression, relationship dynamics. Nor does it explore the subtle, yet powerful layering of emotions which define every human being, as they respond uniquely to their painful life experiences. There is a determination to cure perceived ‘chemical imbalance’ largely by consuming a pill and ignoring the pervasive underlying factors causing human distress.

Where there is diagnosis and drug therapy, I see an overriding need for psychotherapy. As an emotion-focused therapist, I experience many people coming to me with ‘I have depression’ or ‘I have anxiety disorder’ or ‘I have OCD’. These diagnoses were dealt out often it seems in a whimsical fashion, alongside with drug prescriptions and six sessions with the resident psychologist. These people bring with them a huge burden of hopelessness, self-blame and a label: I AM SICK as they project feelings of doom around the anticipation of poor outcomes for their future.

I believe as counsellors we carry a responsibility to challenge or at least offer a balance to the emphasis on chemical imbalance being the cause of many human problems including depression and anxiety. Emotion-focused therapy is an intense yet highly-effective, gentle approach, which challenges the notion of dysfunction and the labeling of emotional response to experience. As with all person-centred approaches, the emphasis is on the wisdom, strength and resilience in each human being to collaborate in their own healing and gain mastery over their own life. The person and the therapist join together in a collaborative ‘moment by moment’ search to find meaning and understanding in the unfolding and highly unique life narrative of each individual.

An emotion-focused therapist therefore would be likely to interpret a period of mental instability as a necessary and productive component of the emotional growth of a client. Responsibility is an essential component to positive growth and change. Even when a client is in a critical, vulnerable state, there remains a collaborative relationship in which the client has choice and ‘knows best’. The therapist is ‘at their service’ working to understand the client’s perceptions before facilitating action, rather than an ‘expert who determines the problem’. Instability is reframed into ‘wonderful turning point’.

Furthermore, clients’ perceptions of life events are heavily determined by background. Therefore action taken without understanding the person-in-environment transaction may be naïve and even dangerous (Ivey et al, 1987, p144). The biopsychosocial approach recognizes the importance of how clients (subjectively) perceive the world; what is their relationship with their unique environment; what are their constructs, and what effect does this system have on their problems. In the writer’s own work with the ‘case study’ client for example, a consideration of environmental factors (past and present) and some focus in therapy on environmental change is an essential component to addressing problems (Appendix A).

The problems of the case study client (and those of many clients seeking therapy) are both ambiguous and messy: a conglomerate of depression, dissociation and phobia. ‘Locking’ this individual in a scientific framework involving a pure form of pathology seems to have served little purpose, and has produced if anything, a more negative outcome with extensive, far-reaching challenges. He has struggled to cope within the mental health system and has described experiences of stigma, despite no referral for counseling throughout connection with Psychiatric Services. According to Parker et al (1995, p39-40), it is a truism that mental health services are discriminatory and a wide variety of statistical sources testify to this. Abnormality is still powerfully defined with reference to so-called ‘normal behaviour’. Consistent with the medical model, the client has been expected to accept his diagnosis and comply with the treatment recommendations.

Within person-centred therapy, disclosure of a sensitive nature generally takes place within a safe and caring environment, and only when trust has been established. The medical model does place great value on trust and empathy within the doctor/patient relationship. For example, during recent a counseling session, the client reported feeling ‘degraded’ by the fact that he had been diagnosed quickly and with little inquiry into his background, his life experiences, or any trauma he has undergone. During a period of intensive person-centred therapy, he has made several disclosures around trauma which have significantly impacted his perception, emotion scheme and choices. He reported ‘feeling protective of his secrets’ in all his passing interactions with psychiatrists. His experience reflects Hobson’s quote: ‘If I am understood too completely and too quickly, I feel invaded’ (1985, p172). A person-centred approach to therapy respects the client’s need for privacy and recognizes that his experience is a delicate process; the biopsychosocial approach promotes an understanding of the whole person-in-environment.

The writer concludes that the biopsychosocial approach challenges the fundamentalism of the medical model. The person-centred approach to therapy offers a comprehension of ‘difference’, reflecting what Rogers (1969) refers to as ‘timeless immediacy’; and recognizes clients’ capacity to deal with their own problems. According to Duncan et al (2004, p36-37) research indicates that therapy works if clients experience the (therapist-client) relationship positively and are active participants.

Many of the writer’s clients have ‘survived’ the medical model for many years. They are now part of a biosychosocial model which, in the writer’s opinion, offers a broader scope for growth. It encompasses intervention on several levels, and encourages a therapeutic approach which values both the person-in-environment and the ‘I-Thou’ relationship. Within an outcome-informed framework, clients report without exception, that they now experience a far better quality of life, that hope is restored and that loss is no longer such a painful problem in their daily lives. Perhaps the ‘medical model experts’ should consider Hobson’s approach to intervention: ‘When I do act in accordance with formulations I do not look first for supporting evidence; I search around for evidence to show that I am wrong’ (1985, p173).


Caplan, P. (1995) They Say You’re Crazy: How The World’s Most Powerful Psychiatrists Decide Who’s Normal. New York: Addison-Wesley Publishing in Madigan, S. (1995) ‘Inscription, Description and Deciphering Chronic Identities’, in Parker, I. (ed.), Deconstructing Psychotherapy. London: Sage Publications Ltd. Duncan, B. L.; Miller, S.D.; and Sparks, J.A. (2004) The Heroic Client. San Francisco: John Wiley and Sons Hobson, R. F. (1985) Forms of Feeling: The Heart of Psychotherapy. London: Tavistock Ivey, A.E.; Ivey, M.B.; Simek-Downing, L. (1987) Counselling and Psychotherapy - Integrating Skills, Theory and Practice (2nd Ed.). Englewood Cliffs: Prentice-Hall International Jackson, G.; Greenberg, R.P., and Kinchin, K. (2004) ‘The Myth of the Magic Pill’ in Duncan, L.D.; Miller, S.C.; and Sparks, J.A. The Heroic Client. San Francisco: John Wiley and Sons Parker, I.; Georgaca, E.; Harper, D.; McLaughlin, T.; and Stowell-Smith, M. (1995) Deconstructing Psychopathology. London: Sage Publications Rogers, C. (1969) in Evans, R.I. Dr. Carl Rogers. University Park: Pennsylvania State University

If you are worried about yourself or someone you care about, Caroline is happy to speak with you and guide you in the right direction.