Psychopathology: A Person-Centred Comparison
What is normal for a warrior could arguably be considered hell for a famer. Yet we all believe in normal people, we all have our own ideas of acceptable behaviour, and collectively we have developed this concept of normality. Psychopathology is the scientific study of mental health disorders, exploring the causes and behaviours of those who operate outside the system of normality that we collectively develop and police. Within this writing we shall explore the medical model of psychopathology, and then the person centred model, to provide an in depth understanding of person centred philosophy.
The medical models early treatments to mental health disorders appeared to be barbaric and are considered fairly ineffective, “As was true of much of medicine at the time, treatment was rudimentary, often harsh, and generally ineffective.” – (Reidbord, 2014). Treatments ranged from placing individuals into isolation for long periods of time, inducing them into low blood sugar comas, purposely giving them feverish illnesses, drilling holes into patient’s skulls and performing lobotomies, (Vann, 2016).
Perhaps it is partly for these reasons the medical model has been severely criticised, “Although the application of the medical model to the understanding and treatment of psychological disturbances is still widely subscribed to, it has also been severely criticised.” – (Lemma, 1996, P. 2) Until Freud developed his theories surrounding psychoanalytical therapy and human development, mental health disorders were considered behavioural manifestations of biological abnormalities, that could only be treated with methods that impacted our biological systems, (Reidbord, 2014). With Freud’s work being released in the early 1900s the psychiatric profession was arguably split into two, those who believed that biology impacted psychology and those who accepted that experience could also impact psychology. There is evidence to support both of these perspectives, yet more time and money appears to be invested in the biological conceptualisation of mental health, and by the 1950s drugs had been developed to help subdue the symptoms of mentally disordered experience and behaviour.
Yet before a practitioner from the medical model can treat a patient, first they must diagnose them. By relating a patients experience to the criteria found within the DSM a professional is able to offer a patient a diagnosis.
The tremendous strides of medicine in dealing with disease processes in the organism have been very largely based upon the discovery, elaboration and refinement of more adequate means of accurate diagnosis. It has been natural to suppose that progress in dealing with psychological difficulties would follow the same path. – (Rogers, 2003, P.219)
With a diagnosis a patient is able use the key word that is offered to them to research and deepen their understanding of their experience. They are able to find others to whom they can relate to or learn from within the realms of support forums and/or groups. Which are arguably two very positive aspects of the medical model.
Without the diagnosis the patient could find themselves feeling completely alone and alien to those around them, possibly aiding an environment to allow the condition to become worse, if one is to accept that a person’s perceived experience has a massive impact on mental health.
But there is the argument that by providing a diagnosis the patient is then enabled to become that diagnosis, creating the environment for a self-fulfilling prophecy to occur. This is the power that acknowledging difference and diversity can have on us, it encourages us to adapt or modify our behaviour for the diverse differences we encounter within the world, primarily our expectations we place upon ourselves or others. If we are told we are different and that we are unwell it can enable us to modify the expectations we place upon ourselves which will most probably have noticeable implications on our behaviour.
So there are supportive and critical arguments offered in relation to the use of the DSM, but that’s assuming the professional has actually diagnosed their patient accurately. A study has proved that different psychiatrists run the risk of labelling the same patients with different diagnoses. – (Lemma, 1996). This isn’t just a critical argument against the systematic and objective approach to subjective phenomena, this is quite clearly an indication of how dangerous this approach could possibly be. Especially when the imbalance of power within the relationship is considered.
Then there is another ethical dilemma when we consider the fact that pharmaceutical medication is highly profitable and there appears to be evidence suggesting the possibility that normal human behaviours are possibly being categorised as mental disorders. For instance Disruptive Mood Dysregulation Disorder, could have people experiencing regular angry outbursts diagnosed as mentally unwell. Yet it could be argued we experience anger as a healthy response to certain environments. These are just possible perceptions that are offered, not necessarily a factual reflection of reality, but phenomenology suggests there is no such thing as an actual reality. On its surface level it appears the medical model ignores this concept of human experiencing, even though some practitioners do acknowledge this.
Classification systems in the natural and biological sciences are based on groupings in terms of stable attributes and from which concepts such as mammal and fruit are inferred. It is not difficult to see how problematic it would be for researchers working within those systems, say, the same cow sometimes reproduced by giving birth and suckling and sometimes by laying eggs… but it can be argued that this is exactly the situation faced by psychologists and psychiatrists with respect to behaviour and one which has been widely ignored; rather than confronting the fact that the same person may behave in very different and quite opposing ways, and attempting to account for this variability, a search has been made for underlying stable attributes, whether they be ‘mental illnesses’ or ‘personality traits’, in terms of which, it is supposed, people may be grouped. – (lemma, 1996, P.10)
This statement appears to acknowledge phenomenology and the experiential process that comes with being human, more than the medical model and DSM appear to allow, preferring to create what is arguably just a tick box system that appears to inspire practitioners to treat the problem over the patient.
The medical model considers the brain as the most vital variable in play when it comes to analysing mental health. There appears to be a belief that how the brain functions is either the cause or at the very least a factor of great importance when it comes to mental health disorders developing, “Researchers studying mental illness believe that abnormalities in how particular brain circuits function contribute to the development of many mental illnesses.” – (Goldberg, 2014). The problem with this systematic belief structure is that there is an incredibly important variable that cannot be measured and quantified, and that is experience. It is impossible to develop an accurate metric to measure subjectivity. There will always lay the possibility that in some cases that the person who is suffering from a mental disorder is actually experiencing a typical reaction to a prolonged experience. Although it must be accepted that there is definitely a connection when the impact of brain injuries are explored.
It feels safe to argue that practising with subjectivity is best considered an art rather than a science, yet we symbolise psychology as a social science, and science creates dogmatic belief structures. Arguably it is with this dogmatic belief system that medication has been developed which could be considered as pain killers for the mind. The problem with pain killers is sometimes we experience pain to stop us from damaging our biological system. Painkillers enable us to carry on with day to day life but at what cost? Could the same perspective be argued for the medical model of psychopathology? We could be experiencing deep depression and we get labelled as unwell, so we take medication to make us feel better. Yet maybe in our reality we feel our partner doesn’t love us, maybe our employer is being emotionally manipulative and being a bully at work. Possibly our depression is telling us we need to change something in relation to our experience because it is damaging us psychologically. In the same way when we pull a muscle we experience pain to tell us to rest to recover. If we ignore the pain and mask it with medication, we are enabling ourselves to damage ourselves even further. The world of subjectivity is so much deeper and infinitely more complex than the example provided, this is just an attempt to expose the dangers of dogmatic belief structures, as Carl Rogers once expressed.
I am sure that the stress I place on this grows in part out of my regret at the history of Freudian theory. For Freud, it seems quite clear that his highly creative theories were never more than that. He kept changing, altering, revising, giving new meaning to old terms—always with more respect for the facts he observed than for the theories he had built. But at the hands of insecure disciples (so it seems to me), the gossamer threads became iron chains of dogma from which dynamic psychology is only recently beginning to free itself. I feel that every formulation of a theory contains this same risk and that, at the time a theory is constructed, some precautions should be taken to prevent it from becoming dogma. (Rogers, 1959, P. 191)
Carl Rogers’s observation may be related to another context but it could be argued that this belief that brain chemistry is the cause of mental health conditions, rather than a possible symptom, has become quite dogmatic for some practitioners within the medical model, and this certainly reflects my experience of being psychiatric patient. My experience, thoughts and feelings were irrelevant to my psychiatrists, the only thing they seemed concerned with was trying to make me objectify my sense of self so they could alter the medication I was being prescribed. They told me I was unwell and would be unable to operate within society without this medication. Well after the medication had kept me close to bed ridden for 18 months. I wasn’t a functioning member of my family, let alone society. With the support of my loved ones it was decided I was to wean myself off the medication, and within 6 months I was enrolled in college, looking for work and becoming a functioning member of society whilst also finding myself becoming a loving partner and father to my family again. I simply refused to see the psychiatric team after I made the decision to not follow their advice. I say advice lightly, they felt like orders. I hate to think of the state I may have found myself in if I followed their treatment plan. I was dosed up on medication to the point I didn’t feel, couldn’t think and speaking was almost a task outside the boundaries of my capabilities. So it is easy to imagine how my views on the medical model can be incredibly biased. Yet there is an acknowledgement within me for the fact that others can find medication extremely beneficial. So I find myself with mixed feelings about the medical model of psychopathology. But I do find relief in the fact there is evidence that suggests these dogmatic belief structures are being challenged by professionals within the medical world.
CEP exists to communicate evidence of the potentially harmful effects of psychiatric drugs to the people and institutions in the UK that can make a difference. The scientific record clearly shows that psychiatric medications, portrayed as safe and effective by areas of the medical profession, often lead to worse outcomes for many patients, particularly when taken long term. Our members include psychiatrists, academics, withdrawal support charities and others who are concerned about the prevalence of the ‘medical model’ and the increasing numbers of prescriptions for psychiatric drugs being given to both adults and children. – (CEP, 2016)
The ethics of offering medication is a complex and diverse matter. Especially when the positive and negative impacts that medication can have on peoples’ lives is considered. There is no definitive perspective here except perhaps, subjectivity and normality is incredibly hard to objectify.
The medical model perspective has developed from studying biology, neurology, psychology, behaviourism and some acknowledgement to the impact of experience, yet others could argue experience is valued higher than what has been made out within this essay, yet my personal experience has suggested differently.
The person-centred view of psychopathology is completely different though. Experience is the main factor that comes into play as far as the development of mental health disorders go. Yet a purist to the person centred approach could argue that mental health disorder labelling is dangerous, and would claim that they don’t work with mental health disorders and that they work with the person as a whole. Which could be considered true to some perspectives, but then there is how difference and diversity impacts our behaviour combined with the intellectual resonance experienced by the symbolisation of certain mental health disorders. If somebody offers there diagnosis of autism, depending on the person centred practitioners understanding of autism, it is likely the boundaries of what are expected and what is accepted within the therapy room will be modified accordingly.
Acknowledging difference and diversity has a powerful impact on human behaviour and emotional responses, and language is on tool that enables us to communicate our diverse differences. So regardless on a person centred practitioners views on the concept of diagnosing, it is hard to imagine a world where diagnoses doesn’t impact their method of practice in some way. Yet the person centred practitioner does not diagnose or openly share their critical judgements with their clients, in a way that a psychiatrist might. This is because it goes against the person centred philosophy because sharing judgements creates conditions of worth, which are what can fuel the development of a mental health disorder by encouraging incongruence. So practitioners of the person centred approach don’t work with the diagnostics of mental health disorders, they work within a spectrum of congruence and incongruence.
Google defines congruence as agreement or harmony, but in the world of therapy its meaning could be claimed to be somewhat deeper. A person who is congruent is completely open to their world of experience, “In 1956, continuing the theme of authenticity and genuineness of the therapists experience towards the client, Rogers first employed the term ‘congruence’ itself in relation to the therapist, using it interchangeably with ‘wholeness’ and ‘genuineness’.” - (Wyatt, 2001, P2). Congruence is a term that has layers of meaning to it. It is also considered the ability to be able to evaluate whether or not parts of our experience are appropriate to communicate or not. Phenomenology suggests the boundaries of appropriateness are within constant movement depending on the others within our environment. What is appropriate to communicate to one person may not be appropriate to communicate to another, it is our experience and empathy for the other that help us gauge this.
If congruence is to be completely open to our world of experience, incongruence is when we are closed off to parts of our experience. We can achieve this state by denying or distorting certain things in our perceptual field of experiencing, keeping things outside the boundaries of our conscious awareness. We do this to maintain our self-concept which is arguably symbolised as the psychological aspect of our biological organisms, in Freudian terms it is our ego’s perception of us as a human being.
Carl Rogers theorised that as human beings we all possess an innate tendency to actualise and to become the very best we can become, yet we also possess a desire to be held in positive regard by those around us. Plus like all living organisms we possess the desire to survive and to live. These different aspects to being human, especially the need for positive regard, can create the right environment for us to become incongruent.
In person-centred theory, it is the pursuit of positive regard at the expense of organismic valuing process that underlies mental ill-health. Put another way, if there is sufficient disharmony between the organism and the self (-concept), the resulting incongruence is likely to manifest as one or more of the complexes of thinking, behaviour and processing which in other models may be called neuroses and psychoses, mental illness or disease. – (Joseph and Watson, 2005, P.45)
Initially we have an organismic valuing system that we rely on to communicate our needs to the world. If a young child is hungry, cold or in pain they will most likely cry and scream communicating their experienced discomfort with the world around them. “He appears to value those experiences which he perceives as enhancing himself, and place a negative value on those experiences which seem to threaten himself or which do not maintain or enhance himself.” – (Rogers, 2003, P. 499) This need for positive regard, which we arguably only initially receive from our caregivers and peers, can get in the way of our organismic valuing system, as we experience the positive regard we all innately desire being removed or increased depending on our behaviour and our environment. It is possible our need for positive regard can override and get in the way of our organismic valuing system, “But the expression of positive regard towards him by someone significant to him becomes more important to him than his own organismic valuing process, and he begins to seek positive regard from others at the expense of any of experience.” – (Merry, 2002, P. 27)
We start to acknowledge conditions of worth being communicated to us on a deep level, outside the boundaries of our awareness, as we begin to grow and become a functioning human being within the environment surrounding us, “As infants we begin to acquire conditions of worth. We learn from experience that we are only acceptable as long as we think, feel and behave in ways that are positively valued by others.” – (Merry, 2002, P.26). These conditions of worth, or the expectations placed upon us, help us to form our self-concept. Which is how we perceive ourselves on a psychological level. This perception doesn’t necessarily reflect the actual reality of who we are. Imagine contestants on the x-factor whose singing sounds terrible, but yet they are completely shocked when they receive negative feedback from the judges. These are people whose self-concepts suggest they are talented singers, probably reinforced by incongruent communication from their loved ones, who then experience psychological distress when the conceptualisation of self is perceived to be attacked.
Once our self-concept is formed we can quite naturally start distorting or denying parts of our experience to maintain our perception of our self-concept. For example a sportsman losing an important sporting event could right the loss off to having a bad day, or because they weren’t quite in the zone, especially if they consider themselves to be incredibly talented. This appears less damaging than admitting the other person was a better sportsman than them, and could be argued to be symbolic of incongruence on some level. Yet another sportsman might have a self-concept that is able to admit this possible factor. Self-concepts are developed by experience, and the range and variations of experience available to a human being are incredibly vast, if not infinite, making the theory of phenomenology easy to accept if the range of variations are considered.
Our self-concepts don’t only inspire to deny or distort experience though, they help inspire behaviour as well. Imagine being a young child who was always chastised for being the tiniest bit dirty. Soon this critical judgement will become internalised. Dirt and uncleanliness would give us reason to feel judgmental and critical of another human being. They are the same judgements we hold upon ourselves, so we transfer these expectations to those around us. At this point we are not valuing our experience from an organismic valuing system. We are arguably operating from the boundaries of our external locus of evaluation, and possibly confusing it as our internal locus of evaluation. So the metric of judgement used to measure our worth as a human being is handed down to us like a torch of judgement, which we then use to illuminate and direct our own path throughout life. Burning those around us with it who don’t adequately meet the expectations that have been placed upon us. Even if we don’t explicitly communicate this to the offending individual, they may still become burnt through either the way our behaviour is adapted on a sub-conscious level, or by the manner in which we communicate our experience of being with said person to others.
If we increase a variable within the above example, from a child being mildly chastised, to being deeply humiliated and punished in an extreme manner. The internalised thoughts and feelings in relation cleanliness could inspire behaviour that a psychiatrist would symbolise as OCD. Now the medical model might suggest that this person have a course of CBT, in an attempt to overcome certain behaviour patterns and cognitive cycling patterns, whilst also providing some medication to minimalize the sense of anxiety the individual could be experiencing (Lemma, 1996). Treating the problem.
A person centred practitioner would provide a relationship with the core conditions present in an attempt to help the individual to get back in touch with their internal locus of evaluation. Through getting in touch with their internal locus of evaluation and evaluating their need to keep things clean and tidy on an organismic valuing level they might be able to readjust the intense emotional response they experience in response to dirty environments, to fit more in line with their own expectations rather than the expectations placed upon them. From this perspective the person centred practitioner is trying to help the individual feel safe in evaluating the world around them for themselves, and to feel brave enough and confident to become their true self, away from the conditions of worth placed upon them by others. In this sense the person centred practitioner is working with the person as a whole and doesn’t see the diagnosis as a problem to be treated, but more as a natural manifestation of behaviour in response to a person’s experience within their life. Not all disorders could be looked at from this perspective though, autism for example, which appears to have a clear connection to brain functioning rather than a reaction to lived experience.
Understanding the difference of perspectives in relation to psychopathology is incredibly complicated. It is probably better to simplify the complexities of being human to something relatively simple in comparison, like a car. The medical model is probably best developed to work on the engine of the car, whereas the person-centred practitioner may be considered under qualified to work on the engine. So they work with the driver of the car, enabling the driver to become the best driver they can be. Although the work is being done from two entirely different perspectives, they both have the same aim. To make the future journey safer and more comfortable for the individual and those around them. The person centred practitioner having psychological contact and human connection to offer, whilst the psychiatrist would have a range of tools at their disposal, from medication to the power to override a person’s autonomy if they feel they may be a danger to themselves or others. The person centred practitioner is an equal looking for genuine human connection, whilst the medical practitioner is a professional, looking for a problem that needs to be fixed.
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