I think we’re at cross-paradigms here…

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12 June, 2011 by ehauke

Earlier this week, I had my most complex teaching assignment yet.

The class I was asked to teach was “When Psychological Distress Becomes Pathological”. To a postgraduate class, studying for a masters in counselling.

I am a qualified medical doctor, with experience in most areas of medicine, including psychiatry. I have experience teaching and tutoring medical and non-medical topics. I have life experience outside of medicine. But I have no experience of counselling. This is not something that I have ever really learnt about in any depth. And I certainly have no qualification that would give me authority in the field of counselling.

As part of my medical training, I was informed that:

“counselling is a psychological intervention. Usually offered on a fixed-term basis – a series of two, six or even ten sessions. Focussed on problem-solving to relieve transient psychological distress. Offered to help with bereavement or other traumatic life events. For success, counselling as an intervention requires acceptance of the process and some personal curiosity as to the nature of the distress. As opposed to psychotherapy which is a personal psychological exploration, requiring innate personal curiosity and aiming to unearth core psychological malfunctions and ‘correct’ them.

Counselling and psychotherapy, being ‘talking therapies’, may offer some success with ‘mildly affected’ patients. Patients who are perhaps a little ‘too introspective’. Psychological distress is the normal, everyday emotional reaction to life. As opposed to mental illness. Which is a pathological condition. Requiring medical intervention. Constant risk assessment, and perhaps detainment of the patient against their will. For their own good, and for the good of society.

Psychiatric illness may remove the patient’s ability to consent to treatment. As a result, the patient may no longer have the right to make their own decisions about their illness, their treatment or their life. Doctors, psychiatrists, will have to make these decisions for them.”

Because doctors know best?

I learnt about psychology and psychiatry from within the medical/biological paradigm. Looking for the biological cause for psychological distress. Looking for the medical pathology in every patient. And the class I was facing had all learnt about mental health in a more psycho-social paradigm.

This may sound extreme. Surely not all doctors, psychiatrists and medically qualified psychologists share this rather polar view of mental distress and mental illness? Well probably not. I am a doctor, and I wholeheartedly do not. And many doctors would sound totally reasonable and measured in their thinking – until you put them in a room with someone who learnt about these issues from within a different paradigm. And then these polarisations might become quite apparent again. They might re-surface.

So in this teaching session, I was asked to talk about the very edges of these two ideas – psychological distress and psychiatric pathology. I was asked to examine the interface between these two concepts. With a class of students who had learnt about, and practiced counselling from within a very different paradigm. The idea was to help them to recognise psychiatric pathology within their usual practice of clients with psychological distress. Recognise when some of these patients might benefit from medical psychiatric intervention.

Now, I would consider myself a ‘psychologically enlightened’ doctor. I recognise the value of psychological rather than psychiatric intervention. But even my considered and moderate view point came under very close scrutiny as the class got underway. And not just by the students. I became increasingly aware of the ‘medicalisation’ hiding behind my every statement.

We began by examining a range of traumatic life events. The sort of thing that could happen to anyone. At any time. And might throw their life into complete disarray – personally, professionally, socially. We looked at things like bereavement, divorce, redundancy, retirement, moving house etc. We considered what might be ‘normal’ psychological and emotional reactions to these events. Distress, depression, anxiety, hallucinations, delusions, substance misuse, suicidal behaviour.

Every one of us has different underlying tendencies to different psychiatric conditions. And life events are well known to trigger emergences of these conditions. So we then considered a range of psychiatric diagnoses. Depression. Generalised Anxiety. Schizophrenia. Eating disorders. And we looked at what symptoms might be expressed in these conditions. And surprise, surprise, the same patterns of symptoms can be seen in both ‘normal’ emotional reactions to life events, and in established psychiatric diagnoses.

So looking out for particular symptoms, is not a good way to differentiate ‘normal psychological distress’ from ‘psychiatric pathology’. Even the more extreme symptoms – like hallucinations – may be a part of a normal psychological reaction (for example, seeing your dead spouse standing at the end of the bed in the days after a bereavement).

We then considered whether there were perhaps any other markers that would signal the possibility of ‘psychiatric pathology’ or at least the need for a medical assessment of any psychiatric need. We came up with the following:

  • Duration – many psychological reactions would normally be considered transient – i.e. they should resolve with time – so perhaps extended duration of distress might signal a need for review or reassessment
  • Impact – if the psychological distress is having a severe personal (e.g. when psychological disturbance leads to physical illness – perhaps through neglect of eating, personal care; or when distress is experienced in recognition of the psychological disturbance), professional (inability to function at work, or loss of job) or social impact (loss of contact with friends/family) then review might be wise
  • Biological – if biological symptoms accompany psychological disturbance, this might indicate the need for psychiatric review – e.g. change in appetite, weight loss/gain, difficulty sleeping/excess sleep, change in libido
  • Risk – either to the individual or society – the individual may be threatening suicide, or engaging in risky behaviours
  • Extra-ordinary – anything that does not make sense – this might be delusional thought, or noted discrepancies such as weight gain with loss of appetite
But even in the presence of these ‘markers’ of a potential need for review, many of the students felt that they still would not seek medical review for their client. They might review the case with their supervising counsellor, but not involve a medical or psychiatric practitioner. The reasons for this were varied – some based on experience and some based on superstition. They were concerned about:
  • medicalising or pathologising ‘normal psychological distress’
  • labelling and stigma – especially with regards to documentation in medical notes and the implications for future employment with HR departments requiring access to medical notes or information about recent ‘medical consultations’
  • ‘sounding like a doctor’ by asking questions in order to elucidate the above ‘markers’
  • counselling pre-assessment – clients are pre-assessed before commencing counselling and therefore there might be less need to worry about potential psychiatric problems during counselling
  • wariness about attributing cause for psychiatric pathology – and therefore about the need to ‘treat’ it
  • violation of confidentiality by involving medical practitioners
  • violation of human rights if medical intervention resulted in hospitalisation

All these are very valid concerns. But from my medical paradigm, I would place these in a secondary position relative to my concern for the safety of the individual and the public. From a psycho-social paradigm, maybe this would not be the case. Maybe the needs and wants of the individual would take precedence. But maybe (because of my medical paradigm), I’m missing the point still further. Perhaps this isn’t about judging the needs of the individual in psychological distress, maybe this is about addressing the needs of the authority figure in this equation. The holder of all the power. The physician, psychiatrist or counsellor. Maybe the counsellor does not assume such a paternalistic and authoritarian role as the medically trained doctor. I like to think of myself as a psychologically-minded (or -enlightened) doctor, but as this bit of thinking through reveals, perhaps I’m more power-hungry than I’d like to let on.

There would be many individuals in whom I would not be happy to impose a diagnosis of a psychiatric nature. But equally, there would be many in whom I would feel confident of such a diagnosis. Using diagnostic criteria like DSM or ICD classifications would give me authority in these assertions. Even though, with critical reading, many of the criteria used to establish diagnosis are highly questionable.

And this class would question each and every one. With much more fervour than I would. With my medical paradigm weighing me down.

I would carefully think through the implications of making a psychiatric diagnosis or intervention as it might impact the life of the patient. But I would not shy away from doing so. At this point in the thinking, I really do start to feel quite bad about the idea of grabbing hold of this power and finding comfort in the idea of imposing a diagnosis or pathology on someone.

But maybe I’m selling myself short. Maybe it’s not the power angle I should be pursuing. Perhaps the value to me as a doctor of making a diagnosis or attributing a pathology, is about responsibility. My responsibility to have spotted a potential issue, assessed it and dealt with it appropriately. And, as a doctor perhaps, evidenced that I have done so. And in the world of the doctor, all evidence rests in the medical notes. It’s not enough for me to have had a conversation with Mrs Jones about how she’s been feeling, and that I’m concerned about her mood. If I haven’t written it down in the notes, it didn’t happen.

So responsibility or power struggles aside, we further explored the ideas of stigma and labelling. And I wanted to make this personal. It’s all very well to think about whether Mrs Jones would be happy with a stigmatising diagnosis, but what about you? Or me? So we did a quick (and anonymous) survey in the room to see how many of us had experienced psychological distress or diagnosed psychiatric illness and what our feelings about stigma and labelling might be.

Interestingly, in a class of 16 (a small sample, I know), 19% had psychiatric diagnoses, and 38% had experienced psychological distress requiring professional psychological intervention. The same proportion had experienced minor psychological distress and the remaining 5% had not experienced any psychiatric or psychological issues. Of the individuals that had experienced psychiatric or serious psychological difficulties, 90% stated that they found those experiences to be stigmatising or humiliating, and that they had concealed those experiences from their friends, family or co-workers. Of those with only minor psychological difficulty or none at all, 90% stated that they would not find serious psychiatric or psychological difficulty stigmatising and they would not attempt to conceal it from anyone.

A fascinating and stark comparison. And this was in a room of psychological professionals. I might have expected this from a bunch of doctors, all trained in the medical paradigm, but not from those who voiced primary concerns with human rights and stigma. But perhaps, when it comes to projecting the value or harm of gaining a psychiatric diagnosis, being labelled, or of experiencing serious psychological distress, it makes a huge difference whether you have ever experienced it yourself. And not so much of a difference which paradigm you have trained with and practice with. But then, if you can’t discuss these experiences because of the fear of judgment and stigma, how will any mental health professional really understand the issues involved for the client or patient?

So this experience of working across professional boundaries, reaching across the paradigms, was very interesting. But while considering the differences in our thinking and training with regards to our paradigmatic origins threw up some very important topics for discussion, there was a bigger white elephant in the room. No matter how much you talk about the issues, and think about what diagnosis, pathology, labelling and treatment intervention might mean to the patient (or client), this isn’t really something that you can take upon yourself to know. Unless you have been on the receiving end yourself.


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