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Psychology, Medicine and Pathology

When I was about eight I told my father a joke. Given that I was only eight, it was no doubt lame. My father asked me what made me think it was funny, and proceeded to analyze my answers using a 1930’s psychology book on children’s humor. I could tell that he was trying to understand something about me that I didn’t know myself — and that whatever he found out was unlikely to be flattering. It wasn’t a comfortable feeling.

My father came of age during Freud’s heyday. Freud was a master of telling people unpleasant ‘truths’ about themselves, so it’s no wonder I felt under a critical microscope. That critical microscope still exists in the helping profession, and it’s far more widespread than it should be.

Freud was trained as a medical doctor and as he developed his ‘talking cure’, he wanted it to be seen as scientific as medicine. Why? Because his patients were reporting all kinds of sexual fantasies and desires that scandalized conservative Viennese society in the late 1890’s. The ‘talking cure’ would be utterly discredited if Freud and his disciples were seen to be inventing or encouraging these fantasies and desires. Applying the rigor of medicine to his newly created field of psychoanalysis was a way to defend against his critics.

And so was born the medical model of psychotherapy. Words such as “patient”, “disorder”, “symptoms”, “diagnosis” and “treatment” all come from medicine and have a reassuring whiff of science about them.

You could be forgiven if, at this point, you yawned and asked “So what? Who cares if psychotherapy uses a medical model?” That can be answered with one word: Pathology.

In medicine, doctors look for what’s gone wrong — the presence of bacteria, the absence of insulin, the malfunction of an organ, and so on. That’s the pathology. In psychotherapy, the therapist — following the medical model — also looks for what’s gone wrong, and tries to identify the pathology. The Diagnostic and Statistics Manual of Mental Disorders (DSM) is full of hundreds of pathologies, and adds dozens of new ones with every edition.

While it’s clearly very useful for doctors to be able to focus on the patient’s pathology, the opposite is true for psychotherapists. If you doubt that, try telling someone that they’re a narcissist, sociopath, borderline, histrionic, paranoid, bipolar, OCD or an addict, and see how they respond. Even diagnoses that are less value-laden (Major depression, generalized anxiety, ADHD, phobic, etc.) can hurt as often as they help.

The medical model with its laser-like focus on pathology and diagnoses fits very nicely with human nature. It is in all of us to judge, criticize, label and demand change — not just of other people, but ourselves too. While the medical model uses words like narcissistic, sociopathic and bipolar, the rest of us just say selfish, immoral or moody. They mean pretty much the same thing; the medical model words sound more scientific and impressive but they’re equally judgmental.

Therapists therefore struggle on two fronts. First, we are trained in the medical model to look for pathology. Second, we are human beings who, like everyone else, instinctively judge, criticize and label. In other words, both our training and our nature direct us toward looking for the pathology in our clients.

Unfortunately, searching for the pathology, diagnosing, judging, criticizing and labeling don’t actually help people to feel better or behave better. Look at your own life: how often did a friend or loved one respond positively to your identification of their faults, regardless of how spot-on you were? For that matter, how much did you change in response to criticism from others?

The best therapists, I believe, are those that throw away the book that details the hundreds of pathologies that flesh is heir to. They are human and genuine with their clients. They dispense with labels, put aside judgement and never criticize. Instead, they become deeply curious about their clients’ lives, asking and listening until they truly understand what drives the person sitting in front of them. They see the strengths in their client: how, despite their deep depression, they still managed to get out of bed and go to work; despite their desire for alcohol they managed to hold off from drinking for a day; despite their fear of flying they managed to get on a plane. They understand that while these things may be easy for others, to the client it feels like climbing Mount Everest, and they recognize and appreciate the effort it took.

When therapists approach their clients using the medical model of pathology and the natural human tendency to judge, label and criticize, clients freeze. When we approach them with appreciation for their efforts and understanding of their struggles, true change can begin.


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