Article of Faith

I have had some thoughtful responses to my last post, particularly from Glenn Macauley which can be read by following the "Comments" link to that post. I won't try to paraphrase Glenn's argument here, but he points out some important objections to the argument that I made about the harmful influence of medical terminology on the development of the self insight which allows us to make sense of a painful psychological condition. It is all very well to argue that medical jargon is inadequate for expressing anyone's emotional life. But what if a psychological problem actually is something that can be effectively treated by medication alone? Would there be anything wrong with that? And isn't a blanket disapproval of psycho-pharmaceuticals rather like suggesting that it is bad form to resort to medication? Finally, wouldn't it be positively harmful to insist on psychotherapy if the only true remedy is medication?

I think there are a couple perspectives on this issue that are not easy to separate. Firstly, there is a personal perspective, that is each individual's experience of a particular psychological condition. Then, there is a medical or scientific overview of that condition which provides all sorts of useful information (or data, as scientists prefer to call it) of a more general nature. The first perspective is based on the  testimony of the client's experience while the second provides relevant information about some of the factors that often, if not invariably give rise to the experience of a psychological condition. As a psychotherapist, I must focus primarily on the personal, experiential perspective of the client rather than on a more general medical overview of his condition. Nevertheless, I must also be informed by a medical perspective on whatever condition my client happens to be suffering from. So when a client comes in suffering from depression, say, I will listen carefully to what he reports and presents, while keeping in mind that depression often possesses features that he might not be aware of.  He may not, for example, be aware of the episodic nature of depression or know that what feels to him like a permanent condition will often remit after six months. I must also keep in mind that medication can be a literal life saver for a client who may be at risk of committing suicide, even while I try to help him deal with his problems which make him feel suicidal.

But if medication rids a client of the symptoms of his depression, why bother with psychotherapy at all? For if a psychological condition is all just a matter of biochemistry, psychotherapy would seem little more than a pointless, if not harmful indulgence. But here we have to be careful about what the medical evidence suggests. While it is true that medication can help people maintain equilibrium for a variety of psychological afflictions, this is not quite the same as getting rid of their symptoms. Perhaps it would be better to say that medication offers relief from symptoms, though such relief, as I said before, can be literally life saving. But does that relief endure over the long term? Here the evidence is inconclusive, but does reveal some undesirable side effects of long term medication. It is not uncommon, for example, for people who take anti-depressants to suffer a loss of libido as a side effect of their medication. And the long term use of anti-psychotic medication can severely disrupt the nervous system, leaving the sufferer with tardive dyskinesia, a condition that both affects his movements and makes him feel like a zombie (this, incidentally, solves the mystery about why schizophrenics often refuse to take their medication). But even in suffering from such unwanted side effects, many people may still prefer to remain on medication. I believe their decisions should be respected, though I would stipulate that they should be fully informed of the pros and cons of medication. But I also believe that, notwithstanding the widespread medical faith in psycho-pharmaceuticals, there is a case to be made for psychotherapy in treating seemingly intractable psychological conditions. Except, of course, when psychotherapy is harmful.

This too, is an issue that I have addressed before in a previous post, but the point deserves to be made again. If a therapist is inept or unethical a client's situation will likely be made much worse by psychotherapy. The point should be obvious, but I have listened to too many arguments in favour of psychotherapy without any consideration of what makes therapy succeed or fail. But even an ethical and skilled therapist may not succeed in helping his client. At some point the client must also accept responsibility for the therapeutic process. So again we come to the single most important factor for the success of psychotherapy, the relationship between therapist and client. In my previous post I talked about how important self expression is for therapy and argued that a medicalised discourse of self experience presents formidable impediments to self understanding (I am well aware that a similar case can and should be made against therapy-speak and psycho-babble). But I neglected to say that a therapeutic relationship involves far more than the self expression of the client. It also demands the effective and meaningful communication of his experience in whatever form of expression feels natural to him. Indeed, the client's self expressive capacity develops though the therapeutic encounter which depends on the therapist's receptive capacity and ability to understand what the client is trying to communicate.     

My argument here may seem like an attempt to reinvent the wheel. Isn't it true, after all, that psychotherapists have always known that therapy depends on a therapeutic alliance which is established by its depth of communication? As an article of faith, perhaps. But that faith has to be redeemed in every course of psychotherapy and there will always be cases that will test, if not entirely disprove it. For such faith is not an established fact like the law of gravity. It is a possibility or a promise that may or may not be realised. Once more I come back to Laing's quotation about psychotherapy being a stubborn attempt to communicate the experience of being human by two people through the relationship between them. They discover the truth of being human by communicating it.