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« The future of psychotherapy | Main | Psychotherapy Versus the Medical Model »

Strange Bedfellows, Level 2

This post continues where the previous post left off. I have just argued that medical issues usually have a clearly defined and well understood organic cause and psychological distress rarely does. The only cases I can think of where psychological distress has such an organic cause involve traumatic head injuries, substance abuse, or exposure to other toxins.

If we are to insist on a distinction between medical and psychological issues, which is precisely what I would like to do, then we should acknowledge that these two categories are at least somewhat overlapping. For instance, many types of physical injury or illness will have psychological impacts. A diagnosis of cancer, for example, often induces a depressive or anxious episode; or the amputation of a limb often results in depression.

So let us propose a clear distinction that allows for such overlaps. To the extent that organic injury, disease, or developmental anomaly results in a dysregulation of mental processes, the problem may be understood as medical and, to that extent, it should be treated medically. To the extent that any dysregulation of mental processes cannot be attributed to such organic causes, the problem may be understood as psychological and should be treated psychotherapeutically.

To give this distinction a quick test drive, let us imagine a case of traumatic head injury resulting in severe depression. The psychological distress involves a profound dysregulation of mood. To the extent that the patient's mood is affected by damage to the parts of the brain involved in emotional regulation, it may be regarded as a medical issue to be controlled by medications or possibly surgical interventions. But to the extent that the depression is about loss--loss of the client's capacity for a full life as a result of the injury--this aspect of his depression may best be treated psychotherapeutically.

This distinction may help clarify the tricky issue of, for example, antidepressant medications. Are they a medical intervention or a psychological one? I would argue that, when they prove useful, antidepressants are showing themselves to be medically appropriate in a given case. So, in the case of SSRIs (Selective Serotonin Reuptake Inhibitors), the depression involves a chemical imbalance in the brain that is remedied by more serotonin floating around the synaptic clefts. In a medical sense, the severity of the depression can be explained, at least to some extent, as an organic problem of too little serotonin in the synaptic clefts of the brain. But it may also be true--and I would argue it most often is--that a deeper psychological cause explains the client's tendency to move toward depression in the first place. This aspect of the client's presentation calls for a psychological treatment, namely psychotherapy.

So far I have glossed over a rather tricky problem, which will require a post all to itself. Many would argue, myself included, that all psychological states (functional and dysfunctional) have physical correlates at the neurobiological level. SSRIs point to that issue: can not every psychological state be regarded as a specific organic state which is to be remedied organically in the end? And, if this is true, does that not eviscerate the distinction I am trying to make between the medical and the psychological? I think this is a very good question, but I still hold that the distinction remains valid. I promise to address this problem in a future post.

Of greater importance than this nit-picky philosophical snare, is the issue of classes of causes. Medicine is interested exclusively in organic causes. Psychotherapy, I would argue, is interested in social-emotional causes--that is, impacts that occur in the intersubjective space between people. Similarly, medicine deals exclusively in interventions that act directly on physiology whereas psychotherapy focuses on interventions that occur within, and act upon, the intersubjective field.

I will continue to argue as this series continues that psychotherapy represents the most effective and efficient approach to alleviating suffering of its native kind--that is, suffering felt by one person in the context of others.

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