Person Centred Approach Vs Medical Model In Mental Health Evolution And Impact

This essay evaluates the developments within Person centred theory, and analyses how the Person centred model approaches treatment of mental distress in comparison with the medical model of mental health. There are some new developments in the Person centred theory, which will be evaluated and discussed within the person-centred practice. Apart from this, two theories, Counselling for Depression (CFD), and pre therapy, are discussed in greater depth. The purpose of this essay is to discuss the Person centred theory within the medical model of mental health, in the background of the developments in the way psychological therapies are delivered; these developments include the introduction of Improving Access to Psychological Therapies (IAPT) and Evidence Based Practice (EBP). This essay analyses how these developments have also impacted the person centred therapy. This essay first discusses the medical model of mental health, then discusses the personal centred theory and then compares and analyses the latter with the former.

Roger (1951) has described therapy as a diagnosis, which is a “process which goes on in the experience of the client rather than the intellect of the clinician” (p.223). This statement indicates the differences in therapy models that can be centred on the person or centred on the intellect of the clinician. The person centred approach is centred on the person or the client whereas the medical model is centred on the clinician (Hayes, 2014). Those who follow the person centred approach view psychopathology from a humanistic, and holistic perspective (Hayes, 2014). They are more creative and open in their approach to psychopathology research as compared to those who follow the medical model. Roger’s model is the classic client centred model which also has relevance to the person centred therapy (Rogers, 1951). Person centred practitioners after Roger shave also incorporated the client centred approach and in some ways have broadened their approach and there are now a number of approaches like pre therapy, Counselling for Depression, relational depth, and expressive arts therapy, that form the part of person centred approaches to therapy (Hayes, 2014). Two of the approached that are discussed in depth in this essay are CFD or Counselling for Depression and pre therapy. CFD is based on the approach of Emotion Focussed Therapy (EFT) and it at times used as an alternative to CBT or Cognitive Behaviour Therapy. CFD is closely linked to the person centred therapy approach while CBT is one of the therapies or interventions for depression that can be linked to a medical model approach (Champion, 2016, p. 1). CFD is being used for people with depression and is also being recommended by NICE because CFD is amenable to testing as per the RCTS and can therefore be aligned to evidence based practices. In that sense, CFD provides an example of a therapy that is based on person centred approach but at the same time can be compatible with medical model as it is evidence based in nature. Pre therapy was developed by Garry Prouty based on his research with clients in repressive states who were confined to the psychiatric institutions (Prouty, 1994). Prouty based his research on Rogers, who wrote about contact and connect with those who were ‘out of reach’ (Prouty, 1994, p. xviii). Therefore, pre therapy is based on the concept of psychological contact. Clients with autism, dementia, brain injury, and other such conditions that make them ‘out of reach’ are treated with pre therapy (Prouty, 2001).

Other therapies include Person Centric Expressive Arts Therapy, which emphasises on the enabling of the client to explore, express, and become more aware of themselves through creative arts (Goldman, Brettle, & McAndrew, 2016). This is a humanistic approach to therapy. Another such humanistic approach can be found in the use of Focussing Oriented Therapy, which is more directive in nature as the client is encouraged to get more connected to their internal selves through bodily felt senses (Goldman, Brettle, & McAndrew, 2016). Emotion Focussed Therapy is also based in humanistic approach, with more directive approach by the therapist who guides the client to reflect on current experiencing. Mearns Configuration of Self is based on the premise that self includes multiple aspects of personality (Mearns, 2003).

With regard to the comparison between person centred approach and medical model approach, the basic difference is that the former is more client oriented. Emil Kraepelin, a German psychiatrist, laid the foundations of the medical model of mental health (Hippius & Müller, 2008). The medical model is based on the approach that links behaviour with psychology. The core tenets of this approach include a notion that mental disorders are linked to biological abnormalities located in the brain and are in that sense indistinguishable from physical diseases, and that such disorders can be treated with the help of biological treatment (Deacon, 2013 ). Kraepelin’s work is important in the context that he laid the foundations for organic etiology, which holds that the genetic or biological factors are related to the psychopathology and each class of psychopathology can be explained on the basis of the specific genetic or biological factors (Decker, 2004). This view is the basis of the generally accepted paradigm than classification can lead to diagnosis and this is linked to organic etiology (Decker, 2004). In other words, the medical model sees mental illness as a set of symptoms that can be diagnosed and treated by approaching these symptoms in a way that classifies mental health conditions and links them to the underlying genetic or biological factors (Deacon, 2013 ). Although, Kraepelin’s work was also criticised for some reasons, there is also a revival of his approach in the American neo-Kraepelinian school of psychiatry, which has also been influential in developing DSM-III (Ghaemi, 2009). DSM or the Diagnostic and Statistical Manual is based on the medical model of psychotherapy as it classifies mental disorders as brain diseases informed by the medical model (Deacon, 2013 ). The DSM is not free from criticism, some of which stems from its medical model roots; it is argued that the medical model lacks clinical innovation and also at times leads to poor mental health outcomes. (Deacon, 2013 ). Furthermore, it is argued that the emphasis on the use of drug trial methodology in psychotherapy research and empirically supported psychological treatments leads to a neglect of the treatment process, and restricts innovation (Deacon, 2013 ). In England, this emphasis on the pharmaceutical industry and drug trials in America has been met with criticism from the NHS itself, which has noted that the DSM-5 is influenced by the pharmaceutical industry that is heavily invested in the production of antidepressants prescribed by the clinician psychologists in America (NHS, 2013). Another criticism of the DSM-5 is that there is an increasing tendency to "medicalise" patterns of behaviour and mood not otherwise extreme in nature (NHS, 2013). In other words, while the DSM is heavily based on a medical model approach, there are some criticisms against it, which may be relevant to how NHS seeks to provide mental health services in a way that is different from how it is done in DSM.

In England, a major review of mental health services was undertaken after a report on depression by Lord Layard, wherein he noted that depression and other mental health issues were becoming a burden on the national health system (Layard, 2006). After the publication of this report, there has been a conscious effort to improve mental health services. The IAPT or the Improving Access to Psychological Therapies programme is one of the developments in this area. This programme was initiated in 2007 soon after Layard (2006) report was published. The purpose of IAPT is to offer Evidence Based therapies that are recommended by the National Institute for Health and Clinical Excellence (NICE) (National Collaborating Centre for Mental Health , 2010). NICE is an independent institution with accountability to the government. One of the tasks of NICE is to provide national guidance for improvement of health and social care. For instance, NICE recommends Cognitive Behavioural Therapy for the treatment of depression (Middleton, Shaw, Hull, & Feder, 2005). The recommendations are usually based on the results of Randomised Controlled Trials or RCTS, which can help researchers to measure the treatment effects (Goldberg, 2006). RCTS involves designing studies for the purpose of measuring the efficacy of treatments and such studies are used for both medical and psychological treatments (Goldberg, 2006). The use of RCTS can also be understood against the background of using more evidence based practices in the field of medicine and psychotherapy. It may be noted that the NICE produces its guidelines using a hierarchy of evidence, with the data from meta-analyses of randomised controlled trials being at the top of the hierarchy and the opinions of acknowledged experts being at the bottom (Goldberg, 2006). This may mean that while the data from RCTS attains top level acceptance for the recommendation of treatments, the qualitative data comprising the opinions of acknowledged experts does not have the same credibility for informing treatment practices under NICE guidelines. The difference accorded to the two kinds of data boils down to the evidence based value of the data.

Evidence based practices are based on the recommendation of the treatments on the basis of the empirical evidence that demonstrates the efficacy of the treatments. RCTS allow researchers to conduct studies to gather empirical evidence on how effective such treatments may be. There is one area where such RCTS based treatments may conflict with the idea of person centred approach, in that, RCTS is based on the empirical evidence and uses methods like screening tests, whereas a person centred approach would be qualitative in nature. This conflict has led to some practitioners questioning the approach of the NICE recommended therapies and NICE guidelines as overriding the interests of the clients. Among such critics of the NICE guidelines and evidence based therapies are those who are afraid that counselling is taking a backseat (Cooper, 2011). It is argued that the over emphasis on the evidence based therapies and RCTS in the NICE guidelines means that there is a downgrading of counselling, which adds to the existing notions of counselling as a control treatment and not as an active intervention (Cooper, 2011). On the other hand, counselling is seen as a more effective method as it involves deep connection and immersion by the therapist (Cooper, 2011).

IAPT is evidence based and uses outcome measurement to assess the efficacy of the treatments; this is done through data collected from client questionnaires that measure recovery rates for the purpose of measuring the outcomes of the treatments (Clark, 2011). Thus, depression in clients is measured through the questionnaire PHQ-9 and anxiety levels are measured through the questionnaire GAD-7 (Clark, 2011). While such measures are supported by evidence based practice approaches, these measures are also linked to the person centred approach (Clark, 2011). For instance, the general framework of IAPT services was outlined in the Department of Health’s National Implementation Plan of 2008, as per which one of the key principles was to apply person-centred assessment method for identifying the key problems requiring treatment and the social and personal contexts for the same and even the goals for therapy and a treatment plan is jointly agreed upon between the therapist and the client (Clark, 2011). It can be said that there is some effort made for reducing the over emphasis on the medical model of therapy and involvement of a person centred approach. It may also be mentioned that there is some criticism of the use of feedback from clients on NHS psychotherapy services, which suggests that while the feedback may improve the outcomes for clients who are at risk of treatment failure, these may not improve outcomes in more severe psychiatric populations (Davidson, Perry, & Bell, 2015). The limitations of such feedback is linked to methodology and study quality (Davidson, Perry, & Bell, 2015). Therefore, when the approach of the therapy is over emphatic of the medical model, there are certain areas of concern that stem from the absence of a person centred approach.

The person centred approach itself is not free from criticism. One of the criticisms of the person centred approach vis a vis the medical model approach is that the person centred approach does not have as robust a methodology as medical model approach and remains steeped in humanistic and holistic concerns that are difficult to define clearly (Sommerbeck, 2014). The medical model uses clear diagnostic terminologies, such as, disorder, diagnosis and treatment. These terminologies are based on evidence based research. On the other hand, it is argued that the terminologies used in person centred approach, based as they are on humanistic principles, are vague, such as, openness of the client to change, and choice of the client (Sommerbeck, 2014). As the person centred approach puts client in the centre, there is a tendency of the practitioners to use the terminologies that are based on the client. Therefore, it is argued that the person centred approach is yet to achieve the same level of credibility as the medical model has. It is emphasised that in order to receive this level of credibility, the person centred approach should align with the medical model. CFD is an example of how this can be done, although it is still seen as a challenge to the medical model by some (Goldman, Brettle, & McAndrew, 2016). Nevertheless, the CFD model is different from a traditional person centred approach in that it is based on collaboration and negotiation on client goals, but it also employs the counsellor instigated regular reviews of the progress and client goals (Sanders & Hill, 2014).

In order to understand the background of the criticism of the person centred approach, it has to be noted that the medical model has long been established as the dominant paradigm of treatment of mental distress, with clear terminologies on the diagnosis and treatment of the mental distress, while person centred approach is a newer model of therapy (Goldman, Brettle, & McAndrew, 2016). Clinician psychologists are already established in their field and it is possible that counselling therapists are viewed by them as being a challenge to the established ways (Lewis & Bor, 1998). This may be a reason why the person centred approach has yet to achieve the level of acceptance and credibility that is already acquired by the medical model approach; in a research study involving NHS clinician psychologists to explore their views about counselling therapists, researchers found that clinical psychologists were by and large confused about the competencies of counselling psychologists and that much of this confusion was attributable to a lack of information regarding the content of training of the counselling psychologists (Lewis & Bor, 1998). Another issue is the role of the clinician in the two models. The medical model approach is based on the premise that the clinician has a directive approach towards treatment of the client. On the other hand, the person centred approach sees the clinician as a non directive force that enables the client to grow. In other words, the person centred approach allows more autonomy to the client and less directive force to the clinician whereas the medical model approach proceeds from the opposite point of view. Contrary to the critique of person centred approach as not having credible measuring criteria for understanding the impact of the treatment on the client, the practitioners in this area do have methods of assessment of the relationship potential between the client and the therapist. The model developed by Dave Mearns is useful in this respect as this model focusses on the ability of the therapist to heal and enable growth of the client through deep and close contact between the two (Mearns, 2003).

The person centred approach sees the client as having autonomy over the self and envisages the function of the therapist to help the client grow through experience. This approach is different from how the medical model uses organic etiology to classify, diagnose and treat mental distress. The major difference between the two models is the level of autonomy to the client and the level of directive force allowed to the therapist. The person centred approach envisages the client to have the central role in the process of change and growth. It uses humanistic approach and principles to create terminologies that will describe the client’s conditions but not label the conditions in ways that are deemed to be pejorative. On the other hand, the medical model puts clinician at the centre, uses medical terminologies to define client condition, and devises treatments based on evidence based approach. Since Rogers first developed the client centred model of therapy, more developments have taken place within the field of person centred approach. Some of these developments, like the CFD, are more closely linked to the medical model in that they are also based on evidence based practice. There is some indication in these developments as to how the person centred approach and the medical model approaches to therapy can be aligned to some degree. Therapies like the Person Centric Expressive Arts Therapy are more focussed on the Person Centred approach as these are humanistic approaches to therapy that are non directive in nature. However, there are other therapies which are based on Person Centred approaches but are also aligned to the medical model approach, because these are directive in nature. Examples can be found in the use of Focussing Oriented Therapy, which is more directive in nature as the client is encouraged to get more connected to their internal selves through bodily felt senses and Emotion Focussed Therapy, which is also based in humanistic approach, but with more directive approach by the therapist who guides the client to reflect on current experiencing. The development of these different kinds of therapies indicate that there is some scope for aligning Person Centred approach to the medical model approach. At the same time, the Person Centred approach has to take a distinct humanistic approach in order to remain centred in the client.

References

• Champion, J. (2016). Research Briefing Psychological Therapies in Wales . National Assembly for Wales Commission .
• Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. International review of psychiatry, 23(4 ), 318-327.
• Cooper, M. (2011). Meeting the demand for evidence-based practice. Therapy Today, 22(4), 10-16.
• Davidson, K., Perry, A., & Bell, L. (2015). Would continuous feedback of patient's clinical outcomes to practitioners improve NHS psychological therapy services? Critical analysis and assessment of quality of existing studies. Psychology and Psychotherapy, 88(1), 21-37.
• Deacon, B. J. (2013 ). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review , 33, 846–861.
• Decker, H. S. (2004). The psychiatric works of Emil Kraepelin: a many-faceted story of modern medicine." Journal of the history of the neurosciences. 13(3), 248-276.
• Ghaemi, S. N. (2009). Nosologomania: DSM & Karl Jaspers' Critique of Kraepelin. Philosophy, Ethics, and Humanities in Medicine, 4(1), 10.
• Goldberg, D. (2006). The “NICE Guideline” on the treatment of depression. Epidemiology and Psychiatric Sciences, 15(1), 11-15.
• Goldman, S., Brettle, A., & McAndrew, S. (2016). A client focused perspective of the effectiveness of Counselling for Depression . Retrieved from http://usir.salford.ac.uk/id/eprint/40613/