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 Selected Sharma Materials: Editor's Introduction to The Medical Model of Mental Illness Sohan L. Sharma, Ph.D.
Chapter II
Chapter VI
Chapter VII
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Medical Model And The Clinical Psychologist'S Professional Identity by Sohan Lal Sharma, Ph.D. INTRODUCTION Professional identity is the awareness of one's role and the functions that one performs or is expected to perform in a social-institutional setting as a member of that profession. This awareness, as it were, brings about a partial psychological amalgamation of the person with the function he performs and defines his role relations with others (DeLevita, 1965; Ekstein, 1957; Erikson, 1956). It is perhaps true that the nature and process of training, and the social status and recognition accorded to a profession are the two major factors in the carving of a professional identity. This is particularly true in the "established" professions of law, physics, engineering, medicine, etc. However, in the emerging and inchoate profession of clinical psychology, a series of historical, sociological, and institutional factors hitherto not explicitly examined have influenced and largely shaped the formation of the clinical psychologist's professional identity. The thesis of this paper is that the professional identity of the clinical psychologist has been formulated with reference to a medical model. (See Ch. 2.) As a consequence, this professional identity has become confused and fraught with disagreement. Further, it is to be concluded that the clinical psychologist can scarcely forge a gratifying identity until he explicitly eschews this model. Development of the thesis is presented under: (A) historical and social factors underlying the formation of the present professional identity of the clinical psychologist; (B) the transition of the clinical psychologist's professional identity during the sixties; (C) a proposal for more appropriate and gratifying professional identity for the profession.
A. HISTORICAL AND SOCIAL FACTORS Clinical psychology emerged from two sources: (1) testing and assessment, and (2) medicine and psychiatry. Both have markedly influenced the formation of the professional identity of the clinical psychologist. Early application of psychology to the practical affairs of life came through developments in testing and assessment. Psychological tests were first used in school systems to assist in the placement of children. Later, during the first World War, and increasingly during World War II, the psychologist's main contribution was in the assessment and selection of soldiers for the armed forces. After the end of the second World War, clinical psychology began to emerge as a distinct field, it was assumed that psychology's contribution in clinical setting would be that of testing. Therefore, the role that was assigned to the clinical psychologists in a medical-psychiatric setting during the early years was that of a tester-psychometrician concerned wholly with clarification of psychiatric diagnosis. It was postulated that he, like any other technician in a medical setting, such as an X-ray technician, would demonstrate and measure the diseased or sick organ; viz., the mind (Frank, 1948). Based on this historical precedent, a major aspect of the clinical psychologist's identity remains tied to the testing function (L'Abate, 1964; Rosenwald, 1963). The tradition of the medical and psychiatric institutions is the second factor in the formation of the clinical psychologist's identity. The early settings of clinical psychology's learning and application were psychiatric and medical institutions. Working in a psychiatric setting, the clinical psychologist tacitly accepted the medical model and extensively employed the concepts and nomenclature of physical medicine. He also assumed the position that interpersonal and psychological disturbances were not unlike physical disease, and thus classified people in terms of sickness and health (Adams, 1964). This institutional setting and role assignment has left many imprints upon the psychologist's professional identity: First, he develops feelings and role definition that, as a "helping profession" his role is somewhat peripheral. Although he works in an institutional setting designed for helping others, their treatment is rarely identified as his role function. He may see this as something lacking or amiss in his training.* +++++++++++++++++++++++++++++++++++++++++++++++++++ *In this connection it is quite significant to note that many psychologists, after completing their Ph.D., resumed their education in order to obtain a medical degree. +++++++++++++++++++++++++++++++++++++++++++++++++++Concurrently, there may emerge some personal doubts about his own professional value. He is a doctor but not a "real" doctor; he frequently must perform with techniques, which he is advised by academic colleagues, may be of doubtful scientific value (Garfield, 1966). The assessment and testing functions which first enabled him to enter the field of behavior disturbance also defined his professional role. It later emerged into an identity depreciable to his profession; viz., as an ancillary member of a medical-psychiatric team (Hulse, 1960). In such a context he has developed mixed feelings about his professional identity, and how indeed prefers to see himself as professionally akin to a psychiatrist; albeit, a junior psychiatrist. 2. Universities and the Professional Model Two additional developments have further influenced the clinical psychologist's professional identity: (1) A schism within university psychology departments (Chein, 1966; Kahn, 1955; Lake, 1960; Robertson, 1959; Solomon, 1953), and (2) The A.P.A.-sponsored model for the clinical psychologist. These two developments occurred concomitantly and are mutually reinforcing (The Scientific and professional . . .). However, for clarification, they will be discussed separately here. One might speculate about how such a schism occurred within the academic psychology departments. After World War II, broadly speaking, two somewhat antagonistic forces pulled at the conceptual framework of psychology: One advocated that psychology should remain an encapsulated experimental study, dealing with such elements or isolated functions as memory, sensation, and various physiological reactions; and the other, in the face of vast socio-cultural changes and concomitant demands for service, advocated that psychology should study "man" as a social and interpersonal being. These two broad and vague trends crystallized under such diverse rubrics as the scientist vs. the professional, research vs. practice, basic vs. applied, academic vs. nonacademic, etc. Those who wished to see psychology remain "scientific" in the academic tradition argued that if psychology is to become scientific in the sense of a biological or physical science, then the psychologist should be primarily concerned with "scientific"' research, of an experimental- statistical nature. Furthermore, it was maintained that since many of the tests, techniques, and procedures of psychology are "unscientific," it would be unfruitful to "apply" them to clinical practice until they have been scientifically validated. A fear also lurked in academic circles that psychology might become "professionalized." If this happened, it would not only lose its scientific character, but become less "academic" and "research"-oriented. For those who had been credited with its growth and had been given the power to control and shape its direction, the threat of losing such prerogative was imminent (McKeachie, 1967; Scientific, 1967). Others, who would come to represent the "professional" aspect of psychology, would assume the control and power within the psychological organization. Thus, from its inception, the development of clinical psychology became enmeshed in a kind of power struggle. This was indeed not only to affect the professional identity of the clinical psychologist by generating doubts and confusion about his professional role, but a decade or so later, would threaten to rend the professional organization itself (Bruner, 1965). The second important development in the clinical psychologist's professional identity occurred when the A.P.A. sponsored a model for the clinical psychologist, called the Scientist- Professional Model. With growing demands for the application of psychology to the problems of life, the A.P.A., in the late forties, recommended that the clinical psychologist should be trained as both a scientist and a professional practitioner (clinician). This was heralded by its architects as a model unique in the area of mental health. It was held that this model would separate the clinical psychologist's role and functions from those of the psychiatrist. The psychologist was to be an expert on "research" with an awareness of clinical problems, while the psychiatrist, on the other hand, would continue to be the expert on "treatment." The epistemological uniqueness of this program was based on the argument that, since little was empirically known about the entire field of mental illness and health, its etiology, diagnosis, treatment, and prognosis, the psychologist's unique contribution would be that of research in a barren an unexplored area of knowledge (Eysenck, 1948; Kelly, 1961; Garfield, 1966; Raimy, 1950). Moreover, if mental illness is to be cured, only through such a research program can a "breakthrough" be expected. In this scientist-professional model, it was tacitly accepted that existing concepts, models of mental illness and health, and the assumptions underlying the prevailing models were appropriate for purposes of research. Psychologists were thus encouraged to conduct empirical research upon various aspects of the medical model. A vast amount of such research was completed, as is evident in the literature. Results of these researches provided no breakthrough in the area of mental illness, as the proponents had expected. Neither did they provide appreciable enlightenment concerning human conflict and strains of social living and other problems with which the field presumably dealt (Bakan, 1965). Ratner, such research has served to point up only the unreliability of a few psychiatric diagnostic categories, and limited comparisons among several forms of therapies. The model had thus carried a research emphasis which served merely as a self- checking function within the framework and constraints of the medical model; viz., in evaluating practices of diagnoses and prognoses of mental illness. Little encouragement was provided, however, to look beyond the confines of the medical model in search for understanding human problems. Indeed, few examined the validity of the model itself for its applicability to problems of living. The intrinsic value of the model itself was a begged question. Operationally, the profession of clinical psychology had been defined. It became a profession having but little substantive content or theoretical models of its own making. In clinical practice, assumptions and concepts of treatment, diagnosis and professionalism were derived from medicine and psychiatry. Its usefulness was defined by a continual process of subjecting its theoretical models of other professions to the test of the controlled experiment or statistical analysis (Sanford, 1965; Linder, 1967; Scientific, 1967). Now after two decades of the Scientist- Professional model of clinical psychology, a consensus seems to be that such a model is impractical. Indeed, it has proven to be less than satisfactory as a basis for providing a meaningful professional identity of the clinical psychologist (Cook, 1965; Hoch et al., 1965; Scientific, 1967). 3. Psychotherapy and its discords No single issue has affected the growth and formation of the clinical psychologist's professional identity as has perhaps the question of "who shall do psychotherapy?" The underlying intensity and extensity of the discord that has arisen on this issue cannot even be gauged by the number of controversial articles and books in the professional journals (Anabel, 1956; Brody, 1956; Cowen, 1960; Glaudin, 1966). Because mental illness was first conceptualized in the same way as a physical illness, treatment (psychotherapy) has been delegated to physician-psychiatrists. A non- medical specialist such as a psychologist or social worker attempting to do psychotherapy was then, by definition, performing in an area for which he was ipso facto, not trained or qualified. He was indeed practicing medicine without a license (Cook & Tucker, 1959; Huston, 1953, 1954). This controversy has repeatedly arisen when a physician- psychiatrist has admonished the clinical psychologist as being not properly trained to do treatment (therapy). The clinical psychologist, although he was not medically trained, it was argued, possessed other skills and qualifications to do therapy, albeit under a physician's supervision. In an attempt to resolve this- conflict, the American Psychiatric and American Psychological Associations set up a commission in 1952 (Sanford, 1952, 19531954, 1955). However, basic issues underlying this controversy were never confronted or openly discussed; thus rapprochement was never achieved (American Psychiatric Report, 1960). Not until Szasz's work appeared (Szasz, 1959, 1961) did basic and hidden issues of the therapy controversy become evident; viz., the question of whether psychotherapy is indeed like the treatment of physical disease, requiring physio-chemical and anatomical interventions, or is it different?* If the +++++++++++++++++++++++++++++++++++++++++++++++++++ *Although Freud raised similar issues in his "Questions of Lay Analysis," his writings on this issue were largely ignored by subsequent writers. +++++++++++++++++++++++++++++++++++++++++++++++++++practice of psychotherapy is a treatment like that applied to physical disease, then it should require a medically trained person. If, however, it is unlike curing a physical disease, then it is neither exclusively nor in specialty the bailiwick of medically trained groups. Psychologists and other groups would thus have a "legitimate" claim to its practice. Professional and historical developments have led the clinical psychologist to believe (at least partially) in the medical model. Hence, in spite of the clinical psychologist's claim and preference to be a psychotherapist, he harbored vague doubts about his competence to do psychotherapy independently. Many continued to seek supervision from a medical-analyst or psychiatrist. Others had misgivings about attempting to work with "extremely sick" cases, restricting their therapy to the "mildly sick." They continued to draw an implicit distinction between psychological disturbance; e.g., obsession and a "real" disease; e.g., schizophrenia or psychosomatic disorders, which he believed to be quasi-biological in nature. In spite of these developments, many clinical psychologists mistrusted their feelings of doubt, since many observations; e.g., independent practice of psychoanalysis by a lay analyst, or child therapy, failed to confirm his feelings of doubt about his competence. Such observations made him more confident and justified to move toward independent practice. Yet, both of these became aspects of his professional identity. The psychotherapy controversy also created difficulties for the clinical psychologist in his relations with more research-oriented colleagues. An admonition was implicitly conveyed to him by his academic colleagues for participating in less important aspects of the field in the practice of psychotherapy, rather than research, which was his more profound professional obligation (Eysenck, 1948; Garfield, 1966; Gingham, 1959). These differences tended to generate a measure of professional alienation among psychologists themselves, as well as strife within the professional organization (Bruner, 1965; Chein, 1966). By the end of the 1950's the clinical psychologist may have been described as a disgruntled professional (Kelly & Goldberg, 1959). Although he saw himself as a highly trained professional, he could not, he felt, perform his professional role autonomously. This restriction in role performance was due to external institutional pressures, and partly to feelings of professional doubt and defensiveness. Yet, on the other hand, the clinical psychologist was competent and felt sufficient confidence in his professional role and training to become professionally autonomous. Phenomenologically, he viewed himself as somewhat professionally alienated, since his role and function fell somewhere between that of a psychiatrist and psychologist. The institutions at which he worked, and the operations he performed, were similar to those of a psychiatrist. Yet, he shared a considerable degree of training and background with the academic psychologist. As a result of this hybrid or marginal professional status, manifest tendencies developed to change or rebel against the then professional role definition. Some have referred to this aspect of his striving for a more firm professional identity as analogous to the struggle of a rebellious adolescent (Kelly, 1961). B. THE TRANSITIONAL PHASE The developments during the past few years, the beginning of the decade of the sixties, might be viewed as the beginning of a new phase in the professional identity of the clinical psychologist. Such a change appears to be due to the confluence of cultural conditions, recent research findings and reorientation in certain legal and institutional functions. Through mass media, greater educational facilities, more extensive mobility and ease of communication, people have become more aware of the nature of emotional and psychological disturbances. Due to such familiarity, the stigma attached to seeking help for "mental illness" has decreased. With increasing affluence, the demand for psychological service has grown to such an extent that no single professional group can now retain a monopoly on the therapy market. In such a seller's market the clinical psychologist has now been able to establish himself as an independent practitioner of psychology (Hoch, 1965). Although negative feelings have arisen among such groups as experimental psychologists and psychiatrists concerning the clinical psychologist's practicing psychotherapy and private practice, no legal nor institutional regulations have militated against this practice. This is likely due to the newness of the field, as well as the lack of a clear-cut definition of psychotherapy (Szasz, 1959). The effect of the subtle but negative pressures, e.g., the lack of insurance provisions for payment to psychologists (or social workers) for psychotherapy, the failure to obtain "private referrals"' from clinics, mental hospitals, and other agencies, were still not sufficient to discourage many clinical psychologists from entering private practice. He needed no longer be primarily concerned with testing and assessment and thus could effectively modify his uni-dimensional, ambivalent role of psychometrician. During the late fifties and early sixties, the clients of a psychotherapist presented him with the kinds of problems hitherto not much discussed; e.g., Borderline States, Identity Crises, and characterological disorders. These problems did not fit the existing categories; nor could they be properly handled by the existing techniques. All this suggested that prevailing concepts and methods of dealing with "mental illness" were either not sufficiently comprehensive or were ineffective. Newer modalities of therapy (treatment) came into vogue. Family therapy, behavior therapy, conjoint therapy, to name a few, were developed, and the search for etiology and cures for "mental illness" were extended into a search for the social causes within the community. Thus, within the decade of the sixties, community psychiatry, family therapy, community consultation, etc., were ushered into the widening field of "mental health." Simultaneously, research findings suggested far more similarities than differences in the rationale, outcome, and results of therapies, than were differences between professional groups-doing the therapy. The psychiatric diagnostic categories not only proved to be unreliable but little functional relationships emerged between diagnosis and treatment (therapy), as is expected in medicine. Such findings generated feelings of self-confidence in non-medical therapists, who were often indicated to be as effective as medical therapists (Mariner, 1967). Implicitly, these trends suggested that the field of "mental health" may be more closely allied to the social sciences than biomedical sciences (Yolles, 1966). Hence, this trend gave more weight to the interpersonal context (family, community, etc.) of mental illness. It also tended to blur the status lines within the "mental health" profession since, as this trend would suggest, the problems to be investigated and the remedies to be suggested could hardly be biomedical in nature. During this period mass media, T.V. and press, has also been an important factor in modifying the psychologist's professional identity (Bauer, 1964). The appearance of the clinical psychologist over mass media and his contribution to various popular magazines regarding the problems with which laymen have been concerned; e.g., delinquency, child development, marital problems, techniques of treatment for "mental illness," etc., brought him some public recognition as a professional expert. Transition in the professional identity of the psychologist was effected by legal and organizational factors, too. During this period, a majority of the states passed either licensing or certification laws for psychologists, much like those for any other professional group. Such legal or quasi-legal acts helped in various ways to further define the role and position of the psychologist. It became possible for the psychologists to present themselves as a cohesive group defined by law. Their "patients" could deduct their fees for income tax purposes. Due to such a quasi-legal recognition, a few years later he would lay his claim to the health insurance companies as one of the "experts" in the 'mental health" field with a right to be reimbursed for his services. A transition in the professional identity of the clinical psychologist could be sensed since his role functions and image in public had begun to change. He now felt like a "professional"; one who is becoming known and accepted and whose worth is being recognized by the community; who was beginning to accord more faith and confidence to his own professional contribution to society; and who might be in the process of gaining his professional autonomy. Without having been able to resolve some of the still-persisting ambivalent and negative aspects of his identity discussed above, these new or positive dimensions made his identity somewhat diffuse and unanchored, but nonetheless, comprising some really positive elements. With a gradual blurring of distinctions between the psychiatrist and the clinical psychologist, with a gradual awareness that many of the mental health problems are social and interpersonal in nature, with the attainment of a legal or quas-illegal status as an expert in the mental health field; and with a growing share of rewards and power in the field of mental illness and health, it became a matter of self-interest for the clinical psychologist and his organizations to implicitly endorse the prevailing mental health ideology and its existing institutions. By the middle of the decade of the 1960's, the field of clinical psychology continued to regard the medical-psychiatric settings, in contrast to non-medical settings, as qualitatively superior places for training and education; such evaluation is endorsed by our organization (American Psychological Association)(Pottharst, 1967). " --- In 1956 all of the Type G* internships approved by +++++++++++++++++++++++++++++++++++++++++++++++++++ *A Type G internship is one that is open to intern from different training programs, offering experience with a wide variety of clinical problems, or else, offering an outstanding experience of its kind. +++++++++++++++++++++++++++++++++++++++++++++++++++the A.P.A. (American Psychological Association) were in medical-psychiatric settings. Ten years later, in 1966, somewhere in the neighborhood of 87 per cent of such internships were still in psychiatric settings. Now this is exclusive of V.A. training settings--if we include over a hundred V.A. internship settings, we come up with a conservative estimate of a 5 to 7 per cent departure from the medical model in the last ten years (1956-1966). At this dizzying rate of change, thirty three years hence, by the year 2000, 72 per cent of approved clinical psychological internships will still be located in medical settings. "With regard to the student counseling centers, psychological and educational clinics, etc., --- many a university will not recognize [these centers to be] potential training settings as qualifying according to its own standards unless psychiatric supervision is provided." (Pottharst, 1967) Thus by the end of the decade of the sixties, the two conflicting and contradictory aspects of his professional identity persisted. On the one hand, there emerged a growing awareness with regard to the conflicts around the medical model, and a gradual, diffuse, and sometimes abortive attempt to disengage from the model. On the other hand, the endorsement of training in medical settings, the implicit acquiescence (along with the academic psychologists) in the conceptualization of the "newer" development within the medical model framework also persisted. Due to such a contradiction he (along with the academic psychologists) has been unable to renounce the medical model. The late sixties and early seventies were to witness various indirect -- indirect, since only a few openly challenged the medical model, endeavors on the part of the clinical psychologist to resolve the existing identity conflict, e.g., setting up a professional school for the psychologists; a zealous acceptance of behavior modification, sensitivity, T-group techniques and procedures, etc., as total ideology for explaining and handling the problems of living, and as a substitute for the medical model (Stayer, 1970). C. THE FUTURE The foregoing discussion suggests a diffuseness and lack of consolidation of the professional identity of a clinical psychologist. Indeed, many psychologists acknowledged that one of the major issues facing the clinical psychologist is the still painful and urgent problems of [professional] identity (Hoch et al., 1966; Scientific, 1967). As this discussion suggests, this painful problem is generated by the acceptance of the medical model. If one continues to accept the medical model of mental illness and believe that disturbed people are "sick" or "ill," like the physically sick, then a clinical psychologist, along with others (physicians, law-makers, etc.) will have to continue to endorse the high priority given to hospital beds, medicines, syringes, and pills, and the available research funds will be spent largely to support such institutions and institutional practices (Albee, 1967). As long as the clinical psychologist accepts such a model, he will perpetuate the present inter- and intra- professional discords, regardless of whether he works within the framework of community psychiatry (Reichler, et al., 1964), school system (Reger, 1965), or a mental health setting. Nor will he be able to contribute meaningfully and significantly to the making of the current and future society, since the illness model generates a "medical ideology" which, as it were, estranges the psychologist from the mainstream of social issues and conflicts which generate conflicts and problems. The medical ideology and illness language provides a framework of research which is tangential to the main issues of social existence and human relationship which constitutes the field of clinical psychology. This dilemma is rather vividly demonstrated by the developments of the past few years. Conceptually, since the-field of clinical psychology (and psychiatry) has accepted the medical model and its ideology, the field could not successfully incorporate within its conceptual- ideological framework many of the newer problems of the past decade: for instance, the problem of the youth discontent; the problems of the "dropouts" from the-culture; the draft card burners and the expatriates; the problems of the marijuana smokers and the LSD-experience seekers; the problems of the black militants and rebels, etc. The major conceptual context in which these problems have been cast and understood has been much the same as for understanding any other form of "mental illness," i.e. a form of deviance from the major value structure of the society which is put in medical language. This is one of the reasons that the field(s) have made little significant contribution to the understanding, clarification, and resolution of the issues and conflicts of our times. What would be a more befitting professional identity for the clinical psychologist? Apparently, it should be that of a social educator (Szasz, 1959, 1963). This could be achieved, first by conceptualizing psychiatric problems not as medical problems but as the issues of social- interpersonal existence (Szasz, 1961) as problems of education and learning (Hobbs, 1964), and as issues of social-ethical dilemmas. In actual practice, whether the situation is testing, psychotherapy, or consultation, these issues constitute the subject matter with which the client, the therapist, or the consultant struggle (Szasz, 1965). It should be noted, in passing, that Freud had suggested that psychotherapy and other similar enterprises are educational and learning endeavor for the client, and presumably for the therapist also. If the field of clinical psychology is conceptualized within such a framework, then the clinical psychologist's professional identity would become relatively more congruent with his background, his training, and the functions he performs. The clinical psychologist's background, training, and value system is that of a behavioral- educational scientist (Janowitz, 1954). By defining the operations he conducts in these terms, he would encroach upon no other field. He will deal with interpersonal conduct, conflicts, and social-ethical dilemmas of people. He will be involved in re-education and retraining of people, an involvement for which he is better prepared, rather than the diagnosis and prognosis of disease, as he does in the medical model. To conceptualize these problems in broader social, historical, educational, and existential framework should enable a psychologist to comprehend far more effectively the interpersonal and social conflicts and personal troubles of his clients, may they be problems of alienation, anguish, despair, or opting out of life. Such a conceptualization would also provide a better framework for psychotherapy and consultation than does the existing medical one. In an illness model approach, these basic issues of existence are handled only indirectly and tangentially, since a client is considered primarily to be sick. Indeed, the illness model and medicalization of human problems is a way of escaping confrontation with the onus of one's choices and the consequences thereof. If the clinical psychologist is to deal squarely with the struggles, frustrations, joys, and sorrows which have led a client to seek help, he will have to eschew the illness model. Another aspect of the clinical psychologist's professional identity should incorporate the role of an educator. Thus far a clinical psychologist has considered education and teaching as the "nadir" of his professional identity and has struggled to affirm a doctor-healer identity. Yet the clinical psychologist, by virtue of the operations he conducts in his daily professional activities, is an educator (Szasz, 1965, 1966). He endeavors to bring new awareness and knowledge to the client (about himself). He assists his clients in the ways of relating to others, in modifying outlook, attitudes, behavior, and new ways of mastery. Hence, in espousing the educational role functions, not only will his training be more suited to the kind of tasks he performs, and the operations he conducts will be more commensurate with his new role, but his work in many diverse settings will be possible with more inner confidence and freedom since he would be unhampered by any externally imposed model which undermines his training and role performance. Without the conceptual constraints and contradiction of the medical model as this discussion suggests, he should be able to create his own unique and autonomous professional identity, As has been discussed above, the acceptance of the medical model, its institutions and its ideological framework has caused an identity confusion; yet at the same time it has also generated a vested interest in the explicit or implicit perpetuation of the illness model and the mental health ideology. Sooner or later, he will have to raise the issue whether he would desire a confused (and ancillary) professional identity with growing material rewards, or whether he would eschew the medical model of mental illness, and possibly the concomitant monetary gains, and desire a more gratifying and consistent identity.
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