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A Discussion of the Medical Model in Clinical Practice

Posted By Robert DePaolo On July 3, 2012 @ 8:50 pm In Psychology | No Comments


Robert DePaolo


This article discusses
clinical practice in terms of the medical model, particularly with regard to
the Freudian notion of a psychic homeostat, and more broadly, the tendency in
physiological and psychological systems to re-integrate in response to systemic
disruptions. The point is made that the personality automatically moves toward
re-stabilization and state restoration when under duress and that clinical
intervention can either enhance or interfere with that process; thus raising
the question of whether counseling is appropriate, whether the ostensible
pathology can be culturally,  as opposed
to existentially defined, and how clinicians might proceed to establish a new
stasis that coincides most closely with the client’s natural restorative
responses and cognitions.

With respect to the process of psychotherapy there is nothing unusual or derelict about “leaving
the client to his own devices” – even in the aftermath of duress (Aubrey, Bond et. al. 1997). Since  Sigmund and Anna
Freud (1967) first developed a framework for the use of defense mechanisms (which Sigmund likened to the immune reactions to disease in the soma)
clinicians have come to agree that defense mechanisms work to restore stability. In that sense they operate much the same way as any system in nature
– seeking, as it were, to revert to a prior state. All such systems, which could encompass everything from physiology to cognition to atoms to the
structure of human language require some degree of redundancy. Indeed one could draw a parallel between quantum mechanics and clinical psychology by suggesting
that, like the photon, the personality has a memory of its inherent structure and is disinclined to deviate from that.

The traditional, psychoanalytic view derives from a medical model and holds that the true essence of pathology is not to be found in the original contaminant – be it microbe
or traumatic event – but rather in the individual’s response to that event. (Shah, Mountain 2007). In somatic terms, an elevated body temperature is needed to mobilize phagocytes.

Yet if this leads to chronic high fever the ostensibly curative immune response would in itself be viewed as the symptom of disease,
i.e. the homestatic correction would be too extreme. Similarly, psychological defense mechanisms are needed to restore psycho-stasis but if mobilized to a harmfully
distorted degree they would themselves come to be viewed as part of the syndrome.

The preceding statements amount to little more than a collective tautology in that they simply reiterate common themes of clinical practice. After all, cognitive-behavior
therapists, psychoanalysts and client-centered counselors all pivot off the idea that the secondary disease process – the client’s maladaptive schemes,
attitudes and self image – must, like an elevated body temperature, be modulated before the original contaminant can be dealt with. So in counseling
the language and cognitions of the client are altered in the direction of reasonableness and functionality, regardless of the method.

On the other hand such a simple premise has two potentially broad and interesting ramifications with respect to diagnosis and treatment. One has to do with the question of whether and to what extent treatment is needed. The other pertains to whether counseling could actually be counterproductive (Baker, 1996), (Whittaker, 2004).

Reverting back to the somatic model: an elevated body temperature could become extreme in response to two factors: the degree of infection (homeostatic disruption) and the duration
of infection. If the instability produced by the event is mild to moderate, the adaptive response will not likely be extreme or lengthy, in which case the “take
an aspirin and call me in the morning” adage would constitute a best practices standard. By the same token, treatment beyond that (for example prescribing
strong antibiotics) would run askew of the ethical mandate against over-treating patients.

In terms of clinical practice it would mean that following an intake the counselor might in some instances explain to the client that the problem is not severe, that using his
own natural coping devices (defense mechanisms and arousal modulating behaviors) would be sufficient. In order to make that determination the counselor would
first have to decide on the severity and duration of the disruptive event or events, on the client’s defensive skills and perhaps most importantly, on the
client’s resilience (Shiskina, Kalinina.et. al. (2010)

The Susceptibility Factor

Just as a minor infection can lead to severe illness in a patient with a pre-existing immune disorder, so too could a minor psychological setback lead to more severe psychopathology for
an individual with low resistance to stress. While determining pathology-resistance is a somewhat subjective process, certain factors could provide grist for the mill, for example..

• A tentative self image, whereby the client has no clear identity parameters and consequently cannot protectively categorize his emotions, behaviors or the effect events have on
him. Bear in mind that this is different from a poor self image which, despite its drawbacks can often provide enough clarity to fend off duress – for example by enabling the individual to revert to a passive, dependent mode, thereby freeing himself from the burden of conflict resolution and allowing him to egosyntonically have his needs to be met by others.

• A constitutional predisposition – high incidence of pathology in the family and a history of susceptibility to duress.

• A chronically high arousal level, as seen in PTSD clients and those with a proneness to panic attacks and medical problems such as hypertension.

• The presence of neurological disorders that limit the client’s capacity to attend and by virtue of perseveratory tendencies preclude his being able to integrate experience.

• Physical problems, forcing the mind-body system to devote more energy resources to physical adaptations, thereby depleting energy resource that might otherwise be used to
enhance psychological adaptation.

• Inadequate language capacities, rendering defense mechanisms (which rely on labeling and proportional thinking/self-persuasion capacities) ineffective at fending off
duress and instability.

Internal and External Gauges

While some have describe Freud’s psychoanalytic model as out-dated (Kihlstrom 2010) his description of the ego is arguably timeless. In general terms, three criteria
of psychopathology are important to consider. One pertains to the incongruous juxtaposition of the client’s self restorative psychological adaptations on
socially accepted norms. This has two features. On one hand the client is able to maintain or restore pycho-stability by distorting perceptions and beliefs to
override anxiety and provide internal closure. This can take the form of extreme use of defenses, aggressive behavior, which actually produces a
rewarding effect in the central nervous system, (Annemoon & Miczek 2000) or even self medication in the form or alcohol and drug abuse. In this context the
client’s cognitive schemes and behaviors serve to alleviate his own internal suffering and anxiety. This can occur through reestablishing stasis within the
self image, by providing structure (even if delusional) to otherwise amorphous, disabling emotions, or through aggression, which converts uncertainty and loss
of control into resolution and the fear of threat into threat-reversing dominance. The pathogen in this case would be found in the lack of congruence
between these adaptations and societal norms. In simpler terms the client makes himself feel better but society undoes all that by making him feel worse due to
the antisocial or socially unacceptable nature of those adaptations.

Despite deriving from psychoanalytic theory, defense mechanisms can be viewed in terms of behavior theory – as Miller and Dollard suggested  (1950). Defense mechanisms have, in effect, many of the properties of a negative (“relief”) reinforcer. Through their use the client is rewarded via avoidance or escape from duress. In accord with general
behavior theory, such patterns will be difficult to undo in therapy simply because they are existentially therapeutic.

A second aspect of psychopathology is the antecedent feeling of duress that causes mobilization of defenses and whether it persists, either chronically or intermittently, despite
patho-adaptations (hesistate to call them maladaptations because on some level they work). As an illustration; aggression produces a temporarily pleasurable
feeling. However the long term effect of such behavior could be divorce, alienation of friends, guilt or even incarceration.

A Test for the Ego

As Freud suggested, there are several key tasks for the ego in moderating between impulse/need fulfillment and the inhibitory restraints of conscience. Here, rather than
reiterate those tasks, it was decided to pose three questions with regard to the ego’s capacity to carry out its functions.

1. Does the temporary relief created by the client’s adaptive/restorative but socially prohibited thoughts and behaviors represent a net loss or a net gain with respect to long term internal equilibrium and external adaptation?

2. Does the temporary relief created by these thoughts and behaviors produce actual, immediate relief from duress or simply redirect arousal levels and emotional impetus to someother source of duress – for example paranoid thoughts could provide ideational closure in a disheveled central nervous system but also foment enough suspicion and sense of threat as to produce more duress than the initial state of confusion.

3. Can the ego facilitate the learning and enactment of cognitive and behavioral responses that provide immediate self-restoration, broad psycho-physiological relief                             and  long  term  benefits within the bounds of social probity?

The last of these items is of prime concern, not just for the ego but for the counselor as well. Whether a perfect or optimal cognitive-behavioral solution can be found for any
given client is open to question. Immediate psycho-physiological gratification seldom coincides with long term adaptations. Indeed, as most counselors know,
the initial stages of counseling tend to be rather unsettling for clients. After all, a world view is being challenged and prior, quasi-functional habits
like substance abuse, chronic acts of dependency and aggression are being redirected.

The use of psychiatric medications can provide psycho-physiological relief but do not entail any sort of training or learning. Since the original source of the self-restorative but
socially questionable thoughts and behaviors is physical discomfort medication might be presumed to obviate the need for extreme defenses. However in many
instances maladaptive beliefs and habits persist despite the use of medication. Perhaps that is because psychotropic drugs do not create new neurological
configurations in the brain. They work primarily by altering arousal and conductivity levels.

Another possible reason medications don’t undo pathology is that the pleasure reaction that comes from self-restorative cognition and behavior is more in sync with how pleasure
response consists not of a singular experience but rather a bimodal one. Whether in the domain of sexual relief, social gratification, or appetite, the
pleasure cycle involves going from a state of uncertainty or tension to one of stability and closure. Since medication typically involves no duress to resolution
sequence it probably cannot substitute for the internally adaptive, self-restorative thoughts and behaviors used by clients in response to duress.

That means the ultimate ego function consists of a quintessential conversion that involves acting and thinking in ways that restore stability, resolve self image uncertainty and
provide long term psychosocial adaptation. In that context the tasks of the counselor are the same as the tasks of the ego, i.e. to prompt or encourage
pleasure-inducing behaviors that are socially appropriate, to prompt or encourage thought patterns that restore stability but are within the domain of
social norms and prompt or encourage behaviors that can operate throughout the life cycle.

In the final analysis, the parameters of the medical model would seem to create a isomorphic relationship between the counselor and the client’s ego, whereby the counselor
provides an external ego function until such time as the client is able to internalize those functions for purposes long term adaptation. In that context the
counselor’s role as “prosthetic ego” involves the dual considerations of whether to treat, as well as how to create an adaptive  balance between the effects of internal and
external experiences of the client.


Aubrey, C. Bond, R, Campbell, R (1997) Clients’ suitability for counseling. The perception of
counselors working in general practice. Counseling Psychology Quarterly. Vol.
10 (1) March 1997. 97-117

Annemoon, MM von Erp, Miczek, K (2000) Aggressive Behavior, Increases Accumbal Dopamine and Decreased
Cortical Serotonin in Rats. The Journal of Neuroscience 20 (24) 9320-9325.

Baker, R. (1996) Mind Games; Are We Obsessed with Therapy? Prometheus Books

Dollard, J & Miller, NE (1950) Personality and Psychotherapy: An Analysis in Terms of
Learning, Thinking and Culture. New York, McGraw Hill

Freud, A. (1967) Ego and the Mechanisms of Defense. Revised Edition.Brooklyn, NY. Goodbooks,

Kihlstrom, JF (2010) Is Freud Still Alive? No, not Really. In. Atkinson,R. Atkinson, RC, Smith, GE.
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Shah, L & Mountain, R. The Importance of Medical Model in Psychiatric Clinical Practice. Article
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Shiskina, GT. Kalinina, TS. Berezova, IV. Bulygina, W. Dygala, NN (2010) Resistance to the Development
of Stress-Induced Behavioral Despair in the Forced Swim Test Associated with
Elevated Hippocampal Bci-Xl Expression. Behavior & Brain Research 213 (2)

Whittaker R. (2004) Mad in America; Bad Science, Bad Medicine and the Enduring Mistreatment of the
Mentally Ill. Basic Books




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