Truth or consequences: a neopragmatic critique of contemporary mental health culture.

The mental health counseling profession has increasingly identified with the values of contemporary mental health culture by adopting a descriptive, medicalized perspective. Using a postmodern, neopragmatic analysis, I argue that the consequences of adopting this perspective must be considered. Two such consequences are discussed: (a) the abandonment of an effective, relational orientation toward helping, and (b) the forfeiting of the unique contribution that a traditional counseling perspective can provide to contemporary mental health culture.

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During the last several decades, mental health culture has been increasingly dominated by a medicalized vision of human emotional suffering (Barney, 1994; Chodoff, 2002; Hansen, 2003, in press). That is, there has been a greater emphasis on manifest symptoms, classification of particular symptom constellations, and technical strategies for improving client functioning. This emphasis on overt symptomatology and concomitant de-emphasis on subjective experience (Hansen, in press), is characteristic of a movement known as descriptive psychiatry (Shorter, 1997).

The descriptive psychiatric movement flourished during the late 19th and early 20th century. However, as psychoanalytic theory, which highlighted subjective experience and minimized focus on overt symptoms, began to take hold of American mental health culture in the early 20th century, descriptive psychiatry became unfashionable (Shorter, 1997). Thus, the reemergence of the descriptive psychiatric movement as a dominant force in contemporary mental health culture is a historically interesting development that is worthy of additional consideration.

There are several reasons for the current dominance of the descriptive psychiatric movement, which date back to mid-20th century advances in psychiatry (Shorter, 1997). In the 1950s, powerful new medications were discovered for the treatment of formerly intractable mental health problems. Specifically, the serendipitous discovery of wonder drugs, such as thorazine and lithium, provided a tremendous boost for the descriptive psychiatric movement and medical model of mental health, as the effective use of these medicines depended on successful identification of particular symptom constellations (Shorter, 1997). Also in the 1950s and '60s, the effectiveness of psychoanalysis began to be challenged, and new therapies were introduced (Shorter, 1997). Over the last 30 years, with the continual expansion of the Diagnostic and Statistical Manual (American Psychiatric Association, 2000), the increased alliance between organized psychiatry and the pharmaceutical industry (Leifer, 2001), and pressures from managed care for practitioners to quickly alleviate client symptoms (Hansen, 1997), the medicalized, descriptive psychiatric mindset has come to dominate contemporary mental health culture.

Mental health counselors, along with other non-prescribing mental health professionals, have increasingly adopted this descriptive, medicalized mindset (Hansen, 2003, in press). As evidence of this trend, consider that practicing counselors are often required to diagnose clients and develop symptom specific treatment plans (Hansen, 1997, 2003), the flagship journal of the American Counseling Association recently adopted a "best practices" section that focuses on specific treatments for particular disorders (McGowan, 2003), and there have been increased legislative efforts among counselors to gain parity in third party medical reimbursement (Hansen, 2003, in press). This participation in the medicalized, descriptive psychiatric model represents a significant departure from the assumptions of traditional counseling orientations, which emphasize subjective experience, client strengths, free will, and actualization (Hansen, 2003).

This paper addresses the question of whether the mental health counseling profession's participation in the current medicalized, descriptive psychiatric culture is reasonable. I contend the answer depends on a modernist versus a postmodernist reading of the history of mental health. Each of these interpretations of history is overviewed, along with the consequences of adopting either. To accomplish the goals of this discussion, this paper will be divided into the following sections: (a) Conceptualizations of History, (b) Truth or Consequences, and (c) Discussion and Conclusions

CONCEPTUALIZATIONS OF HISTORY

History, generally, can either be read as (a) a gradual progression of ideas toward greater truth, or (b) simply as shifts and changes in perspective that do not progressively approximate some ultimate truth. The first reading is modernist, while the second is characteristic of postmodern thought. The reasonableness of the mental health counseling profession adopting the descriptive, medicalized version of human emotional suffering is dependent on which version of history is endorsed. Each version is detailed below.

Modernist Version of History

Modernism, as an epistemological system, assumes that phenomena have essential properties that can be ascertained by observers (Erwin, 1999; Hansen, 2002, 2004; Laugharne, & Laugharne, 2002; McNamee, 1996; Sexton, 1997). For example, a chemist can discover the true nature of a chemical compound and accurately represent this truth by utilizing the language of chemistry. The Enlightenment ideal, then, was for science to unlock the essences of the things in the world. As accurate knowledge of essences and universal laws accumulated, humankind would progressively advance (Anderson, 1990). History, then, represents a gradual evolution toward ultimate truth.

This Enlightenment ideal has been traditionally applied to the social sciences (Rosenau, 1992). That is, human betterment could occur once the essential nature and laws that govern human beings were uncovered. The traditional goal of the social sciences, then, is to gradually discover ultimate truths about people and the laws that mediate their behavior for the greater good of society (Rosenau, 1992).

More specifically, mental health history can be read through this modernist lens (Hansen, 2002; Laungani, 2004). That is, science drives us continually forward in understanding the essential nature of mental health issues. Therefore, contemporary conceptualizations of mental health, which draw from a descriptive, medicalized model, are closer to the truth than previous ideas about the etiology and treatment of mental health issues.

If this modernist version of mental health history is embraced, the mental health counseling profession's active participation in the current descriptive, medical model is laudable. As history advances, the mental health counseling profession has an obligation to embrace the latest uncovered truths about mental suffering. Endorsement of and participation in the latest discoveries is an ethical necessity for any profession that aims to alleviate human emotional suffering. Truth becomes the compass that guides the mental health counseling profession. An alternative, postmodernist, version of history, however, would reach a different conclusion.

Postmodernist Version of History

Postmodernism is a complex, heterogeneous philosophical system that began to influence a diverse array of professions (e.g., architecture, literary analysis, biology, etc.) during the mid-20th century (Hansen, 2002, 2004; Rosen, 1996). It is only in the last two decades, however, that postmodern assumptions have begun to influence the social sciences and counseling in particular (Sexton, 1997).

For purposes of this discussion, the primary philosophical thrust of postmodernism is a rejection of Enlightenment, modernist assumptions about truth, certainty, and human knowing (Rosenau, 1992). Specifically, in contrast to the essentialism of modernism, postmodernism is anti-essentialist (Muran, 2001). That is, phenomena are not assumed to have essential properties that can be objectively discovered by scientific observation. Rather, conclusions about phenomena are a product of observer mindset (Hansen, 2002, 2004).

Consider apples, for example. Depending on whether one is a botanist, an artist, a hungry person, a physicist, or someone who is allergic to fruit, apples would be perceived in widely different ways. Is the botanist, who considers apples from an organic perspective closer to the essential nature of apples than an artist who views apples aesthetically? Or rather, is the physicist who considers apples as a collection of subatomic particles the one who has grasped the true nature of apples? From the postmodern perspective, apples do not possess any essential qualities (i.e., anti-essentialism). The physicist is no closer to the true apple than the artist. They are simply different perspectives that have utility in the various communities that the observers represent. Therefore, what is called "truth," is a function of observer mindset, not the essential properties of that which is being observed (Hansen, 2002, 2004).

Under an anti-essentialist epistemology, then, history cannot possibly represent a progressive march toward ultimate, essential truth (Rosenau, 1992). Rather, history simply represents changes and shifts in perspective. Granted, some of these shifts have resulted in the betterment of humanity, such as the progress medicine has made in curing diseases. However, under the postmodernist vision, it would be a mistake to assume that these advances represent progressive movements toward essential truth. Certain perspectives simply have greater utility than others in particular domains (Flax, 1990; Gergen, 1999; Rosenau, 1992). For example, if one wishes to build a bridge, a modern engineering perspective is a pragmatic viewpoint to employ. However, this perspective would have little utility to the artist, who wishes to consider the aesthetic properties of the bridge, or to the traveler, for whom the bridge is merely a means to another destination. From the postmodern vantage point, it would be a mistake to assume that the perspective of the engineer most closely approximates the essence of bridges when there are other legitimate perspectives from various communities. What implications does the postmodern vision of history have for contemporary mental health culture?

The fundamental postmodern insight as applied to mental health is that the currently fashionable descriptive, medicalized version of emotional suffering is simply one of many possible perspectives, and that this orientation should not be privileged as being closer to the essence of mental health problems than competing points of view. Mental health theorizing and science in general, do not evolve in linear fashion toward essences, but rather undergo paradigm shifts that are largely determined by socially constructed forces within scientific communities (Kuhn, 1962). This view of the evolution of ideas as responsive to social forces, and not as a progressive march toward essences, is quite evident when the history of mental health is examined.

For instance, although he considered psychoanalysis a science, there is no doubt that Freud stifled the free flow of ideas in the early days of psychoanalysis (Gay, 1988). When Jung and Adler, for example, posited reasonable challenges to psychoanalytic orthodoxy, a scientist would have taken their ideas seriously and subjected them to empirical investigation. Freud, however, reacted in a way that is inconsistent with a scientific mindset by expelling these theorists from his inner circle for their heresy (Gay, 1988). This dogmatic, rather than scientific, attitude is not an anomaly that was only present in the early days of psychoanalysis. Rather, this dogmatism, and the forces of social construction, is representative of the history of mental health theorizing.

To illustrate this point, throughout the 20th century, psychoanalytic institutes continued to expel members who deviated from orthodox Freudianism. Even in contemporary times, there is evidence that these institutes are quite intolerant of competing ideas (Kirsner, 2000). Furthermore, it has been cogently argued that various mental health orientations, such as cognitivism and behaviorism, are actually insulated mini-cultures that support their own ideas and systematically ignore, minimize, and suppress competing orientations (Fancher, 1995). Thus, the history of ideas in mental health is not about a gradual progression of theories that has become ever closer to approximating essential truth. Rather, the story of mental health is one of intellectually cocooned, non-scientific cultures whose fundamental agenda is to protect their own turf of ideas.

Cross-cultural studies of healing provide even more compelling evidence for this anti-essentialist vision of mental health history. That is, healing orientations in other cultures often posit radically different assumptions about emotional suffering than Western conceptualizations (Torrey, 1972). For example, upon observing signs of what Westerners would term depression, witchdoctors in certain tribal communities would conclude that a person's soul had left their body. Elaborate rituals would be employed so that the soul would return. While this treatment would obviously not be suited to the Western mindset, it is actually quite effective in the tribal communities that employ it (Torrey, 1972). Alternatively, Western interventions, such as cognitive-behavioral treatment, would undoubtedly be ineffective if applied to a person in this tribal community. Therefore, given the radical differences in effective healing perspectives across cultures, positive treatment outcomes would appear to have little to do with knowing essential, extra-communal truths about human nature. Rather, healing is always dependent on the mindset of the society in which it takes place (Hansen, 2002).

This postmodern view of truth and history, however, creates another potential problem: If we can no longer base our choices on how closely a perspective approximates essential truth, how are we to decide among competing perspectives (i.e., problem of relativism)? Certain postmodernist philosophers (e.g., Rorty, 1982) have answered this question by reviving an older, distinctly American philosophy known as pragmatism. The core assumption of pragmatism is that ideas should be endorsed based on their consequences, not on their approximation to transcendent truth (Polkinghorne, 2000). The revival of pragmatism within postmodernist philosophy has been termed neopragmatism (Polkinghorne, 1992).

TRUTH OR CONSEQUENCES

If one is persuaded by the postmodern, neopragmatic critique, mental health counselors can no longer use truth as a justification for making professional choices. Rather, the consequences of adopting particular orientations must be examined (Gergen, 2001). With this in mind, what are the consequences of the mental health counseling profession's increasing identification with the contemporary descriptive, psychiatric mindset? The adoption of this ideology has major consequences for the counseling relationship and for the identity of counselors as mental health providers.

Counseling Relationship

What is it about counseling that causes healing to occur? By knowing the mechanisms of healing in counseling, ideologies could be adopted that would support and facilitate those factors.

In the earlier days of counseling, up until the late 1970s, it was generally thought that the specific techniques of particular orientations were responsible for healing (Fancher, 1995; Frank & Frank, 1991). For example, cognitive behavioral counselors supposed that cognitive reframing caused healing to occur, while psychodynamic counselors posited that interpretation of unconscious conflict was the mechanism that promoted change. Each counseling culture presumed that their specific techniques were responsible for client change and were superior to the methods of other orientations.

During the late 1970s and early 1980s, however, meta-analysis of counseling outcome studies concluded that, generally speaking, all major counseling orientations were equally effective (e.g., Shapiro & Shapiro, 1982). No single orientation or technique emerged as superior. Indeed, in an exhaustive review of this research, Wampold (2001) concluded that "decades of psychotherapy research have failed to find a scintilla of evidence that any specific ingredient is necessary for therapeutic change" (p. 204). More precisely, "the evidence indicates that, at most, specific ingredients account for only 1% of the variance in outcomes" (p. 204). This finding has led some theorists to argue that factors common to all counseling orientations are responsible for client change, not the specific techniques of particular orientations (Frank & Frank, 1991). This "common factors" position has been fortified by research, which has demonstrated that the quality of the counseling relationship is the factor that accounts for most of the variance in treatment outcomes (Wampold, 2001). Thus, we now know that relationships cure, not techniques.

Given these findings, it is logical that counselors should adopt treatment orientations that focus on facilitating high quality counseling relationships. Thus, from a neopragmatic perspective, the mental health counseling profession's increased adoption of the contemporary descriptive, medicalized orientation is reasonable if that orientation promotes the emergence of healing counseling relationships to a greater extent than competing orientations. What, then, are the consequences of adopting a descriptive, psychiatric mindset for the counseling relationship?

The descriptive, medical model is an ideology that minimizes the importance of relational factors (Hansen, in press). Traditional medicine and psychiatry view clients as having particular, identifiable diagnostic conditions for which there are specific, effective techniques. Relational factors are minimized by a focus on overt symptomatology and techniques. Therefore, the adoption of a descriptive, medical mindset necessarily takes the treatment focus off of the counseling relationship, which according to the outcome literature, is precisely where it should be, and places it upon techniques, which only account for a trivial portion of the outcome variance.

If the descriptive, psychiatric model is analyzed in terms of consequences, rather than its supposed truth value, then, the increased adoption of this model by the mental health counseling profession necessarily has the effect of trivializing and suppressing the counseling profession's most powerful means for bringing about human change. Of course, individual practitioners may have to participate in the medical model in order to be reimbursed and to discuss various aspects of care with their clients. However, from the vantage point of consequences, it is unreasonable for the mental health counseling profession as a whole to identify with an ideology that de-emphasizes the importance of the counseling relationship, when it is this relationship that has proven to be the most effective route to healing.

Counselor Identity

Traditionally, counselors have had a unique identity among mental health providers (Hansen, 2000a). That is, counselors drew from a humanistic orientation, which promoted client actualization, conceptualized clients in terms of strengths instead of pathology, and focused on the importance of the counseling relationship (Hansen, 2000b, 2003). This approach was distinctly different from other mental health providers, such as clinical psychologists and psychiatrics, who typically focused on psychopathology (Hansen, in press).

Nowadays, practicing counselors regularly reduce clients to pathological entities, develop treatment plans to address discrete symptoms, and utilize techniques as a substitute for empathic responsiveness (Hansen, 2000a, 2003). In other words, a unique counseling identity has been lost because counselors have increasingly embraced the descriptive, medical model (Hansen, in press). Mental health counseling is rapidly becoming a profession of para-psychiatrists who are virtually indistinguishable from other mental health professionals.

Again, this identity transformation would be desirable if the consequences were an increase in treatment effectiveness. Ironically, however, research informs us that the adoption of a traditional counseling identity, which places emphasis on the treatment relationship, is far more likely to produce effective results than the adoption of the contemporary, medicalized identity (Wampold, 2001). Therefore, the consequence of embracing a medicalized identity is the suppression of the traditional counselor identity, ironically at a time when mental health providers who value the treatment relationship are most sorely needed.

Discussion and Conclusions

I have argued that instead of viewing the increased identification of the mental health counseling profession with a descriptive, medicalized orientation as a natural professional evolution toward discovered truth, a postmodern, neopragmatic reading of mental health history, which emphasizes the consequences of this identification, should be considered. The primary consequences of this identification have been to minimize the importance of the treatment relationship and to suppress the traditional counseling identity. Neither of these consequences is desirable, as they undermine treatment effectiveness and prevent counselors from making a unique professional contribution to contemporary mental health culture. Many of the ideas contained in this paper were stimulated by an interaction I had with a supervisee. By presenting a summary of this interaction, I hope to fortify and consolidate the concepts that have been presented.

The supervisee presented a session with a client who had been suffering from symptoms of depression. For virtually the entire hour, the supervisee tried to persuade the client to take medication for this problem. The client, who had also been seeing a psychiatrist on a regular basis, expressed concerns about taking medication. The supervisee responded by continuing to urge the client to take medication.

When I challenged the supervisee about her reasons for intervening in this way when the client was already seeing a psychiatrist, the supervisee's defense was that it was widely known that depression was caused by a chemical imbalance. Thus, she argued that she had been acting responsibly by using the latest scientific evidence to inform her treatment intervention. In other words, she defended her actions by an appeal to truth.

As we talked further, though, it became apparent that her commitment to so-called "truth" entailed particular consequences that she had not considered. For example, from an analysis of the session, we were able to infer that there were many meanings inherent in the dialogue between the supervisee and the client. One such meaning was that the counseling interaction seemed to recreate a relational pattern that the client had with her mother, whom the client experienced as forcing things upon her against her will. In a parallel manner, the supervisee, at least at the beginning of the supervisory hour, felt I was forcing my perspective onto her when she preferred the medicalized version of the client. Multiple meaning structures and missed opportunities for deepening the relationship were detected when we reconsidered the session from a counseling rather than medical point of view.

Thus, there were two primary consequences to the supervisee's identification with the descriptive medical model. First, it caused the supervisee to miss the psychological meanings inherent in the interaction and the opportunities for deepening the counseling relationship. By identifying with the medical model, the supervisee had abandoned the relational perspective she had learned during her training. The descriptive, medical perspective did not aid the supervisee in helping the client, as the supervisee could not prescribe medications. Ironically, the healing skill the supervisee did possess, the ability to establish a helping relationship, was abandoned when the medical model was adopted.

Secondly, the unique type of help that this supervisee could have offered the client was withheld. The client had already been seeing a professional who prescribed medication and viewed the depression from a descriptive, medicalized point of view. The client did not require the services of another professional that would see her in this same way. Rather, the client would have likely benefited from a traditional counseling perspective, which would have emphasized the establishment of a highly engaged counseling relationship.

I hope I have illustrated both the consequential problems of the mental health counseling profession adopting the descriptive, medical model as if it were the only truth, and the inadequacy of invoking the "truth defense" to justify the selection of particular orientations. The descriptive, medical model certainly has good utility for professionals with prescription pads, but little utility for those without them. Therefore, the mental health counseling profession's increased identification with the descriptive, medical model of emotional suffering cannot be justified in terms of the supposed "truth" of this model. Rather, the consequences of our ideological choices must always be given the highest consideration.

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James T. Hansen, Ph.D., is with Oakland University, Rochester, MN. E-mail: [e-mail].