The Social Conflict Caused by Epistemology in Medical Psychotherapy

Medical Psychotherapy Faculty Newsletter Spring/Summer 2015

The world of psychotherapy has developed different epistemological models breaking away from the basic mainstream tenets of our culture. These models tend to be at odds with each other and give rise to different schools (psychodynamic, systemic, etc). It is possible to find representatives of the black box model of mind in different psychotherapeutic schools. However, I would like to argue that in the UK, with the permeation of psychoanalytic culture into our professional body, the most basic feature of the epistemological model used in Medical Psychotherapy is the importance of human subjectivity.
Medicine and psychiatry in general, on the other hand, favour a biological, objectivistic approach which tries to measure and quantify, and leaves little or no room for human subjectivity. This is the realm of outcome measures, evidence based medicine and homogenization of practice through guidelines.
I would like to address the situation of the Medical Psychotherapist amidst professional colleagues who use a different epistemological model which is not only different, but contrary to their own.
I have often argued that unless we “play the game” and move within the “objectivistic” model we are bound to extinction like the riders of Sybaris. Thus, we need to conduct randomized controlled trials to prove our efficacy, conform to a large extent to norms and guidelines to avoid the maverick route and “talk the talk” showing that we know the “scientific facts” which are considered relevant by the medical community.
In any case, pretending and blending in cannot be the whole answer and we can’t avoid facing the conflict posed by a clash of cultures. What can be our answer to it? We can look at society at large to see some ways of managing ideological differences. Probably the clearest field in which this can be seen is religious diversity, but race and other traits have also served to mark a dividing line between groups which later needs to be managed.
To begin with the taboo, the option taken by the Nazi party in the 1930s was to assume their own superiority and fight to displace (and even annihilate) the rest, which are seen as inferior. While apparently alien to us, we can see traces of this approach in ourselves if we look under the surface. Psychoanalysts, especially in the past, have often been accused of having this “holier than thou” attitude and none of us can boast of being immune to hubris.
The French have established an explicit mainstream ideology (let’s say laicism), excluding difference (religious approaches) from the common public arena, but respecting it in the private sphere and in specifically allocated places. I reckon this is exactly what mainstream psychiatry has done with us and what we do with approaches which constitute minorities among us, e.g. cognitive-behavioural Medical Psychotherapists.
The Spanish of the 15th and 16th century did not tolerate difference even in the private sphere. They forced conformity to the mainstream ideology forcing the Jewish to leave the country or convert to Catholicism. Then, they developed the inquisition to monitor if this conversion was true and the conversos really stood up to the proper thoughts and practices expected of a good Catholic. Revalidation, recertification, exams, peer scrutiny, etc, are steps to ensure the purity of professionals in order to detect and cleanse heresy in those who stop seeing the light. I admit I haven´t been able to identify measures corresponding to this approach which are specific to our small professional body.
The British way of dealing with difference has often been that of separating distinct groups according to differential traits, as can be seen in the independence of Ireland or India or the development of communities (almost ghettos) within British soil. The development of a separate Faculty for Medical Psychotherapy or the classic distinction between a Kleinian and a Freudian group in the Psychoanalytic establishment are examples within the profession.
Many of those who see themselves as enlightened feel the responsibility to return to the Platonic cavern and illuminate the rest, which has been a drive behind evangelization and colonization. We have fought to make Psychiatry trainees undergo some learning and experience of Psychotherapy as part of their training. Also, Consultation and Liaison Psychiatry involves some sharing of our secret fire with the medical profession at large. Alternatively, wizards might retreat into their ivory tower, knowledge can be restricted to the initiated and training might be restricted to those who make a vow of secrecy, as in EMDR. This obscurantism can also be useful to protect patient´s confidentiality, the thinking capacity of therapists who need to swim in the dark waters of transference-countertransference without intrusions, etc.
In summary, history shows us some ways of dealing with cultural difference. Lemestmatearnett . Our distinctive epistemology which sets us apart from our medical colleagues, including most psychiatrists, makes this problem relevant for us. It appears that we have incorporated aspects of most of these historical approaches, even of those we would officially reject (nothing human is alien to us) but there is a lot of room to consider how we want to balance these approaches. I believe that our answer to how to manage this conflict can be useful to society at large, which is paying with blood the difficulty of managing it. But before taking a leadership role, my recommendation is to think on what we are doing, assume what it says about ourselves, and ponder whether there are changes we want to make.