With reference to two models of psychological therapy, compare and contrast the impact of social, cultural and paradigmatic shifts on the conceptualisation and treatment of psychological distress.

For the purposes of this essay, the definition of psychological distress comes from Kessler et al. six-point scale (K6) which is used to monitor population prevalences in non-specific psychological distress. The six criteria used to define feelings of psychological distress in the scale are: nervous, hopeless, restless or fidgety, so depressed that nothing could cheer you up, that everything was an effort and worthless.

The K6 scale is used widely in the United States and by the World Health Organisation and is less than twenty years old, and as such is relevant today and in Western cultures. Accordingly, the social, cultural and paradigmatic shifts this essay will focus on will also have taken place in Western societies and cultures to ensure both consistency across the conceptualisation of psychological distress, and parity across the treatment models discussed. This culturally specific context is problematic in the treatment of psychological distress which we will go on to discuss.

We will use Greenfield et al’s definition of culture, which is ‘A framework of beliefs and values shared by a group, that influences the perception and interpretation of experiences by individuals within that group’ and so a cultural shift, following on from that definition, would be a change in that framework of values and beliefs. Our definition of social shifts comes from Rogers definition of social change, which for him is a process which alters the structure and function of society.

A paradigmatic shift refers to a change in the way that a norm is conceived of. A good example of a paradigmatic shift would be the removal of ‘ego-dystonic homosexuality’ from the DSM III-R as previous editions had included ‘homosexuality’ and then ‘ego-dystonic homosexuality’ as a listed psychological illness. Its removal indicates a shift in the paradigm which was both preceded by and reflected in culture and society at the time too. As such, we will explore how social, cultural and paradigmatic shifts interlink and may in fact be difficult to separate.

The two models discussed in this essay will be Freudian psychoanalytic and psychodynamic theory, and Cognitive Behavioural Therapy (CBT). These two models have different concepts of the causes of psychological distress and propose different treatments; CBT in fact being developed by Aaron Beck as an alternative to psychodynamic therapy, which he did not support.

The first shift we will consider is the introduction in 1952 of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, by the American Psychiatric Association (APA). The production of the first DSM represents a shift that is paradigmatic, cultural and social all at once. The current conceptualisation of mental illness as a disease which can be categorised and should then be treated has roots in ancient Greece and Rome, but it is the advent of the DSM and its subsequent revisions that is one of the factors which has helped to alter the way that psychological distress is conceived of and treated in the West in the last sixty years, socially and culturally as well as paradigmatically shifting the way that individual mental illnesses are conceived of.

David Pilgrim argues that despite this shift, the human need to categorise mental illness has remained constant. Pilgrim argues that Kraeplin’s empiricist model for classifying mental illness has become the main paradigm in modern Western psychiatry, proposing that mental illnesses are separate, they are a function of degeneracy and they are caused by diseases of the brain or nervous system. Pilgrim writes that this legacy has dominated beliefs about mental abnormality from the 1800s to the present in spite of the shifts that the DSM has been through, which have seen it continue to maintain categorisation.

Pilgrim goes on to explain how the DSM can be seen to be a text which enables the psychiatric profession to benefit from socially constructed ideas about mental illness. Szasz, himself a psychiatrist, argued against the DSM and proposed instead that individuals who were psychologically distressed were not enduring symptoms of a medical condition but were suffering from problems of living and being in the world. For Szasz then the DSM is an example of the perpetuation of the medicalisation of mental abnormality and a move towards frequent medical diagnosis and treatment and away from the psychoanalytic model of treatment.

Pilgrim also argues that the DSM can be read as a political manifesto for the psychiatric profession rather than as a scientific document. This means that changes in public policy and in society would be reflected in its revisions, as we see in the revised third edition which removed ‘ego-dystonic homosexuality’. For Pilgrim the political shift is one away from accepting aetiological assumptions and instead towards more cautious checklists of symptoms that might be observed within some mental conditions, as we see in Hippocrates and then again many many years later in Kraeplin’s work. What this means for the paradigm around the diagnosis of mental illness is that it is never fixed – as we have seen, it moves from the Socractic belief that it is not especially a problem to the current desire to define it, categorise it and treat it medically.

The paradigm shifts in response to cultural and societal beliefs at any one time, and so naturally the anti-psychiatry movement in the 1960’s that Szasz was part of encouraged revisions to the DSM which created a more cautious text and so altered the conceptualisation of mental illness from a holistic suffering that an individual undergoes to a list of possible symptoms. This goes on to affect the way in which psychological distress is treated, as Pilgrim notes, with the increase in the prescription of pharmaceuticals for the treatment of mental illness. Pilgrim writes that the very term ‘anti-depressant’ or ‘anti-psychotic’ suggests that they are magic bullets capable of alleviating suffering, which can be used not as an adjunct to therapies like CBT or psychoanalysis, but in lieu of them. In this way, it is not only the paradigm that shifts but also society, and so the concept and treatment of mental illness is altered.

Michael Strand argues that the move towards classification of psychological distress that the publication of the DSM-III was part of was one of several factors that moved society away from a psychoanalytic treatment model. For Strand, the publication of DSM-III ‘revolutionised’ the treatment of mental illness because it served this function of classification in a way that the psychoanalytic therapists active at the time were resistant to. Naturally it is difficult to provide a simple definition of any treatment model for psychological distress but in brief, psychoanalysis was developed by Freud, although many of his ideas are now more than a hundred years old and psychoanalysis today does look different from a century ago, and is based in the processes of the unconscious mind. The aim of psychoanalysis is to rediscover unconscious fears and wishes and then to relive them through the relationship that the client has with the analyst, and then rather than banishing them back to the unconscious to learn about them no matter how frightening or unacceptable they may be to the individual (Milton, 2004). Psychoanalysis typically lasts for years rather than weeks and ‘clients need to have the capacity for thoughtfulness and reflection’ (Milton, 2004). Naturally these two latter points can be used as criticisms of the treatment and evidence that at the time, treatment of psychological distress was restricted to the socio-economic elite who had the time and money to commit to years of treatment as well as the kind of education and background that would help them to be thoughtful and reflective. Interestingly, Milton’s introduction to psychoanalysis does include a chapter on critiques of the theory but these are holistic and broadly rebuffed later in the text, and they do not include the criticisms above.

By the time that the DSM-III was published, psychoanalysts had become dominant in the profession and especially so in the United States – Strand writes that in the mid-1960s ‘58% of psychiatry departments were chaired by psychoanalysts’, demonstrating their influence in the practice of treating mental health. But following the publication of DSM-III, ‘the classification of mental illness developed by diagnostic psychiatry…took precedence.’ Whilst this does tell us that there was a shift away from the psychoanalytic model we should note that the statistic given is specific to the United States and as such may not be relevant beyond that cultural context. In fact, Strand notes one of the criticisms levelled at psychoanalysis was that most of its clientele tended to be, as noted above, ‘Young, Attractive, Verbal, Intelligent and Successful’, and as such we can question how useful a treatment model it was in society beyond these narrow criteria. Arguably the paradigm at the time when psychoanalysis was the dominant therapy model, that has now shifted, has become more relevant to a greater number of individuals suffering psychological distress as a result of moving away from that model. Strand goes so far as to argue that the publication of DSM-III and the subsequent dominance of diagnostic psychiatry went so far as to ‘render psychoanalysis obsolete’.

Where the first and second editions of the DSM had been dominated by the influence of psychoanalysts, the third edition made some effort to provide classification schemes that could be used in the effective diagnosis of mental illness and so aid treatment. A good example of this is the use of the word ‘neurosis’, a term used extensively in psychoanalysis which had been utilised in the first two editions of the DSM – ‘neurosis’ appear in DSM-III but usually in parentheses and minimally. Similarly, the first two editions included homosexuality as a psychological disorder because in Freudian psychoanalytic theory, homosexuality occurs when the psychosexual development of an individual stalls prematurely, however, the third edition did not include homosexuality as a mental illness, except where it causes distress to the individual who is unable to reconcile their sexual orientation with the rest of their personhood. As such, we can see here a clear example of a shift in the way that mental illness was conceptualised as a consequence of the dominant model of psychological treatment being destabilised. The shift is paradigmatic, societal and cultural all at the same time although as has been noted, it is possible that the shift is confined to its specific physical location.

The next shift we will examine is the ‘ascendency’ (Pilgrim, 2009) of the use of CBT within the British National Health Service (NHS). CBT began with Aaron Beck, ‘a psychiatrist dismayed by psychoanalysis’ (Pilgrim, 2009) and who proposed a medical approach to psychological distress, without pharmacological treatment. Naturally, it is difficult to provide one single definition for a treatment model but in brief, CBT can be described as an evidence-based treatment that aims to provide a rational analysis of the clients thoughts and subsequent behaviours. It seeks to help clients to analyse those existing thought patterns and to try out new approaches that aim to alleviate psychological distress (Sheldon, 2011). For Pilgrim, the context of post-World War Two reconstruction provided the perfect environment for the CBT model to develop and start to flourish; we have seen already that the shift towards more diagnostic psychological practice meant that the previously dominant model of psychoanalysis began to lose ground, and so there was space for the paradigm to shift and a new treatment model to become the norm. CBT has a stronger basis in evidence than psychoanalysis does and does not require as lengthy a potential commitment from the client which can make it a more appealing prospect and has contributed to its becoming the current normative treatment model.

Currently, CBT is the main psychological treatment recommended and provided by the NHS in the UK (Shawe-Taylor, 2010). This is because there is a strong-evidence base for its efficacy in the treatment of a wide range of disorders that cause psychological distress, and because it can be more accessible than a treatment like psychoanalysis; we would be unlikely to state that the majority of individuals who undergo CBT conform to ‘Young, Attractive, Verbal, Intelligent and Successful’. That it is available on the NHS also means that it is more cost-effective on an individual level than psychoanalysis which is more widely available through private practitioners. As with the discussion on psychoanalysis however, we should bear in mind that the context is highly culturally-specific and may not be representative of mental health treatments in other parts of the world or paradigmatic shifts that occur elsewhere. Interestingly, in Shawe-Taylor’s text the introduction of CBT to the NHS and its subsequent successes has been a positive thing despite the increased demand for mental health services as more clients have been treated, however, for Pilgrim, CBT in the NHS has been ‘an imposition of vaguery’. As such we might say that although a shift has occurred and CBT has now become the expected treatment for psychological distress, it has not been universally applauded as consistently being the best available treatment model. What we could say however is that is represents a shift in the understanding of psychological distress as having moved away from the ‘neurotic’ ideas of psychoanalysis and towards a more holistic approach with the aim of treating many different disorders which can be individually classified and diagnosed.

Shawe-Taylor’s paper on the utilisation of CBT in one particular NHS trust in Surrey gives a detailed overview of the process of developing CBT training programmes for clinical practitioners and the challenges therein, emphasising that until quite recently CBT was not practised by a majority of clinical psychologists. The findings in this trust were that CBT did not suit all practitioners and that for some further training and assessment would be necessary – this emphasises that the introduction of CBT is a significant shift away from previous models of treatment. We should of course note that this study took place in just one NHS trust and so may not be representative of the broader impact of introducing CBT as the dominant model of treatment for psychological distress, and given that the paper notes that it is indeed the dominant model now, the implication is that there must be other trusts which did not see the same level of resistance to CBT. In terms however of the paradigmatic shift, we can see that CBT has become the most accessible model of treatment but the impact of this shift on the conceptualisation of psychological distress is less clear. It is also difficult to define whether the paradigmatic shift came before or after the cultural and societal ones, or indeed if they happen concurrently. We know that CBT has become the preferred counselling model for treating individuals suffering from a form of psychological distress within the NHS and that it was developed as a consequence of dissatisfaction with the dominant psychoanalytic model and in line with the growing interest in being able to categorise and diagnose mental illness and so possibly a combination of these factors led to the paradigmatic shift.

In conclusion, through comparing the utilisation of psychoanalysis and CBT in the West we can see that the introduction of the DSM-III caused a seismic shift in the way that psychological distress was conceived of and treated, predominantly paradigmatically but also within societies and cultures. One limitation of this comparison is that we are looking at these treatments within a specifically Western culture which means that the shifts discussed are not replicated across the world. The second shift examined demonstrates to us that psychoanalysis was extremely popular for a limited amount of time but whilst still practised, its dominance has been superseded by CBT in the UK, where CBT is now the normative treatment for most kinds of psychological distress. Possibly this is because it is less time-consuming and less costly for an individual to commit to, and possibly it is because of the earlier shift towards diagnosis and classification which was at odds with psychoanalysis but which CBT can accommodate much more readily. Naturally, as the treatment of psychological distress changes so too does the way in which it is conceptualised by society and we can see that in the revisions to the DSM, which reflect new and changing cultural attitudes and ideas and an emphasis on classification and a diminished desire to focus on the ‘neuroses’ that were favoured among psychoanalysts. In the UK specifically, a notable shift is the use of CBT in the NHS which has become widespread and is now the expected treatment for individuals suffering from psychological distress.

References

Kesler, R. C., Andrews, G., Colpe, L. J., Hirpi, E., Mroczek, D. K., Normand, S. L. T., Walters, E. E. and Zaslavsky. A. M. (2002) ‘Short screening scales to monitor population prevalences and trends in non-specific psychological distress’ Psychological Medicine, 32(6) pp. 959-976

Milton J., Polmear, C. and Fabricius, J. (2001) A short introduction to psychoanalysis. Sage Publications: London

Pilgrim, D. (2008) ‘The survival of Psychiatric Diagnosis’ Social Science, 65(3) pp. 536-547

Shawe-Taylor, M., (2010) ‘Towards the development of an integrated CBT provision within a large organisation offering services to people with mental health problems and/or learning disabilities’ Psychological Topics, 19(2) pp. 387-399

Strand, M. (2011) ‘Where do classifications come from? The DSM-III, the transformation of American psychiatry, and the problem of origins in the sociology of knowledge’ Theory and Society, 40(3) pp. 273-313