Developing different models for the relationship between the medical psychiatric and psychotherapeutic approaches
The psychodynamic model in general and psychoanalysis in particular have the most developed and elaborated theoretical psychotherapeutic model, one capable of describing and explaining (more thoroughly than other psychotherapies) all the nuances of both the clearly pathological and habitual “normal” psychic manifestations. It was the very first psychotherapeutic model, and founders and developers of the psychotherapies that emerged later (with the exception of behavioral therapy) based their models on it. The appearance and development of psychoanalytical theory started the differentiation between psychotherapeutic and psychiatric medical concepts of psyche, and their interaction began to take shape. The issue of the interaction between psychiatry and psychotherapy has been approached in various ways in different countries. In the USA, a certain conjoint, unified model has been developed that combines both the medical and the psychoanalytical (psychotherapeutic) approaches into a single system in which psychoanalytical concepts are pronounced to such an extent that they sometimes cast the biological precursors of the disorders described into the background (Stone, M.H., 1986 b). In European countries, especially in Great Britain (Stone, M.H., 1986 a) and Germany (Stone, M.H., 1986 b), psychoanalysis (as well as psychotherapy in general) and its associated terminology have been developing relatively independently from biological psychiatry, a field of medical science with its own language. In the USSR, as in the USA, a unified model combining psychiatry and psychotherapy into a single system was developed; this remains true to a certain extent for present day Russia. But unlike in the USA, it was built on the platform of the psychiatric medical paradigm, which significantly prevailed over the psychotherapeutic model. In Russian psychotherapeutic practices today, this is apparent in typically endless searches for “residual organic brain lesions,” “mild manifestations of endogenous mental disorders,” “genetic predisposition,” “hiding” behind neurotic manifestations, and in overlooking the psychodynamic mechanisms involved in causing these phenomena. This is likewise reflected in Russian legislation prohibiting psychologists, who in particular lack formal medical education, providing full-fledged psychotherapeutic treatment of patients; they may provide only counseling. This is also shown by the fact that the oversimplified version of the psychodynamic model employed in Russia, namely, Miasishchev pathogenetic therapy, is mostly applied to neurotic cases where therapists can clearly, and patients much less so, observe the connection between neurosis symptoms and patients’ controversial attitudes towards people of special significance in their environment, as well as correlation with the patients’ parents’ attitudes towards them during childhood. Besides, these are cases in which patients can accept their therapists’ interpretations clarifying those connections (often in a rather straightforward and oversimplified manner) and use them (interpretations) to facilitate their recovery process. Otherwise, therapists habitually turn to searching for neurosis symptom triggers in “implicit endogenous psychic disease,” “organic cerebral disorders,” and so on, returning to the well-beaten psychiatric track. The influence of this conjoint model based on psychiatry dominating over psychotherapy is quite obvious in pathogenetic therapy practices. Patient–psychotherapist relations in them are based on the same principle as in psychiatry, that is, patient–doctor, where patients’ “wrong” beliefs are exposed to “correct” clarifying and convincing influence of domineering flawless medical specialists guiding errant patients in the right direction. In this context the dynamics of transference–countertransference in patient–psychotherapist relations is mostly overlooked, as well as the fact that the way these relations develop is affected by both participants. Such attitude, caused by the psychiatric paradigm taking precedence over psychotherapy, is also manifested in the fact that in Russia, psychotherapy students are not required to undergo a certain amount of personal psychotherapy as patients during their education. On considering another conjoint (unified) model, the American one, which was greatly influenced in its establishment and development by psychoanalysis, one can also find certain problems arising from combining psychotherapy (psychoanalysis) and psychiatry paradigms into one single system. For instance, the American classification of mental disorders (and now the international classification based to a large extent on the American model) DSM-5 does not distinguish between psychogenic and endogenous types of depression, which largely results from a number of specialists’ opinion that depression should be regarded as a continuum ranging from mild to severe, without taking into account qualitative differences in depression types. According to this point of view, closely linked to psychoanalytical tradition, all types of depression are caused by the same psychological mechanisms, and so there is no need to qualitatively differentiate between them. As a result, authors of a number of recent publications evaluating effectiveness of antidepressants in depression treatment have reached a conclusion about their effect being statistically insignificantly higher than that of placebos, i.e. about their ineffectiveness (Fournier, J.C., DeRubeis, R.J., Hollon, S.D., Dimidjian, S., Amsterdam, J.D., Shelton, R.C., Fawcett, J., 2010; Kirsch, I., 2009). Patients in the studies discussed in these publications were selected according to DSM and ICD-10 criteria without dividing the cases into endogenous and non-endogenous depression types. However, the studies where those depression types were taken into account repeatedly demonstrated that the effectiveness of antidepressants on endogenous depression patients was much higher than that of placebos (Winokur, G., 1986). Those studies also demonstrated that in cases of endogenous depression, ECT produced a much better result than in treating cases of psychogenic depression (Winokur, G., 1986). Another example deals with introducing two new items into DSM-3: “borderline personality disorder” and “schizotypal personality disorder” instead of “latent schizophrenia” in DSM-2 (Stone, M.H., 1986 b). While it is quite productive to place patients with “borderline disorders” (a term, like that of “latent schizophrenia”, describing people balancing on the edge of psychosis) whose state dynamics resemble those of personality disorders rather than of schizophrenia into the personality disorders group, and while it is also useful to break that group into one subgroup of patients with prevailing affective instability symptoms and one subgroup with ideational disturbances similar to schizophrenic ones, certain considerations should be kept in mind. R. Spitzer et al., working on diagnostic criteria for the two above-mentioned disorders, justified replacing the old “latent schizophrenia” item with the two new ones in the new classification in the following way. He reasoned that two groups of different researchers used one and the same “borderline disorder” term to describe two different forms of pathology. Spitzer then suggested defining those two pathologies as “borderline personality disorder” and “schizotypal personality disorder” accordingly (Spitzer, R., Endicott, J., Gibbon, M., 1986). Spitzer, however, seems to overlook the fact that one group of researchers he mentions, O. Kernberg in particular (Kernberg, O., 1967), studied their patients from the point of view of psychoanalysis. Meanwhile, the second group of researchers he refers to, namely S. Kety and D. Rosenthal (Kety, S., Rosenthal, D., Wender, P., Schilsinger, F., 1986), regarded their patients from the position of psychiatry clinicians employing a medical approach. R. Spitzer tried to classify borderline patients from the whole sample group into two separate groups, “borderline personality disorder” and “schizotypal personality disorder,” with the help of questionnaires he and his collaborators developed. The result was that 54% of the patients met the criteria for both schizotypal and borderline unstable personality disorder (Spitzer, R., Endicott, J., Gibbon, M., 1986). One explanation for this could be that the two research groups discussed by Spitzer were sometimes looking not so much at two different groups of patients as they were describing the same group from two different positions and using different terminology. Thus attempts to mix the psychiatric (medical) approach with the psychotherapeutic (psychoanalytical) one, each of them characterized by their own language and terminology and their own concepts of norm and pathology, into a single logical system often lead to distortion of their internal logic, misunderstanding, and confusion.