Thinking About Lee Kassan's Thoughts on the Medical Model: Response to Thinking About Our Work: What Do We Mean by “Mental Health”?

Abstract

Thinking About Lee Kassan’s Thoughts on the Medical Model: Response to Thinking About Our Work: What Do We Mean by “Mental Health”? Albert Brok1 issn 0362-4021 © 2017 Eastern Group Psychotherapy Society group, Vol. 41, No. 2, Summer 2017 149 1 Director of Group and Couple Therapy, Training Institute for Mental Health, New York; Faculty, Derner Institute, Adelphi University; Guest Lecturer, Argentine Psychoanalytic Association, Buenos Aires and Asociación Psicoanalítico de Madrid. Correspondence should be addressed to Albert J. Brok, PhD, CGP, 11 Riverside Drive 8N-E, New York, NY 10023. E-mail: drajbrok@ gmail.com. The issue Lee Kassan raises is certainly an intriguing one and relevant to our daily work with patients. However, his essay is given to some polemic in that it implies that the concept of mental illness is irrelevant, except in extreme cases, such as bipolar disorder and schizophrenia. Furthermore, he suggests that mental illness is a phrase used to assuage insurance companies and has become a reason for patients to use insurance. All of this is certainly relevant and realistic, but not totally on the mark in my experience. I, of course, agree with Kassan completely about the problem of labeling. It is very clear that once you categorize people as mentally ill, you then tend to see them in terms of pathology and thereby may not discover other aspects that are not part of such a category, whether positive qualities, capacity for resilience, or a hidden positive self-esteem frozen deep inside until discovered. It reminds me of a patient who had a persistent dream of a very sweet orange frozen deep inside a freezer. In effect, therapy was a thawing-out process, in addition to an interpretative process. Another patient who presented as an angry woman, domineering and critical, filled with pathological symptoms, over a long analysis (including group therapy) terminated with the lovely gesture of presenting each member of the group with a rose, having removed the thorns from each stem, symbolically indicating that she no longer needed her “thorny side.” If either one of these patients were seen solely 150 brok as being “mentally ill,” and needing primarily to be medicated, as opposed to being conflicted and psychologically injured, but also having a vulnerable and sequestered caring, loving, and related self deep inside, their outcomes might have well been different . Indeed, the second patient’s previous therapist had diagnosed her as obsessive with borderline qualities and missed the neurotic-level qualities and pristine ego that were indeed there and could be developed with a way of therapy that included both containment and interpretation of her anger as well as a holding environment. Diagnostic understanding in all its complexity of combined developmental overlap very much helped me work with her, as with all patients. This, of course, includes using my own personality in the process. This brings me to the problems of nomothetic versus ideographic conceptualization of people. A nomothetic approach derives its assumptions from group data obtained from the observation of many individuals from which certain categories based on laws derived from multiple average data are created. Discrete individuals are then fit into these categories. Ideographic data, conversely, are obtained from the study of one individual at a time across a wide social, ecological, and historical context. They refer to the unique idiosyncratic, individual qualities of a person. This implies that all people are not alike, even if superficial symptoms they evince are similar. In fact, a symptom may be similar in different people, but the reason for its manifestation may be quite idiosyncratic. The ideographic approach is derived from the seminal thinking of Gordon Allport of Harvard, who first discussed it in his book Becoming, published quite some time ago in 1955. So if we categorize people as mentally ill, we may then be wrongly focusing on getting them back to a state of stability or normality rather than to a state of optimal development. My own inclination is to separate the medical model from the value of diagnosis , when the latter is used appropriately. In my clinical experience, people have multiple diagnoses rather than any one, and of course, insurance companies push therapists to pluck people...