I have always been intrigued with the meaning of the word ‘treatment’ in the context of counselling and psychotherapy. People seeking help will often ask what the sessions will comprise of and how long the work will last. Indeed they might also ask, even in the first session, whether or not the work has actually started during the initial deliberations. ‘Treatment’, because of dealing with physical health conditions, tends to have a medical (and biological) connotation and usually involves adherence to clinical guidelines and manualised approaches. Cognitive Behavioural Therapy (CBT) can often be the manualised approach in the NHS especially when the presenting issues are anxiety and depression. ‘Treatment’ is also synonymous with approaches to addiction recovery in rehabilitation centres, when the medical model prioritises the role of experts in the management of ‘recovery’.
For therapy to be more holistic and integrative, rather than having a manualised focus, I believe that it is useful to think of the broad categories of your life as well as investigating lifestyle patterns around sleep, diet and physical exercise. It can be worth asking which aspect of your being do you neglect? This might inform how your symptoms manifest and how you feel dissatisfied in your life.
The biopsychosocial model could be viewed as a modern humanistic and holistic view of the human being and has useful insights for psychotherapeutic practice. This model, brought by George L. Engel (1913–1999) to medicine, tasked physicians to think more holistically when seeing their patients and is a useful guide across multi-disciplinary settings. The model can also help to assess positive self-care regimes and social support structures in an individual’s life.
The broad categories of the biopsychosocial model are:
Biological (physiological pathology)
The important questions might be: Are there family histories of mental illness? Is there genetic inheritance to trauma, anxiety, depression? Where does your temperament come from?
A genetic predisposition (which is not to say pre-determination) can also be referred to as genetic susceptibility, and is an increased likelihood of developing a particular disease based upon your genetic make-up. A genetic predisposition results from specific genetic variations that are often inherited from a parent. This can be a common route of diagnosis in physical health conditions. Examples might be single-gene disorders, where a mutation affects one gene, such as sickle cell anemia.
Some research shows that anxiety can be genetic but that it can also be influenced by environmental factors. Depression can often be seen as running in families but research is not conclusive to prove this. Some ‘genome wide linkage studies’, have claimed that both genetic and environmental factors can cause depression. Such studies have also implied that genetics play a more prominent role in depression which presents as severe and recurrent compared to less severe, non-recurrent depression.
There may be times when depression needs to be treated by a medically qualified professional and if you are worried about your mental health you could speak to your GP in the first instance. There are very eminent medical professionals who advocate a pharmacological solution for people who suffer from depression whilst there are equally eminent medical professionals who claim that medications, and specifically selective serotonin reuptake inhibitors (SSRIs), falsely address the serotonin deficiency theory. The latter would rather emphasise the importance of neurogenesis to relieve symptoms of depression, without the risk of serious side effects associated with SSRIs.
The biological aspect of psychotherapy has its limitations as therapy tends not to be led by the presentation of symptoms. Psychological ill-health is not treated like physical ill-health. Take the treatment of cholera, for example. The symptoms have not changed over centuries and evidence based medicine and clinical guidelines will equip a medical practitioner to diagnose and effectively treat the disease. With psychological ill-health it is less obvious what the problem is as symptoms are not always an accurate signpost for the direction of therapy. People can present with a set of symptoms at the outset but their real worries can often be something else entirely.
Psychological
The important questions might be: What are your coping skills? Are there attachment wounds in the bonding process with mother? Have avoidance strategies developed to hide past wounding? What so-called ruptures may have occurred in the developmental stages? Is there a history of abuse? Has there been any fixations in the stages of sexual development? How do you feel about your body image? What were your early abandonments and rejections? When was your heart broken?
The first model of attachment available to you as a child was the relationship between you and your parents. A so-called ‘secure base’, if thinking in terms of attachment theory, is needed that is safe, consistent, stable, and trustworthy in order to safely experience rejection from peers out in the world. Rejection is an inevitable part of a child’s social life. However, a safe and secure home-life enables a child to unconsciously find a reparative experience following such rejection. The unconditional love offered at home by the primary care givers enables the child to heal their emotional wounds suffered from the socialisation process with their peers and in their early education. Having a secure base can help a child to develop the ability to trust others, and to become embodied, when encountering conflict, distance or confusion.
Sexual problems are very common and the best way to address them is to talk to someone about them. Talking about your sex-life, real and imagined, in a safe and non-judgmental space can be an illuminating and liberating experience. It can be useful to explore any projection of magical others, when someone is viewed as a saviour to your plight in life. It can also be an opportunity to explore porn use and affairs.
Some view therapy as a form of re-parenting since it offers a place of safety to explore past emotional wounding. This language may seem very patronising for others, as it risks associating with a hierarchical view of therapy that puts the therapist in a place of power and authority. I like the view that sees therapy more as a consultation, and a place of co-exploring, that allows for a safe exploration of internal parts, early shame and feelings of isolation. Therapy can help you to explore where you victimise yourself, where you play the role of rescuer and where and how your inner critics sabotage your self-esteem.
Sometimes it is necessary for you to be referred to specialised psycho-sexual therapists who have had special training to address deep past traumatic memories. However, you may find that learning to talk about aspects of your inner experiences that have always been very private can prove to be cathartic and transformative.
Social
The important questions might be: What are the socio-economical, socio-environmental, and cultural factors impacting your mental health? What are the early wounds around peer association, such as exclusion, wounding and emotional hurt? Are there instances of bullying, exclusion and isolation? What is your relational style in adulthood? Are there inter-generational issues being played out in your life?
The fight-or-flight response is generally regarded as the prototypic human stress response, both physiologically and behaviourally. Stress, and how we cope with it, is the barometer of how we emotionally regulate, how we can tolerate difficult feelings and whether we trigger addictive behaviours. Having positive social interactions before being exposed to acute stress can play a pre-eminent role in helping us control our stress response. It follows that engaging in prosocial behaviour (such as trust, trustworthiness, and sharing) in response to stress might also be a protective pattern.
Therapy could explore your social avoidance strategies, threats and fears associated within your social world. It is often the case that the strategies devised to deal with anxiety can often be the very things that can escalate the very anxiety that you are seeking to dissolve. Therapy can be a safe place that helps you to address difficult emotions such as fear, guilt, anger and sadness. It can also be an opportunity to assess how you manage stress and how you emotionally regulate. A useful question is to ask yourself whether your friends meet your needs or are you in hostage relationships with others?
The constancy of therapy refers to a psychological phenomena that allows for a healing space. Object constancy could be seen as the ability to believe that a relationship is stable and intact, which is robust even though there might be negative transference such as setbacks, conflict, or disagreements. Therapy offers constancy due to its professional framework. You are paying for the service, there are contractual obligations, and you are consulting with a practitioner with ethical standards surrounding the work.
The biopsychosocial model could be expanded to include the spiritual category. Investigating consciousness and spiritual realms does not, however, imply that one needs a belief in deity or God as some form of external agency. The important questions in a spiritual category could be: can all aspects of self be embodied? How do you feel about your own mortality? Was there any toxic messages from strict religious upbringing?
There may be obstacles to feeling good enough in the ‘here and now’ and there might be a pattern of seeking to escape from the present moment with addictions, fantasy or by staying busy. Sometimes there is a risk of spiritual bypass when people seek peak experiences from psychedelic drugs, deep meditation or enthusiastic emphasis on spiritual theory and to claim a stage of self actualisation and enlightenment. However, upon closer inspection they might have some unresolved conflict in their lives that they are in denial about which have not healed. They might be raging against perceived past hurts and are still stuck in their past. A rough rule of thumb when assessing whether behaviour has become problematical or not is to ask yourself what happens to your mood when you don’t have the drugs or can’t indulge in the behaviour which allows the escape.
“when assessing interventions a therapist should perhaps flirt with their hypothesis but not to marry it“
Therapy can be like assessing pieces of a jigsaw with a view to making sense of the bigger picture of someone’s life. When assessing interventions a therapist should perhaps flirt with their hypothesis but not to marry it. That is why I advocate an integrative approach and this is where the biopsychosocial model can be helpful. There might be pieces of information from biological and psychological sources but also from sexual, social and spiritual sources as well. The purpose of getting in touch with difficult aspects of self is to learn to better dialogue with contrary internal parts, or sub-personalities, and to transform such aspects by bringing about greater insight and mastery. The work could involve addressing shadow aspects of self, the parts that perhaps need to be manifested and brought into consciousness in order to better function out in the world.
Therapy ought not to be a space whereby the therapist imposes an agenda, a set of beliefs or even ways of working, but should offer an open and non judgmental space that allows for unbiased exploration of past wounding. Therapy can be a space to reflect, to let go and can be an opportunity to become embodied. A good therapist should be open to seeking clues from each broad category, outlined above, as well as addressing general health indicators such as sleep, diet and physical exercise.
The options in positive daily living is to spend energy on activities associated with a healing path, rather than on a destructive path. Getting in touch with difficult feelings can be when the real therapeutic growth occurs. There might be instances of insight from attending therapy sessions that are revelatory and which might feel good but ‘states’ of consciousness are not the same as ‘stages’ of consciousness. A massage, for example, may bring a transitory ‘state’ of consciousness, generally pleasurable (hopefully), whereas in counselling and psychotherapy it can be less about pleasure but perhaps more about getting in touch with difficult and discomforting feelings. The process of being able to tolerate difficult feelings can ultimately prove to be a ‘stage’ that is more durable, resilient and solid. Perhaps the therapy journey could involve uncovering the reasons for how your early survival and trauma based learning systems developed in early life so that you can become more aware of how you get triggered by others today.
Noel Bell is a UKCP accredited psychotherapist based in London and can be reached by telephone on 07852407140 or by email noel@noelbell.net
