The Medicalization of Conversation

Talking to a counsellor about upsets, relationship difficulties, or just feeling stuck seemed a lot simpler before these normal life challenges came to be seen as signs of possible mental disorders needing treatment. I am referring to a medicalizing trend that seems to be taking at least two directions. Seen one way, medicalizing our concerns legitimizes them; seen another way, this medicalizing renders normal life challenges into the stuff that others diagnose and treat for us. Unsurprisingly, this has been a boon for big pharma as is well known at this website. But I want to speak to what this has meant for counselling — that modest way of conversationally helping people overcome life concerns that haven’t always been seen as medical in origin or nature.

Alongside concerns one might have about madness are the everyday moods and forms of stuckness that ebb and flow. The diagnostic dividing line on what is or is not a psychiatric concern changes in small and big ways. Only some fears will morph into anxiety, while few sadnesses or stucknesses will stabilize into depressions, and I will be restricting my comments here to those concerns undiagnosable as a severe mental disorder. Mostly, such emotions relate to people, developments, and circumstances in our lives — and only secondarily, relate to the functioning of our organs or intellect. Sharing and reflecting upon our stuckness and emotional ebbs and flows with others often helps us move on. Sometimes such sharing and reflecting isn’t enough and so we might remain stuck or moody enough to want to talk to someone else who is not close to us, burned out by us, or entangled in relations with us — like a counsellor, perhaps.

A counsellor and counsellor educator myself, I joined my profession back when people presenting such forms of moodiness or stuckness seemed able to talk their way through many concerns with a counsellor’s assistance. And they didn’t need to think of themselves as needing a diagnosis to see me. I’m a psychologist, too, and will sometimes refer to myself as a family therapist, yet things get blurry as to who does what these days, as a “mental health professional.” I still like considering myself as a counsellor first, though; someone who works to help others through good conversation.

Emotionally speaking, ours has become an era focused on wellbeing, with the quality of our mental health at its center. A particular kind of logic increasingly informs public and professional approaches to wellbeing, a medicalizing ‘diagnose and treat’ logic according to sociologist Peter Conrad.¹ Diagnostic boundaries around what passes for normal seem redrawn culturally and professionally as more human woes evolve into new or expanded mental disorders requiring treatment. There is a complex backstory here to this medicalizing in counselling. Some of it relates to counsellors’ professional legitimacy in the public’s eye, but another aspect is about their economic viability within our mental health services.

Mad in America has been a cyber (and occasionally virtual) forum for many readers, in large part thanks to Bob Whitaker’s and others’ critiques of the psycho-pharmaceutical industry’s excesses and abuses. But the medicalizing logic of psycho-pharmacology hasn’t stopped there; a version of it found its way into the mental health industry which rations counsellors’ services. Primarily enabling this rationing is use of DSM5 (Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition) diagnoses, and evidence-based interventions for treating each diagnosed disorder. As far back as the mid-1980s, software algorithms based on this ‘diagnose and treat’ logic and language supported rationing mental health service delivery.² Unsurprisingly on first evaluation, pharmaceutical interventions were identified as most cost-effective for relieving the symptoms of DSM diagnosable disorders. Lagging behind, it seemed, were the conversationally oriented ‘treatments’ of mental health professionals, like counsellors. Such treatment evidence is more equivocal nowadays, particularly for addressing the moods and stucknesses raised above. Still, a medicalizing logic persists in spheres like counsellors’ work, counsellor education, mental health administration, and for a public who understandably wants to understand their moods and stucknesses — as mental health professionals do.

Cultural critic Eva Illouz³ claimed that the default language of self-understanding is increasingly based on DSM diagnoses. Psychologist Svend Brinkmann⁴ suggested that we have been losing our languages of suffering as mental health discourse overtakes other ways people understand and discuss their concerns. A recent pair of edited books advocates, “De-medicalizing misery.”⁵⁶ Even Allen Frances, who oversaw the DSM-IV’s development, entitled his recent book on the DSM5 process “Saving normal,” to warn of the DSM5’s excessive medicalizing.⁷

For counsellors, such medicalization enables some parts of their work while constraining other parts. My concerns began out of my own conversational work as a counsellor. Generally speaking, counsellors learn several approaches to helping, diagnostic and intervention aspects of psychiatry included. In learning these approaches, they acquire different languages for making sense of and addressing the concerns clients bring to them. In my own case, I practiced in the language of couple and family therapy where concerns are seen to occur between people, not inside them. However, in practicing within a provincial mental health system, my language for understanding and addressing client concerns fit poorly with the diagnostic and treatment language used to manage services within that system. The issues are even more commonplace today. This lack of fit wasn’t only because of my using the language of couple and family therapists either. Try counselling to empower clients in abusive or discriminatory relationships, or exploring existential meanings around personal loss, or building on personal strengths. Such conversations, to me, typically do not involve treating symptoms inside people.

Counselling has always dealt with client and professional meaning in some form; the languages used, and how they’re used, are central to its meaning-making. It matters that we can share and transform our meaning with each other in understandable ways, which makes language, and how we use it, important to counselling’s conversational work. By social constructionist thinking (e.g., Burr, 2015⁸), any language is always partial and can’t get at an experience’s full meaning or significance. Take one of Allen Frances’ concerns for example: grief after someone we love passes. What does a symptom-based language of grief leave out, that other spiritual, financial, or relational languages of understanding and talking might supplement? What might each language cue up for the conversational work of counselling?

Answering my last question: if medicalizing discourse is expected, one will evaluate the client’s physical and emotional symptoms (e.g., sleep disturbance, despondency) for severity and possible diagnosis. Treatment of those symptoms, in some form or another, would follow. This clearly involves a different conversation than one focused on the importance of the deceased person in the clients’ life, or the spiritual meaning of a close one’s passing. My point is not to pit one language against the other; medication can temporarily relieve a spiraling-out-of-control sleep disorder, enabling later conversations with clients that couldn’t otherwise happen. Medicalization’s ‘diagnose and treat’ logic and discourse isn’t one size fits all, however, when it comes to the conversations of counselling.

Medicalization has had an effect not only on such conversations but on everyday thinking as well. As the palette of language for bringing colour and meaning to our emotional experiences and life predicaments gets displaced by a more official-sounding psychiatric language, insidious things can happen. We might take on psychiatric understandings as exclusive self-understandings to live by. An upside of doing so is that a kind of medical legitimacy is conferred. A stable sense of community among those sharing a diagnosed condition can also develop as Svend Brinkmann (2016) showed through his research into “diagnostic cultures.”⁹ From a Masters student, Stephany Huynh, here at my university, I learned of the diagnostic legitimacy and community issues somewhat in reverse. Stephany spoke to members of the “Aspie” community after Asperger’s Syndrome was dropped as its own DSM disorder in the then new DSM5, being later placed under a broader category: Autism Spectrum Disorder. Gone, for the aspies she talked to, was the kind of medical legitimacy mentioned above. That former diagnosis, for some, enabled particular funded services, but more importantly, many had seen their diagnosis as a kind of identifying badge of honour, a diagnosis conferring legitimacy on behaviour previously seen as eccentric (at best) by others. These aspies became diagnostic ‘outlaws’ or outliers of a sort.

There can of course be potential downsides to living by medicalizing language. I recall some years ago, in my training, hearing someone saying that behind every important self-description used in counselling lies a story. Moods and stucknesses clients bring to counselling find their storied coherence, in part through how they are talked about. DSM diagnoses originally offered a diagnostic shorthand, enabling researchers and mental health professionals to readily communicate about the symptomatic meaning and severity of concerns that clients (or patients — consider the differences in terminology) present. However, a diagnostic term does not a full story make; the media can also play a role in furnishing the meanings and storylines publicly associated with any psychiatric diagnosis. The self-help media are thriving in ways that help one officially (i.e., medically) learn about their concerns and what to do about them, as any quick search of Google or YouTube reveals. One’s moods and stucknesses can be diagnosed (by self, professionals, or others), but they also arguably (to me at least) remain fair grist as conversational material in search of further actionable understandings.

Even for diagnosed concerns of lesser severity (e.g., depression or anxiety), diagnoses may still be usefully supplemented with other languages of suffering, or of unused meanings and resourcefulness. It is whether (or how) clients live according to the languages they are exposed to (or that are proposed to them) that matters most. Linguistic downsides can arise if one feels limited by a diagnosis’ media-furnished storylines, particularly if such storylines implicate one’s sense of identity and possibility. At worst, diagnoses offer a totalizing or exclusive language that furnishes convincing storylines to clients and counsellors of progressive enfeeblement, demoralization, and failure.¹⁰

The ‘diagnose and treat’ medicalizing logic and discourse I have been describing has seen its share of resistance from counsellors, including from me. Among scholars of counselling, debates have raged over what counsellors should listen for and respond with as they converse with clients. Considerable research has been informing the debates, without any clear winner over what should be said and done — other than research consistently identifying the quality of the conversational relationship as paramount, and with client feedback on the process and outcomes helping to keep the relationship that way.¹¹ For me, this is not another way of saying that the (mental) health professional needs a good “bedside manner.” It is about counsellors engaging clients on what they want to see different in their lives, conversed with in respectful and resourceful ways about which clients have considerable say. Medical language and logic is but one language and way for engaging in these conversations.

A concern that brought me to academic life as a counsellor educator came from recognizing the effects that medicalizing logic and language were having on my own practice as a counsellor. Sometimes the effects crystallized in bureaucratic expectations that I stick to a medicalizing discourse, despite it being antithetical to my preferred approaches to practice. How, for example, should one square a relational understanding of parent-child conflict with an agency or insurer’s need for a diagnosis like “oppositional disorder” (i.e., in the child) so that the parent and child can legitimately be seen together in counselling? More importantly, I have been concerned with the increasing incursion of ‘diagnose and treat’ understandings into normal aspects of the human condition: the moods, stucknesses, and relational conflicts that can seem unadressable in clients’ lives without some kind of professional assistance. When, or how often, do such concerns foretell acute or chronic mental disorders, and when might they otherwise relate to parts of the warp and weft of everyday life?

My hope is that students of counselling engage in conversational work that clients deem collaborative, reflective, resourceful, and above all useful in addressing what concerns them. As all of this relates to the medicalizing logic and language that I have been critiquing; my concern is not that counsellors need to know and be able to use this logic and language (they do, to talk to other health professionals and to sometimes make referrals when warranted). Counsellors are professionally obliged to engage in ethical conversational work not tethered solely to a medicalized language and logic. However, for economic, professional, and cultural reasons, this language and logic seems to have become primary. For the public, this primacy brings constraints on what users of counselling might be able to discuss, should their concerns be non-diagnosable within increasingly rationed counselling services paid for by public funds or private insurers. The moods and stucknesses once seen as legitimate reasons to talk to a counsellor arguably may be diminishing in cultural significance given how our formerly responsive social safety net is defunded. As what is left of that safety net becomes more prescriptive in line with a medicalizing logic, I am concerned for what this means for the conversations of clients and counsellors.