The medical model is dead   long live the medical model

Many people criticise, and psychiatrists apologise, for theuse of the ‘medical model’. We examine what iscurrently meant by this term and suggest a refinement of definitionto reflect the ideals and contemporary practice of medicine.We propose that psychiatrists should use the medical modelto improve and validate bio-psychosocial psychiatric medicine.

INTRODUCTION

TOP

INTRODUCTION

The term ‘medical model’ is frequently used in psychiatrywith denigration, suggesting that its methods are paternalistic,inhumane and reductionist. This view has influenced mentalhealth organisations, which in certain areas advocate a departurefrom the medical model, and contributes to the difficultiesin leadership being played out between politicians, professionalsand patients. The view has some support from within psychiatry (with some psychiatrists being apologists), from the 1960s’ anti-psychiatry movement, as well as from some in the recoverymovement (Ralph et al, 2002). Although diversity is healthy,it may fuel unproductive rivalry to be recognised as the therapeuticagent between divergent therapies and agencies.

WHAT IS CURRENTLY MEANT BY THE MEDICAL MODEL?

TOP

WHAT IS CURRENTLY MEANT...

There are various definitions. Clare (1980) suggested thatit is a scientific process involving observation, descriptionand differentiation, which moves from recognising and treatingsymptoms to identifying disease aetiologies and developingspecific treatments. Wikipedia, the internet encyclopedia,currently defines it as ‘the predominant Western approach to illness, the body being a complex mechanism, with illnessunderstood in terms of causation and remediation, in contrastto holistic, and social models’. The Disabled People’sMovement (http://www.bfi.org.uk/education/teaching/disability/thinking/medical.html) believes that it is based on a false notion of ‘normality’,with people being judged on what they cannot do. They believethat it sees people with disabilities as the problem, focusingon impairment, provoking fear and patronising attitudes, thepowerful doctor shutting the ‘disabled’ away. Thesedefinitions potentially combine to form the caricature of a reductionist, mechanistic, disability-enhancing approach, takenby powerful doctors towards patients.

Matters are aggravated in psychiatry because of the Descartiandivide between biological and psychosocial psychiatry. Biologicalpsychiatry is assumed to be mechanistic and reductionist, exclusivelyconcerned with neuroimaging, genetics and medication. Psychosocialpsychiatry, championed as being empowering, humane and holistic,is regarded as the antithesis and aligns itself to models suchas Engel’s (1977).

IS BIOLOGICAL REALLY REDUCTIONISTIC?

TOP

IS BIOLOGICAL REALLY...

The idea that the ‘biological’ is reductionist andundesirable leads to curious contradictions. The negative viewof psychiatric drugs contrasts with views of drugs in otherspecialties or alternatives such as homoeopathy. The parallelassumption that psychosocial treatments are without risk, areholistic and the treatments of choice ignores evidence thatsome psychological treatments can cause damage (Rose et al, 2002). Furthermore, psychological treatments may work synergisticallywith drugs (Keller et al, 2000). In the extreme, advocatingexclusive psychological approaches amounts to ‘psychologicalreductionism’ and could harm patients by denying themother effective treatments.

Biological explanations and treatments for diseases have helpedto reduce fear, superstition and stigma, and to increase understanding,hope and humane methods of treatment (Tallis, 2004). For example,epilepsy is now better understood as a medical condition, whichhas reduced the perception of it being a fearful phenomenon of demonic possession. Logically a biological perspective inpsychiatry should do the same.

Neuroscience demonstrates that biological, social and psychological experiences translate into changes in brain structure and function.Childhood sexual abuse (Teicher, 2000), personality traitdifferences (Breier et al, 1998), and psychological and pharmacological treatments (Seminowicz et al, 2004) have all been associatedwith differences in discrete brain systems, making it difficultto maintain the mind–body split, and offering a potentialexplanation for how bio-psychosocial treatments actually work.

We suggest that the difficulty lies in accepting that the humanmind is also biological. This challenges cherished assumptionsabout our self-attributed uniqueness and the specialness of‘the mind’. As Tallis (2004) comments, regardingone’s body as part of oneself but also objectively is difficult. How much more difficult is it to accept that whatwe experience as ourselves can be understood in terms of brainfunction? Banishing biology to reductionism merely defendsour need to preserve the sanctity of ‘the mind’.

A CONTEMPORARY DEFINITION OF THE MEDICAL MODEL

TOP

A CONTEMPORARY DEFINITION OF...

We believe that we need a simple definition of the medical model,which incorporates medicine’s fundamental ideals, tofacilitate clarity and precision, without denying its shortcomings.We propose that the ‘medical model’ is a processwhereby, informed by the best available evidence, doctors adviseon, coordinate or deliver interventions for health improvement.It can be summarily stated as ‘does it work?’

Face validity
Evidence has always been at the core of the ‘medical model’, encapsulated in Hippocrates’ diktat ‘first, dono harm’. This assumes that the doctor has specific knowledgeand expertise (evidence) that an intervention causes greaterbenefit than harm. Further, it is what most doctors do today,and it is what our patients expect – the days of treatingon ‘gut feeling’ have long gone. Although some people question how much daily practice is evidence based (Imrie & Ramey, 2001), there is no call to abandon evidence and rely on faith or instinctalone. Practice is also increasingly determined by guidelines,with legal consequences for not doing so. We suggest that patientsare not primarily concerned with a treatment’s ideologicalbackground but are more interested in what helps and what harms.Patients want us to provide a balanced view to enable themto decide.

Ideology and assumption free
The history of psychiatry well illustrates the perils of treatmentby assumption or ideology. Our definition avoids invoking either ‘psychological’ or ‘biological’ ideologies.Although some people debate whether empiricism is reasonable,we contend that ideologies have fruitlessly divided pharmacologyand psychotherapy (as well as psychotherapies themselves).How ‘it works’ is important but is secondary todefining ‘what works’. Not knowing how it worksdoes not invalidate good evidence: vitamins were undiscoveredwhen Lind conducted his scurvy trial (Bartholemew, 2002). Evidence,then, is the first critical step in elucidating what worksand helps to validate our bio-psychosocial treatments, definingtheir dangers and efficacy.

Scrutiny of interventions
The model requires all interventions to be scrutinised usingthe same methodology. As each intervention is understood onits own merits, protagonists need to justify their treatmentwith standard evidence and not ideology. It is an unfair assumptionthat ‘mind’ treatments are beyond scrutiny andthat some treatments are somehow innately ‘better’than others. Such scrutiny is particularly important when publicmoney funds interventions (e.g. in the National Health Service). Indeed, the benefit of the medical model is that it justifiesexpanding non-pharmacological as well as drug treatments.

THE MEDICAL MODEL AND POWER

TOP

THE MEDICAL MODEL AND...

We do not believe that the medical model is simply about doctors’ apparent power. The relationship between a patient and theirdoctor is complex. Patients initially seek a doctor becausethey believe this may be useful, which could be seen as conferringpower to the doctor. However, getting better has always beenan active process involving seeking help, evaluating optionsand making decisions about treatments. Patients do choose notto engage with treatment (e.g. only half of patients collecttheir prescribed medications), and may sabotage their own care.When vulnerable, people respond in various ways which are probablyinfluenced by their experience of life: some feel powerlesswhereas others are motivated. Patient behaviours and expectationsare not passive – if they were, patients would meeklystop smoking, curb their alcohol intake and have cervical smears! The doctor’s task then is to advise on the most effectiveintervention, the patient’s task being to decide andact on that advice while making sense of complex and conflictingemotions. ‘Patient empowerment’, therefore, haslittle to do with rescuing patients from the medical model.In this context, Engel’s psychosocial model does notcontradict the ‘medical model’ but rather enhancesit.

FUTURE OF THE MEDICAL MODEL IN PSYCHIATRY

TOP

FUTURE OF THE MEDICAL...

We believe that it is important to adhere to the medical modelas we have defined it (‘does it work?’). If wedo not we may lose our hard-earned gains in defining effectivepsychiatric treatments. We must continue to gather qualityevidence in order to establish which interventions work. Thismay be particularly challenging when defining which elementsof psychosocial treatments are effective. This is criticalto improve the credibility of psychiatry as a medical specialty,which has been attacked because psychiatric treatments aremultidimensional.

We also contend that the well-informed psychiatrist who usesthe medical model is ideally positioned to challenge thosewho engage on both sides of Descartian extremism. We need toacknowledge that our medical approach may sit uncomfortablywith other doctors and mental health professionals, who maynot perceive that psychosocial factors and interventions translateinto biology. However, we should use and encourage the developmentsin neuroscience, which blur the distinction between mind andbrain and which may demonstrate how bio-psychosocial interventionsactually work. This offers the potential to bring rationality,specificity and validity to our interventions.

Most importantly, we should not apologise for using the medicalmodel. Instead, we should challenge those who use it as a professionalattack and question what is being criticised. We should notbelieve that the medical model is only about doctors’powers, but remind ourselves that patients are active participantsin the interaction. Medicine has always been about helpingpatients ‘take charge’ of their recovery by whatevermeans available.

Finally, we should rigorously challenge those who regard thepsychiatrist as a unidimensional pharmacologist and reductionist.Psychiatrists’ training involves the use of biological,social and psychological treatments, a fact recognised in statute(e.g. the Mental Health (Care and Treatment) (Scotland) Act2003). Thus, we should highlight what is undoubtedly psychiatry’sbest asset (an area that the public may accuse our specialistcolleagues of lacking): that of being a medical specialty inwhich the specialist understands and uses the holistic bio-psychosocial approach.

REFERENCES

TOP