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Models of Mental Health:
A Critique and Prospectus

The "medical model":
strengths and limitations

The Medical Model
commitment to alleviation of human suffering

professional responsibility

expertise

objectivity

presumption of "illness" as distinct category

presumption of perfectibility

presumption of all people as aspiring to same "ideal"

presumption of "patient" as object

search for efficient and rapid therapies

biology and .... culture?

The "medical model" represents an approach to issues of mental health that incorporates aspects of both science and biology without being synonomous with either. Reflecting as well an extended professional medical tradition, the "medical model" has strengths and limitations of its own that need to be evaluated in their own terms. In the following we do so with the objective of showing in what ways a useful broader perspective on mental health can be achieved by incorporating additional insights from scientific, biological, and cultural perspectives.

Relevant readings elsewhere on Serendip include:

Alleviation of human suffering, professional responsibility, expertise

Like all humans, proponents of the "medical model" profess an ideal that may conflict with other personal aspirations and hence be less than fully followed at any given time and in any given life. Our concern here is not with the impact of temptations that influence all human beings (wishes for power, prestige, or money, for example) but rather with the significance and usefulness of the ideals and insights themselves.

One can't, we believe, argue with the value of a commitment to the alleviation of human suffering, nor with the recognition that some cases of human suffering are most effectively relieved by people who have special training and experience and who are willing not only to make that available to others but to take on some measure of personal responsibility for the their well-being. The history of medicine includes many success stories of this sort, and the aspiration to have others recognize and take some responsibility for alleviating our own suffering is deep and at times productive in all of us.

That said, it is important to recognize as well that the successes of the "medical model" ought not to be taken as evidence that it is an effective means of dealing with all cases of human suffering. The model reflects successes in dealing with cases of human suffering that involve relatively simple cause/effect relations producing "symptoms" that are generally accepted as debilitating and undesirable (traumatic injury to parts of the body other than the brain, infectious disease, and so forth).

"expertise" may require redefinition, involving not only attention to what is common to all human beings but also the skill of being able to identify and work with what is distinctive in individual human beings.
As understanding of biological organization advances, it is becoming increasingly clear that both simple cause/effect relations and clear dichotomies between desirable and undesirable should in general be recognized as the exception rather the rule. This caution is particularly relevant in dealing with issues of mental health, as is becoming increasingly clear with increasing understanding of the complexity of the brain, in and of itself and in interaction with other brains. In this sort of context, "expertise" may require redefinition, involving not only attention to what is common to all human beings but also the skill of being able to identify and work with what is distinctive in individual human beings.

Objectivity

"science and humanity can both be perfectly healthy without Weinberg's "objective reality of science". Indeed, both can probably be healthier without it ... "

Just as the "medical model" evolved in the context of a particularly simple set of challenges, so too did the "science" which it borrowed from and reflects. Scientists themselves are increasingly being forced by their own observations to recognize that "objectivity", in the sense of an understanding stripped of all idiosyncratic characteristics of human understanders, is not only not achievable but not even desirable (see Revisiting Science in Culture; see also bat, stanford). Contemporary research on the brain is among the most significant pointers in this direction (see Getting It Less Wrong: The Brain's Way).

There is no legitimate basis for claiming expertise or authority based on an abstract conception of "objectivity". And substantial reason to believe that ... some measure of "subjectivity" ... can be valuable.
The "medical model" appropriately encourages practitioners to be aware of personal interests and perspectives that might influence their treatment of others, to be skeptical of such idiosyncratic characteristics, and to continually reassess their value in part by comparing them to the perspectives of others in a wider professional community. In these terms, an aspiration to "objectivity" (defined as that which has been tested against the perspectives of others) has demonstrated value in a wide array of contexts. What needs to be more widely recognized, however, is that "expertise" is only as good as the array of observations and perspectives which it reflects. There is no legitimate basis for claiming expertise or authority based on an abstract conception of "objectivity". And substantial reason to believe that, in more complex situations, some measure of "subjectivity" (intuition, gut feelings, countertransferences) can be valuable.

Ideals, norms, and categorization

The history of both medicine and science provide abundant evidence that, in many cases, it is, as a practical matter, useful to characterize norms and to create categories. In such cases, both norms and categories can be helpful to call attention to anomalies that merit further investigation. In addition, the creation of categories is frequently helpful in calling attention to variables that correlate with one another. Medical practice has had substantial successes based on noticing correlations between etiology, symptomatology, and effective therapy.

Strong correlations between etiology, symptomatology, and effective therapy have, however, always been the exceptions rather than the rule, and this appears to be increasingly the case as one moves into more complex situations such as mental health. It is already clear, for example, that "depression" may have multiple origins (genetic, traumatic, situational) and is not amenable to treatment in all cases by any single form of therapy. Furthermore, there is substantial reason to suspect that depression is not the same entity in each individual so diagnosed, and is not actually a discrete category but rather one end of a continuum of human circumstances.

every individual is in one way or another different from every other individual with effectively continuous variation on almost any measurable parameter ...

the very concept of an "ideal" becomes problematic in the light of an ongoing evolutionary process.

Ongoing research in molecular, organismal, and evolutionary biology provide clear reasons to suspect that the usefulness of categorizations and simple causal correlations will get less and less in the future. At every level of organization from molecules to cells to organs, humans are complex systems in which lots of different parts interact to yield any given observable outcome and in which each part plays some significant role in lots of different observable phenomena. Moreover, every individual is in one way or another different from every other individual with effectively continuous variation on almost any measurable parameter.

Perhaps the single most significant challenge to the "medical model" from the biological sciences has to do with "norms" and their relation to "ideals". Contemporary understandings of the evolutionary process suggest that biological organisms (including humans) are best thought of not as unavoidable deviations from some intended "norm" but rather as significant variants, components in a ongoing process of exploring viable living systems out if which further variants will arise. One may, for one reason or another, identify norms at any given time in such continually varying populations but there is no biological foundation for characterizing them as "ideals". Indeed, the very concept of an "ideal" becomes problematic in the light of an ongoing evolutionary process.

The relation of "patient", "doctor", and "culture"

In the context of the sort of problems and successes that gave rise to the "medical model", it made sense (and still makes sense) to think of a "patient" who had a problem and a "doctor" who fixed it. The interaction is straightforward and unidirectional (offset by the payment of a fee). The doctor is an active agent and the patient a passive recipient. One party is made "right" by the expertise of the other who is more or less unaltered by the exchange. Largely unaltered too is the broader culture of which both are part. In this context, it also made (and makes) perfect sense for one party to seek and the other to try and provide the most efficient and rapid intervention possible.

This is, of course, the context presumed by the current health care system in the United States, and has some quite significant general problems in terms of both doctor and patient satisfaction, as anyone involved with it in any way can attest. The problems are, however, particularly acute in the mental health area, for a variety of reasons that relate both to the previous discussion of the lack of a biological foundation for understanding "ideals" and to improving understandings of the architecture and function of the brain.

traditional practices of assessing health by objective measures easily made from outside a person may be inadequate. The internal subjective experiences of a person are important

The "patient" needs to be thought of not as a passive recipient of repairs but rather as someone actively engaged in their own shaping and reshaping of themselves

effective mental health care requires acknowledging that effective therapies may require not only personal change but participation in cultural change as well.

the most "efficient and rapid" therapy may sometimes not be the optimal one

It is increasingly clear that the "self" emerges from a complex interaction of brain processes, some unconscious and some conscious, and that the self has a distinctive and important role in individual lives: to conceive of ways of being that provide alternatives to what one finds oneself with at any given time and to incorporate those at both conscious and unconscious levels into a continually revisable self. A rich set of internal conscious experiences (feelings, intuitions, thoughts, dreams) play an essential role in such self-revisions.

Several things follow from this that offer challenges to the "medical model", particularly in the arena of mental health. The most obvious is perhaps that traditional practices of assessing health by objective measures easily made from outside a person may be inadequate. The internal subjective experiences of a person are important, and can be at least as relevant as weight, blood pressure, immune system status, and so on.

Still more importantly, effective mental health care needs to acknowledge the existence in people of some measure of influence on their own conditions and lives, and indeed to encourage the development of increased individual agency. The "patient" needs to be thought of not as a passive recipient of repairs but rather as someone actively engaged in their own shaping and reshaping of themselves.

These considerations have significant ramifications at interpersonal and larger scales. When the primary task is to assist another person in the shaping and reshaping of themselves, the task of the "doctor" is even less amenable to definition in terms of a pre-conceived "ideal" state and requires instead a willingness to support and engage in a process of exploration that may move in totally unexpected directions and have consequences for both parties to the interaction. A detached "objectivity" needs to give way to a more bidirectional engagement.

On a still larger scale, it needs to recognized that problems in shaping and reshaping oneself may have their origins within the "patient" but may equally have their origins in interactions with others, and/or with the broader culture within which they are working. The "medical model" presumption that someone who is suffering has a problem within themselves is too limiting. In the absence of a biological "ideal", effective mental health care requires acknowledging that effective therapies may require not only personal change but participation in cultural change as well. In this context, the most "efficient and rapid" therapy may sometimes not be the optimal one.

Conclusions

The "medical model" has its strengths in some arenas, particularly those in which there is substantial consensus among humans as to what constitutes a "problem" and such problems reflect situations involving fairly simple cause-effect relationships. In other arenas, of which mental health is a significant example, the "medical model" has clear limitations. Among these are

  • an over-reliance on "categories", "ideals", and "objectivity"
  • a failure to appreciate the significance of internal experiences
  • lack of appreciation for diversity and for the essential role played by individuals in their own evolution
  • lack of appreciation for the role of culture in mental health


This synthesis of a variety of materials on Serendip grew out of discussion in the Serendip/SciSoc Group Summer 2006 and was prepared by Paul Grobstein and Laura Cyckowski. Your comments and further thoughts are warmly invited in an on-line forum. For longer contributions, contact us.




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