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Models of Mental Health:
A Critique and Prospectus

Expanding the view:
the "biological/neurobiological/cultural model"

The Biological/Neurobiological/Cultural Model
commitment to sympathetic and productive engagement with human suffering

professional responsibility

expertise (modified)

presumption that humans are nothing more (and nothing less) than complex assemblies of matter

accepts existence of continuous variation among individuals, both now and in future - indeed encourages diversity

emphasizes importance of innate influences, as well of experience and of personal choice

acknowledges that some kinds of changes take extended time at best, may not be achievable at worst

incorporates cultural context dependence

raises new significant issues, such as the potentials and limits of personal responsibility

In the previous section, we explored both the strengths and the limitations of the "medical model" perspective on mental health, pointing out ways that additional insights from biology, neurobiology, and cultural studies could yield a broader perspective that overcomes some limitations. In this section we make explicit such a broader "biological/neurobiological/cultural model".

A novel element of the broader perspective is the presumption that humans are nothing more (and nothing less) than complex assemblies of matter. This presumption derives in part from the kinds of clinical observations and experiences that the "medical model" makes use of but derives as well from additional biological and neurobiological observations to make a broader claim that includes not only aspects of the body, as that term is often used, but also internal human experiences (ie, "mind"). Most importantly, the broader claim makes it possible to bring together in one integrated framework not only the body and the mind but the self and culture as well.

We do not regard the "materialism" assumption as "true" but rather as one that reasonably summarizes available observations and seems to open productive new directions for thinking about mental health (among other things). We will consider it further in a concluding section but note for the moment that it in not equivalent to denying the admissibility or significance of terms like "choice" or "self-determination" or "spiritual experience". As Emily Dickinson said "The Brain in Wider than the Sky ..." and so there is plenty of room within the brain for all aspects of human experiences.

A traditional view of body/mind/culture

As schematized to the right, many people today think of themselves as the product of two separate and distinct kinds of influences: nature or "biology" (their bodies, influenced by genes, hormones, and so forth) and "nurture", a distinct sphere of experiential and cultural influences. Such a scheme embodies a useful distinction between things going on inside one and things influencing one from outside. It also is a comfortable fit to the "medical" model in that it distinguishes "biology" (around which the medical model develop) from other things. Notice thought that it gives no clear place for "brain" and portrays the "self" as the passive resultant of forces on which it itself has no influence.

The biological/neurobiological/cultural perspective

The images to the right provide a somewhat different way to think about oneself and one's place in the world, a way that we think may better support a broader perspective on mental health.

As shown in the upper part of the figure, an individual consists of a body that contains within it a brain which in turn contains a sub-region of the brain that supports internal experiences. The "self", as discussed in the previous section, is an emergent product of the body interacting with both the unconscious (green) and the conscious (yellow) parts of the brain, with the "experienced self" restricted to the latter. Since conscious thinking is dependent on prior processes occurring in the body and the unconscious parts of the brain, it is not only the "self" but all understandings of the outside world that have a "subjective" element to them. This is a significant challenge to any absolute standard of "objectivity" but also provides the opening by which change can occur in understandings both of oneself and the world.

This scheme is not only consistent with all existing biological and neurobiological observations but provides a clear way to visualize the complexity of the self as well as of the various influences on it. Moreover, since each of the nested boxes is both influenced by and influences its surrounding box, there is a clear mechanism by which the experienced self can play a role in its own construction and revision. The scheme also appropriately (we think) emphasizes that neither "brain" and "body" nor "body" and "mind" nor "brain" and "mind" are separate and distinct entities (as sometimes thought). Mind is an aspect of the brain which is in turn an aspect of the body. Hence what affects the body can affect the mind, and vice versa.

The lower part of the figure extends the nested notion to incorporate as well both individual experiences and culture. Individuals interact with an outside world that consists of both inanimate and animate entities. Among these are both other individuals and the collective products of individuals working together such as libraries and the like. The interactions among individuals and the products of such interactions are what we call culture.

Several aspects of this further nesting are particularly important in the context of thinking about perspectives on mental health. One is the recognition that culture does not exist independently of individual human beings. It is instead the product of the interaction of human beings, and so individuals are both influenced by and capable of influencing culture. The second important point is that cultures emerge from diverse groups of individuals, each of whom is simultaneously engaged in a process of shaping and reshaping their own lives as well as participating in such a continual shaping and reshaping of community lives.

Conclusions

The broader perspective ... offers a common framework within which a variety of people approaching issues in mental health from different professional backgrounds might comfortably share existing insights and work together toward additional ones.
The biological/neurobiological/cultural perspective and model includes some features of the medical model that we think are valuable, and more explicitly extends others (humans as complex assemblies of matter). At the same time, it avoids problems that have become increasingly apparent with attempts to extend the medical model to the kinds of more complex circumstances that characterize many problems in the mental health area (difficulties in dealing with diversity, ideals, norms, categories; absence of attention to people as causal agents and to cultural considerations). The broader perspective achieved by adding additional insights from biology, neurobiology, and cultural studies also offers a common framework within which a variety of people approaching issues in mental health from different professional backgrounds might comfortably share existing insights and work together toward additional ones. It is not intended to invalidate the medical model (or any other) but rather to set that model and others in a useful larger context. We do not wish to deny that some issues in the mental health arena may in some circumstances be productively approached using the presumptions of the medical model (or any other) but only to argue that the medical model cannot be expected to deal well with all problems in the mental health arena and so a broader perspective that integrates it with other insights is desirable.

the primary objective of mental health professionals ought to be not to "fixing problems" but rather to encouraging and facilitating the potential inherent in each individual to be continually shaping and reshaping their own lives ... commits mental health professionals to a continual engaged process of helping individuals, themselves, and cultures "get it less wrong".
Among the important distinctive features of the biological/neurobiological/cultural model is the attention it gives to individual diversity as well as to ongoing individual change and the role of individuals themselves in that process. And the highlighting of bidirectional interactions between individuals and the cultures in which they live. In this context, it is actually the case that some discomfort is probably not only inevitable but, even more importantly, a positive feature. It is from differences, and associated discomfort, that new directions of exploration and movement arise. In this context, what is needed is not so much a commitment to "alleviating human suffering" but rather one to a "sympathetic and productive engagement with it". The primary objective of mental health professionals ought to be not to "fixing problems" but rather to encouraging and facilitating the potential inherent in each individual to be continually shaping and reshaping their own lives, recognizing the some level of discomfort may be a significant contributor to that process. In simpler circumstances, of the sort that gave rise to the medical model, this objective translates appropriately into "fixing problems" but without the necessity to commit to particular "ideals". "Problems" are those things that detract from the ability of individuals to distinctively shape their own lives. More generally, the broader objective commits mental health professionals to a continual engaged process of helping individuals, themselves, and cultures "get it less wrong".

The usefulness of a broader perspective relates not only to its ability to provide a common framework in which insights from diverse perspectives can be brought together but also to its ability to generate from that diversity new issues that deserve more general attention. In the following section, we discuss some of the likely growing points that could emerge from the "biological/neurobiological/cultural" model of mental health, include the important questions of the potentials and limits of individual change and their relation to cultural change.


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.




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