What is the medical model? And why do people seem to hate it so much?

Caroline wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate
 

"Raise your hand if you believe in the medical model!"

This challenge was issued by a professor on the second day of my MFT graduate program. Hesitantly, I and about half of my class sort of raised our hands.

You ever have the feeling where you are on-the-fly asked to give a definition of a word you've been using with confidence forever, and you instantly start to question whether you have any idea what the word actually means?

Yeah. That.

If someone had asked me to define "the medical model," I would have said, "um...like...hospitals? And doctors? And it's a model, so like...the idea that we go to the doctor when we're sick?" So, yeah. I believe in that, I guess? Which is why I raised my hand. I like doctors. I go to them frequently. My brother even is one.

But as my professor surveyed the room with a judgey raised eyebrow, I started to wonder what I had just committed to.

"So you believe all of your clients should get a diagnosis?" he questioned in an admonitory tone (admonitory: giving or conveying a warning or reprimand).

I was embarrassed. I didn't have much experience in the mental health field, wasn't super-educated about current theory, and felt that clearly everyone else knew what this was all about and I was the only one raising my hand in total ignorance.

And instead of elaborating on the medical model and what it had to do with diagnosis, he moved on to ask whether it was ethical or unethical to assign a diagnosis to a client just so they could get treatment covered by insurance.

I was left feeling like I'd just missed the bus. My inner monologue was scream-whispering inside my head: "Wait so but what is the medical model also why wouldn't you give a diagnosis WHAT'S WRONG WITH DIAGNOSIS??"

After all, I'd been diagnosed with an egg allergy when I was a toddler. Without that diagnosis, I would have spent many years wondering why breakfast foods made me feel like I was dying.

This kept happening. Someone would say something obliquely critical of "the medical model," like if you were in favor of the medical model then you were not going to be a good therapist and you were probably a terrible person to boot. And it always happened in a hush-hush sort of way. Like, "well I know I shouldn't be saying this BUT..." And then there was never any further discussion.

One of my professors suggested clients don't need medication as much as they need unconditional positive regard. Another professor warned that doctors don't treat their patients like people. Another begged/demanded that "you must never refer to your clients as a diagnosis!" 

Apparently, there was something wrong with "the medical model." I had to find out what the hell this thing was, and why it was so bad.

So I started asking around. My classmates' definitions varied. Some thought "the medical model" referred to  using medication to treat things. Others believed "the medical model" was responsible for stigmatizing disability. Still others believed it was somehow connected to science and psychotherapy in general. And we were all aware it had a negative connotation.

Finally, this summer, I decided to do some real reading.

Me, realizing what I'd gotten myself into:

Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

But it was too late.

I'd lifted the lid on what seems to be a Great Debate in the field of mental health. Many authors identify that the term "the medical model" is used as an epithet "with denigration, suggesting that its methods are paternalistic, inhumane and reductionist" (Pies, 2017; Shah & Mountain, 2007, p. 375). I found lots of reasons why this is the case, but I also found many authors arguing that this is unfair. Mostly, I realized there are a lot of things to be confused about.

At this point, I've done a good amount of research, but trust me that I've only just scratched the surface.  I make no claims to having figured this all out. But I'm going to share what I've learned thus far--I feel much less confused now than when I started this project. Still, if you think I've wrongly interpreted something or am just in general way off the mark, I welcome feedback, clarification, and edification! Seriously. 


What I think is going on is this:

  • "The medical model" is a term for how we conceptualize illness, and the definition has changed over time.
  • It's a concept that came about during the Scientific Revolution, began to be applied to mental health and psychotherapy in the 20th century, and was successfully challenged starting in the 1960's.
  • At that point, people were pointing out a bunch of things that were seriously problematic about the model, and "the medical model" got a really bad reputation.
  • (I think it was also around this time that "the medical model" and all its oppressiveness got conflated with "applying scientific principles to psychotherapy." I'll be addressing this in a later post.)
  • In the latter half of the 20th-century, people started trying to address all the problems raised by critics, and "the medical model" shifted from a biomedical emphasis to a biopsychosocial emphasis as a result.
  • The "new" (and improved) medical model as used today by clinicians is--or should be--quite different from the "old" medical model, though people still call it just "the medical model."

Now here's why I think this is such an important issue:

Poisoning the well against "the medical model" without defining the term and explaining the debate is dangerous, because it unfairly prejudices new clinicians against whatever they decide "the medical model" means to them--diagnosing, giving clients a medication referral, reading published studies to inform their practice, etc. This results in clinicians more likely to justify opting out of evidence-based practice as the taking of a principled stand against "the medical model," when in reality it is simply unethical practice

Part 2 of this article will address this argument, and I'll include some things I think we can do as ethical psychotherapists instead of sitting around demonizing the medical model.

In the meantime, let's start with figuring out what the hell it really is.


    I've included a list of references at the end of this article in case you're interested in following me down this insane rabbit hole. And even if this is not the most interesting thing you've ever learned about, I hope you'll at least hear me out to the end of this post, because I do think this is really important and I'm not sure why it's not covered more in-depth in school.

    Ready to learn more than you ever wanted to know about the medical model?

    HERE WE GO!

     

    The Classic Medical Model

     Image: Paul K.,  Le Docteur Alchimiste (18th cent.) , bibliodyssey.blogspot.com/2008/10/alchemy-laboratories.html

    Image: Paul K., Le Docteur Alchimiste (18th cent.), bibliodyssey.blogspot.com/2008/10/alchemy-laboratories.html

    Once upon a time (starting in the 1500s), the Scientific Revolution happened. People started trying to figure out what was going on when other people developed pustules or hacked up blood. They started taking dead people apart like cars. Displeased, the Church, who had previously cornered the market on "why do people get pustules?" (because God), wasn't real happy about this infringement on its philosophical territory. But it agreed to a compromise and said, "hey you know what, you can take apart bodies as long as you leave us the mind, by which we really mean soul" (Engel, 1977). The proto-doctors decided this was fine, so they started trying to find biological reasons for biological symptoms like pustules--and the medical model was born (Wade & Halligan, 2017). But they stayed away from the mind/soul because that was the Church's turf, which resulted in the mind/body division that existed in the Western world for hundreds of years (Engel, 1977).

    So, simply put, the classic medical model "is characterized by a reductionist approach that attributes illness to a single cause located within the body" (Wade & Halligan, 2017). This is the medical model that, in general, most people are referring to when they say "medical model" in a derogatory way.

    Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

    A Tiny Bit More History

    Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

    However, after the Industrial Revolution, some folks started to think that maybe people shouldn't be thought of as machines made out of meat, while the rise of democracy was fueled by the idea that individual humans are more equal than not (we're just gonna gloss over that historical hypocrisy for now). The backlash against the medical model happened shoulder-to-shoulder with the rise of humanism and postmodernism. Humanism emphasized the value and agency of people, while postmodernism in part challenged notions of power--including the power of knowledge.

    At the same time, the medical model had been identifying and curing diseases like gangbusters, but a bewildering paradox came to light: sometimes, people felt ill but had no physiologically identifiable disease, while others with an identified disease did not feel ill at all.

    Also by this point, the Church had lost a lot of ground and couldn't really tell doctors to stay out of people's minds anymore. So naturally, the field of medicine came to incorporate the "mental" as well as the "physical," and they began to apply the tried-and-true medical model that had worked for hundreds of years to the human mind--resulting in the new discipline of psychiatry.

    Considering the chronological context, it was a relatively short amount of time before people realized this wasn't gonna work out so great.


    The Anti-Medical Model Movement and the New (Medical) Model(s)

    The conceptualization of illness as biological resulted in "great advances in the diagnosis and treatment of some life-threatening and debilitating diseases " (Wade & Halligan, p. 996). In fact, even treating some mental disorders, like schizophrenia, "in a medical sense has led to significant benefits for a segment of the population" (Corrigan & Ralph, 2005, p. 8), and "biological explanations have helped reduce fear, superstition, and stigma and increase understanding, hope, and humane methods of treatment" (Shah & Mountain, 2007, p. 375).

    However, the medical model has a lot of drawbacks that caused significant debate, which we'll explore in a moment. For the most part, when people hate on the medical model, they do so because they believe it's ultimately harmful to the people it was designed to help.

    In large part, the consensus seemed to be that taking a strictly physiological approach to issues of illness/wellness was too narrow.

    In a series of articles published from the 1960s through the 1980s, George Engel sought to identify the shortcomings of the classic medical model and replace it with something new; his landmark article was, in fact, titled The Need for a New  Medical Model: A Challenge for Biomedicine. His suggestion was to replace the classic medical model (what he called the biomedical model) with the biopsychosocial model:

    The existing medical model does not suffice. To provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system. This requires a biopsychosocial model.

    This does not do away with the "bio" part of medicine, but it does incorporate entire domains of human existence that had been neglected, like interpersonal relationships, intergenerational trauma, adverse childhood experiences, minority stress, etc. 


    The Biopsychosocial Model

    Many authors I read suggested that the ideology of the classic medical model is no longer reflected in actual current clinical practice. Today, the biopsychosocial approach is the prevailing perspective in both the medical and mental health fields:

    • In 1981, an article in The Journal of Marital and Family Therapy declared that "recent developments in the understanding and treatment of mental disorder have resurrected the medical model--no longer the narrow, reductionistic model of the past but one that encompasses biological, psychological, social, and even moral-existential parameters" (Abroms, 1981, p. 385).
       
    • In 2009The Australian and New Zealand Journal of Family Therapy, stated that "case formulation, with a strong biospychosocial emphasis, is considered a key task in the training of psychiatrists and psychologists" (McDonald & Mikes-Liu, 2009). 
       
    • In 2014, Bolton said the biopsychosocial model "has become part of the ideology of medicine" (p. 180).
       
    • In 2016, Searight described the biopsychosocial model as "a mainstay of North American medical school curricula and postgraduate psychiatric education" (p. 289).
       
    • In 2017, Wade and Halligan argued that "the model has been used to structure guidelines, is used clinically, and is discussed in relation to person-centered care and in other contexts" (p. 997). 

    Many people seem to believe the biopsychosocial approach has overhauled "the medical model" rather than done away with it, so they still use the term "medical model" to describe how we conceptualize mental health in this more expanded way--hence my desire to clearly identify whether we're talking about the "classic" or the "new" medical model.

    Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

    The Biopsychosocial Model and the Field of Medicine

    Because nothing can ever be easy, there is, of course, criticism of the biopsychosocial model. I'll refer you to Farre and Rapley (2017) and Searight (2016)  for a fuller exploration of the critiques and the various models proposed to address those critiques, because honestly this post is turning into a Complete History of Medical Philosophy. For you and me, I think the most relevant critique is that the biopsychosocial approach requires clinicians to collect an unreasonable amount of data on each patient before being in a position to diagnose and treat. It's from this context that some mental health professionals feel medical professionals "don't spend enough time with their patients." The field of medicine has offered solutions such as patient-centered clinical care, which attempts to narrow the medical scope while still honoring biopsychosocial principles (Searight, 2016; Weston, 2005).

    The Biopsychosocial Model, Mental Health, and Psychiatry

    With his biopsychosocial model, Engel waded into a heated debate within the field of psychiatry during the latter half of of the 20th century. On the one side, "psychosocial extremists such as Thomas Szasz ...argued that mental illness was not 'real illness' but instead a medicalization of 'problems in living.' On the other side, ... [the] biologically oriented psychiatrists [who developed the DSM] sought to reunite their specialty with medicine... Psychiatry eagerly adopted the [biopsychosocial model] because it provided a 'big tent' and prevented a split in the psychiatric community. Thanks to Engel, the molecular biologists investigating serotonergic synaptic activity and the anti-psychiatrists attributing mental illness to a sick society could be at home with one another" (Searight, 2016, p. 291).

     
     

    This fundamental debate--whether mental health should fall under the purview of medicine--is still alive and well today. 

    Psychology ≠ Biology, Psychotherapy ≠ Medicine

    This camp believes that "problems of living" for which people seek mental health care are not illnesses at all. Depression (as far as we know now) isn't caused by a virus. Therefore, the argument goes, mental "abnormalities" shouldn't be treated like illnesses, and psychotherapy isn't an "intervention" as much as it is "an interpersonal process" (Elkins, 2009). Elkins seems to really believe we as therapists should opt out of the medical model in its entirety and cast our lot with "alternative practitioners" like psychics.

    Going even further, some people believe the "medicalization" of the mental health field has cultivated a mindset of "low-efficacy," where people who aren't doctors feel like they are not in a position to effect mental-health change precisely because they are not doctors--and therefore, must be powerless to "fix" anything (Gutkin, 2012). They believe the medical model perpetuates this power dynamic in the mental health field, and we would be better off without it, because then everyone would feel empowered to "fix" mental health.

    I completely understand why these folks hate the medical model. And for the conspiracy theorists in the back--no, I don't think these therapists are just afraid they're losing all their income to Big Pharma so they want to position themselves as a totally separate alternative.  Like the Church, this group believes the mind and body should be separate disciplines entirely. If you believe this, then I can understand how frustrating it must be to have to  learn stuff you don't believe in so you can get licensed and practice as a psychotherapist.

    The truth, I suspect, is that this group is a minority. 


    The Recovery Model

    Perhaps most relevant to MFTs is the rise of the recovery model in mental healthcare in America. It seems to me that this approach is a significant way that the field of marriage and family therapy has incorporated biopsychosocial values into mental health care. It came from the world of substance abuse treatment but has been applied more broadly to treatment of chronic illnesses such as hypertension, diabetes, HIV, and cancer (Barber, 2012; Gehart, 2012a).

    In 2004, the Department of Health and Human Services (HHS) issued a recommendation for a shift to recovery approaches in treating mental illness. HHS defines "recovery" as "a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential" (Gehart, 2012a, p. 430).

    Unlike the classic medical model, full symptom remission is no longer the ONLY metric of recovery from illness. Essentially, it moves the goal line, and the person with the illness decides where the goal line is.


    YouTube Break

    Because if you're not taking every possible opportunity to watch Debbie Reynolds as a dancing football, what are you even doing with your life? With bonus Donald O'Connor!


    The recovery approach was created and promoted by "consumers"--the individuals more commonly called "clients" or patients, a marked difference from both the biomedical and biopsychosocial approaches which were conceived of and implemented by providers. "Consumer" is used to reflect that the person receiving treatment is more actively choosing to "consume" an available option (much as we "consume" entertainment or news) rather than passively get treatment applied to them by a clinician (Gehart, 2012a).

    One framework of the model outlines three types of recovery:

    1. Cure, or clinical recovery: The consumer is symptom free and does not need further treatment.
    2. Illness management: The consumer and healthcare professionals are collaboratively involved in symptom control and monitoring of the illness over time. Treatment can help minimize impact of the illness.
    3. Personal recovery: The consumer is functioning at their best even in the face of ongoing symptoms. It can be thought of as living a fulfilling life while having an illness. (Barber, 2012)

    Since I think this is the model that will most likely affect practicing MFTs now and in the near future, I'm going to highly recommend you read two articles from The Journal of Marital and Family Therapy on the topic: Gehart (2012a) and Gehart (2012b). For now, the most important thing to know is that Gehart describes the recovery approach as "in dialogue with" the medical model, not fundamentally opposed to it:

    Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

    Now that we've more or less (less, trust me) covered the historical shift from the classic medical model to wherever the hell we are now, it's time to figure out what my professor was so upset about when I admitted that I did, in fact, believe in the medical model.


    The Great Debate - So What's Wrong with the Medical Model?

    I think it's really important to take a look at the charges leveled against the classic medical model and consider how the biopsychosocial approach and the recovery model have attempted to address these concerns.

     

    As I understand it, the classic medical model has some fundamental assumptions:

    1. There is "normal," and then there's "abnormal."
    2. It's better to be "normal."
    3. When things are abnormal in a person, getting back to normal is the highest priority.
    4. Abnormal things in people are caused by something physical/biological.
    5. Experts are the best people to identify what's abnormal, who has an abnormality, what's causing it, and how it needs to be fixed.
     

    No one tends to argue when this approach is applied to a broken arm. Yes, we generally agree it is better to have a non-broken arm than a broken arm. Yes, this problematic arm has a physical/biological source of abnormality--that bone is broken. Yes, we can get this arm back to "normal" by putting a cast on it so the bone can grow back together, and yes, we all think a doctor is a better person to set that bone than my UPS guy.

    As Engel puts it:

    The biomedical model was devised by medical scientists for the study of disease. As such, it was a scientific model; that is, it involved a shared set of assumptions and rules of conduct based on the scientific method and constituted a blueprint for research. (p. 319)

    Boy, did this work out great for awhile. They found cures for all sorts of things this way. Like broken arms! And tuberculosis! And the plague! It worked so well for bodily ailments that people started applying it to the nascent field of psychiatry.

    It's when this approach started expanding to "abnormalities" less obvious than broken arms--like mental health--that things really started to go off the rails.


    Normal and Abnormal: Which is Which, and What to Do About It

    Let's begin with the very first assumption of the medical model--there is "normal" and there is "abnormal." You can't get around to fixing anything unless you know what something looks like when it's "fixed" and you can tell the difference when it's "broken," right?

    Critics of the medical model raise some important questions:

    • Who, exactly, gets to define what is "normal" and what is "abnormal?"
    • Why is it better to be normal??
    • Who gets to decide someone needs to "fixed" if the "abnormal" person doesn't agree that they're "broken?"

    I'm sure you can see how the concept of normal/abnormal is going to start getting fuzzy when we look at mental health issues. But we're already at fuzzy just talking about physical issues. For example, if that broken arm doesn't heal entirely straight, is it normal? Does it need to be straight? If it's your arm and you'd rather not have a surgery to straighten it out, does the doctor have the right to knock you out and do it anyway 'cause it's in your best interests?


    The Medical Model of Disability

    Click to enlarge! Image: Taxi Driver Starter Pack

    These hypothetical questions carry real-life weight when it comes to issues of disability. The medical model of disability dictates that there is a "normal" way the body should function, and if it doesn't function that way, the body should be "fixed" until it gets as close to "normal" as possible. Ableism, or "the idea that those who are 'more able' are 'more includable'" (Shyman, 2016, p. 367), is the natural outgrowth of this way of looking at disability--it locates the "problem" in the person with the disability. This is a very valid critique of the classic medical model's fundamental assumptions, and disability advocates argue there's an alternative to this perspective (Laner, 1976; Shah & Mountain, 2007; Shyman, 2016 ).

    The Social Model of Disability

    Informed by the biopsychosocial perspective, they argue that problems of inclusion for people with disabilities are not only caused by the physical disability--rather, barriers to inclusion exist in the psychological (such as minority stress) and sociocultural (stigma, abled-centered design, etc.) domains as well. Shifting the locus of responsibility from the person with disabilities to the greater context also shifts the understanding of where change should come from. Rather than people with disabilities being expected to conform to "normal" functioning, society needs to make changes to accommodate people with disabilities. This is called the "social model" of disability, and is what the recovery model is based on (Gehart, 2012a).


    The Medical Model, Diagnosis, and the DSM

    Similarly, when the medical model is applied to mental health, it identifies psychopathology within individuals as the reason they can't get along with the world at large. Therefore, the solution is to identify these psychopathologies and discover effective treatments so everyone can function optimally in society. This has resulted in the Diagnostic and Statistical Manual, or DSM, a catalog of mental "disorders," each with its own suite of signs and symptoms and each with its own diagnostic label (like Major Depressive Disorder). Because this manual is the manifestation of the power to define normality/abnormality, some people find it intrinsically problematic.

    Diagnosis is Dehumanizing

    Some make the humanistic argument that diagnosis reduces a human being to a label, stripping them of their humanity (this is why some of your professors may vehemently exhort you to say "my client with borderline personality disorder," not "my borderline client"). The act of assigning such a label to a person makes them vulnerable to social stigmatization and may even insidiously alter the person's self-concept to the point where they take on an "illness identity." Receiving a diagnosis could also lead to a "self-fulfilling prophecy," where the diagnosed resigns themselves to never living without the diagnosis and may give up on recovery (Byrne, Happell, & Reid-Searle, 2015; Kvaale, Haslam, & Gottdiener, 2013; Scott, 2010).

    Diagnosis as an Instrument of Power

    Others make the postmodernist argument that the act of diagnosing is how those in power classify as "deviant" those whose behavior "annoys or offends" them--diagnosis, therefore, is an oppressive act. We're not talking about "my roommate annoys me when they don't pick up their socks, therefore they must have a disorder." It's more like "my roommate's sadness annoys me, and I want to change their behavior so I'm not bummed out, therefore they have a disorder that needs to be fixed, I shouldn't have to learn how to cope with their sadness." Some even suggest diagnosis is "an attempt by professionals to distance themselves from the consumer by creating difference" (Byrne et al., 2015, p. 221). And if you've ever heard the phrase "the myth of mental illness," it's referring to the mind-bending idea that something like "depression" isn't really an illness like "influenza" (you can't see a depression germ under a microscope) and we just use the word "illness" metaphorically. In this conceptual framework, the concept of "mental illness" is semantically dismantled and reduced to a turn of phrase, or story--thus, myth (Laner, 1976).

    Mental gymnastics aside, the idea that diagnosis could be dehumanizing and/or oppressive is another completely valid critique of the medical model.

    The Biopsychosocial/Recovery Approach to Diagnosis and the DSM

    If you're of the mind that there's nothing medical about mental "illness," then diagnosis is bad and that is that. However, if you believe that mental health deserves to be researched and treated according to the best available evidence, but you also don't like dehumanizing or oppressing people, you're in luck--the biopsychosocial and recovery approaches to diagnosis should appeal to you.

    Wong (2010) states that the clinicians he knows "use the DSM as one of several assessment tools within the context of interpersonal therapeutic conversations" and that "to diagnose someone as 'depressed' does not necessarily mean that the client is apathologized as long as the client is treated with empathy, unconditional positive regard, and genuineness as a unique human being" (p. 251). From that standpoint, the DSM is a tool that can be used to empower clients as much as to oppress.

    And this is how Gehart (2012b) describes the recovery approach to diagnosis: "Similar to the medical model, mental health diagnosis is an important step in the recovery process; however, in contrast to the medical model, the diagnosis does not drive the recovery process" (p. 449). Diagnosis, Gehart argues, helps the clinician to better understand the consumer and identify resource options for treatment. However, the clinician does not tick off symptoms in the DSM like a checklist counting down to zero. There may be recovery goals, for example, articulated by the consumer that are unrelated to an official "symptom," and the consumer is not considered to be "in recovery" until those goals are met. In this way, the recovery approach resolves the paradox of the medical model in which a patient has no symptoms and yet still feels "ill."

    Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

    Diagnosis as Taxonomy

    According to postmodern principles, there is no objective "true" definition of any word. What I mean when I say "depression" may not mean exactly what you think when you hear "depression." Before we can meaningfully communicate about what's going on with me that I'm using the word "depression," we need to agree on a definition.

    This is, in part, what the DSM is designed to do--provide a common language and the basis for an organized body of knowledge about what is effective in treating various problems (Kane, 1982). Without operationalizing variables, there is no scientific method, and no way to identify common risk factors, which are crucial to prevention, or develop screening tools, which can help make sure the people who really need care are the ones who are getting it (Kane, 1982).


    Semiotics Break

    Almost nothing makes me happier than semiotics. These are quick little primer videos if  you want to understand why it's a big deal that "depression" doesn't mean the same thing to both you and me:

    Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

    Diagnosis for Reimbursement

    The ethical debate my professor raised in class after challenging us about our beliefs in the medical model springs from fact that the institutions of healthcare administration and funding ("the entities and individuals who control the levers of power in our mental health system" [Deacon, 2013, p. 856]) have been slow to respond to the biopsychosocial approach. Indeed, the entire third-party payer reimbursement system is firmly entrenched in the classic medical model where diagnosis drives treatment. In order to get treatment covered by insurance, a diagnosis is almost always (ok always) required.

    This puts the clinician in the difficult position of having to assign a diagnosis in order for the client to access affordable treatment--often before the clinician is confident of the diagnosis, and sometimes in violation of ethical principles if the clinician believes no diagnosis in fact applies.

    Wade & Halligan (2017) make an eloquent case for the "political and managerial arenas" of mental healthcare to catch up to the clinical arena; they argue that using a biopsychosocial approach, especially within records-keeping and information systems would streamline healthcare, increasing efficiency and lowering costs. I know I'm probably preaching to the choir here, but take a look at pages 1000-1001 if you're interested.

    Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

    The Medical Model and the Expert Clinician

    None of these critiques would exist if there wasn't also a fundamental assumption that certain experts deservedly have the power to define normality and they also get to decide what to do with people who are "abnormal." As a society, when it comes to issues of health, we decided those experts would be doctors. We had the option of saying psychics have that power, or fishermen! We also had the option of letting the Church keep that power. But we didn't. We, as a society, decided to invest that power in doctors.

    I mean...they do spend a ridiculous amount of time in medical school. They have to take some really hard tests, get really good grades in classes you couldn't pay me to take, and then work for like 18 hours straight in the ER. The societal hope is that, through all of that, they end up knowing more about "health" (what is normal/abnormal) than the rest of us.

    But at the end of the day, doctors wield the power society invests in them, and some people take exception to the idea that these expert clinicians are privileged above the very people they're supposed to be helping (Byrne et al., 2016). Even with all that education and training, why do they get to stand around and tell other people they're defective? It is a question, ultimately, about who gets to be in power and why.

    The Biopsychsocial/Recovery Approach to the Role of the Clinician

    In the "new" medical model, the clinician is envisioned more as a collaborator rather than an authority. However, an important critique of the biopsychosocial approach from the postmodern/constructivist perspective is that "it still positions the clinician as being best equipped [rather than the client] to appraise a clinical scenario by applying theoretical and technical knowledge. The therapist’s version, while aiming to be collaborative, may be privileged above that of the client" (MacDonald & Mikes-Liu, 2009, p. 276).

    So, if you're a postmodern purist, you may believe the relationship between clinician and client must be 100% egalitarian, and maybe the "new" medical model doesn't go far enough. I think this is tough to achieve in practice, because of what Engel refers to as our "folk model of disease" in the Western world, wherein "the historic function of the physician [is] to establish whether a person soliciting help is ‘sick’ or ‘well;’ and if sick, why sick and in which ways sick; and then to develop a rational program to treat the illness and restore and maintain health" (Engel, 1977, p. 386).

    The biopsychosocial and recovery approaches have redefined the clinician's relationship to and with the client while bearing in mind this societal context. When incorporating a biopsychosocial perspective into treatment, MacDonald and Mikes-Liu (2009) suggest that, "we live in a society that values certain ideas about health...[and clients] will have developed certain formulations and expectations of treatment based on the medical ideas currently dominant in society's thinking...As clinicians, we need to be able to join with clients around their current formulation before inviting them to consider other ideas that might expand their thinking" (p. 279).

    These "other ideas" include the concept of the clinician as collaborator rather than authority. The recovery approach "does not privilege the therapist with 'expert' knowledge whose role is to identify irrational beliefs, dysfunctional dynamics, or other areas of pathology" (Gehart, 2012a, p. 437). Instead, the client is in the driver's seat of their own care. Gehart suggests that clinicians working in the medical model provide goals, while clinicians working from a recovery approach remove barriers to consumer's identified desires and goals (Gehart, 2012b, p. 449).


    The Medical Model and Medication

    From what I can tell, the broadest consensus is that the classic medical model, which assumes that there is a physical explanation for every ailment and which extends this idea to mental health problems when applied to the mental health field, is too narrow in focus. This was Engel's point when he argued in 1977 that the medical "model of disease [was] no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry" (p. 129).

    The classic medical model only considers biological factors that may be contributing to disease or dysfunction and ignores other factors that may be critically important in a given person's context--like their personal psychology, or living environment, or relationships, etc.

    Many also argue that this emphasis on a biological foundation for mental health problems has resulted in an emphasis on treating mental illness with medication, following the logic that biological/chemical therapies are best for biological/chemical problems.  Some see medication as oppressive because it is "prescribed" by a power-invested expert clinician; some think that the biological foundations of the medical model result in a glorification of biological therapies that overshadows non-biological therapies (Byrne et al., 2016; Scott, 2010). Some also argue that those on public assistance are deprived access to "better" treatments and are only offered medication because it's the cheapest treatment option (Byrne et al., 2016). And some have argued that the founding theorists of family therapy, writing and practicing at the height of the debate over the classic medical model, "expressed negative feelings about the appropriateness of medication" that came to define the field (Springer & Harris, 2010, p. 361). 

    The Biopsychocial and Recovery Approaches to Medication

    FFS Brenda.

    As discussed above, the biopsychosocial approach does not ignore biological determinants of disease--it just also takes into consideration other dimensions, as well. In Pies's (2017) "real" medical model that incorporates biopsychosocial values, biological explanations of behavior do not negate valid psychosocial/cultural explanations and vice versa, and "biological factors are part of a comprehensive differential diagnosis, even if psychological or cultural factors prove more relevant or informative" (p. 30).

    In the biopsychosocial approach, therefore, pharmaceutical treatments are one in an arsenal of available options for mental illness. This is echoed in the recovery model, which is not "against interventions such as diagnosis or medication; such medical interventions are valued yet secondary to psychosocial needs, such as autonomy, which are considered primary needs for successful recovery" (Gehart, 2012a, p. 431).

    Gehart describes a consumer in recovery from severe mental illness who articulated a recovery goal as being able to work a job; however, though she experienced hallucinations, she no longer wanted to take medication. The recovery-oriented therapist did not insist she remain on medication and instead helped the consumer work towards the goal of employment. Ultimately, however, the consumer determined that not being on medication was getting in the way of successful employment, and she decided to start taking them again: "Thus, medication was used as a resource when the consumer determined it was most beneficial to help her live a meaningful life" (Gehart, 2012a, p. 431).


    Now You Know More About the Medical Model Than When You Started

    Congratulations! You made it through the longest blog post I've ever written.

    Hopefully you have a basic understanding of how the medical model came about, the major problems with the model, and how the newer approaches to mental healthcare have attempted to address these problems. 

    Just in case it takes me a really long time to get around to writing Part 2...

    Caroline Wiita Marriage and family therapy therapist psychotherapist graduate student masters degree doctorate phd MFT licensed prelicensed clinical social worker trainee intern associate

    THIS IS ME GETTING ON MY SOAPBOX. It's a little soapbox, because I'm just a grad student with a blog. But after having to do way too much work to find out why people hated the medical model so goddamn much, I think I have a right to a little soapboxing.

    Don't throw the baby out with the bathwater. Yes, the medical model is the scientific basis for evidence-based practice (Karam & Sprenkle, 2010; Lilienfeld et al., 2013; Patterson, Miller, Carnes, & Wilson, 2004). But just because you take issue with some parts of the medical model doesn't mean you should dismiss out of hand anything that smacks of medicine and/or science. If you hate the medical model because there used to be a heavy emphasis on a biological basis for mental illness, and you think that's why pharmacological treatments are privileged in research and practice over psychological treatments, FINE! But don't disregard the literature that suggests pharmacological treatments are helpful--like the overwhelming evidence that suggests depression is best treated by a combination of psychotherapy and antidepressants. Please read Dr. Ben Caldwell's excellent book Saving Psychotherapy for many compelling arguments about how and why psychotherapists should be embracing science, not denying it.

    And if you're a teacher, I think it would be really great if you bring up this debate in class instead of just snarking on the medical model. In my humble opinion, it elucidates a lot of the theory and philosophy of the field and makes it much easier to understand the current state of affairs. And just one class discussion would have saved me so much Googling.


    Resources

    Adler, R. (2009). Engel's biopsychosocial model is still relevant today. Journal of Psychosomatic Research, 67(6), 607-611.

    Barber, M. (2012). Recovery as the new medical model for psychiatry. Psychiatric Services, 63(3), 277-279.

    Bolton, J. (2014). Case formulation after Engel—the 4p model: A philosophical case conference. Philosophy, Psychiatry, & Psychology, 21(3), 179-189.

    Bott, N., Radke, A., Kiely, T., & Brown, Ronald T. (2016). Ethical issues surrounding psychologists’ use of neuroscience in the promotion and practice of psychotherapy. Professional Psychology: Research and Practice, 47(5), 321-329.

    Byrne, L., Happell, B., & Reid-Searl, K. (2016). Lived experience practitioners and the medical model: World’s colliding? Journal of Mental Health, 25(3), 217-223.

    Carpenter, W. (2017). Organizing knowledge in the biopsychosocial medical model. Psychiatry, 80(4), 318-321.

    Corrigan, P.W., & Ralph, R.O. (2005). Recovery as consumer vision and research paradigm. In L Davidson, C. Harding, & L. Spaniol (Eds.) Recovery from severe mental illnesses: Research evidence and implications for practice, Vol. 1 (pp.3-18).  Washington, D.C.: American Psychological Association.

    Deacon, B. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review, 33(7), 846-861.

    Dutch, M., Ratanasiripong, P., & Callahan, Jennifer L. (2017). Marriage family therapist’s attitudes toward evidence-based treatments and readiness for change. Journal of Psychotherapy Integration, 27(4), 540-547.

    Elkins, D. (2009). The medical model in psychotherapy: Its limitations and failures. Journal of Humanistic Psychology, 49(1), 66-84.

    Elkins, D. (2010). David Elkins responds. Journal of Humanistic Psychology, 50(2), 256-263.

    Engel, George L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-36.

    Farre, A., & Rapley, T. (2017). The new old (and old new) medical model: Four decades navigating the biomedical and psychosocial understandings of health and illness. Healthcare, 5(4), Healthcare, 2017, Vol.5(4).

    Flaherty, M. (2012). A medical model for today. Psychiatric Services, 63(5), 510.

    Gaudiano, & Miller. (2013). The evidence-based practice of psychotherapy: Facing the challenges that lie ahead. Clinical Psychology Review, 33(7), 813-824.

    Gehart, Diane R. (2012). The mental health recovery movement and family therapy, part I: Consumer-led reform of services to persons diagnosed with severe mental illness. Journal of Marital and Family Therapy, 38(3), 429-442.

    Gehart, Diane R. (2012). The mental health recovery movement and family therapy, part II: A collaborative, appreciative approach for supporting mental health recovery. Journal of Marital and Family Therapy, 38(3), 443-457.

    Goldfried, M. (2013). What should we expect from psychotherapy? Clinical Psychology Review, 33(7), 862-869.

    Gutkin, T. (2012). Ecological Psychology: Replacing the medical model paradigm for school-based psychological and psychoeducational services. Journal of Educational and Psychological Consultation, 22(1-2), 1-20.

    Henningsen, P. (2015). Still modern? Developing the biopsychosocial model for the 21st century. Journal of Psychosomatic Research, 79(5), 362-363.

    Hernandez, Barbara Couden, & Doherty, William J. (2005). marriage and family therapists and psychotropic medications: Practice patterns from a national study. Journal of Marital and Family Therapy, 31(3), 177-189.

    Kane, R. (1982). Lessons for social work from the medical model: A viewpoint for practice. Social Work, 27(4), 315-321.

    Karam, Eli A., & Sprenkle, Douglas H. (2010). The research-informed clinician: A guide to training the next-generation MFT. Journal of Marital and Family Therapy, 36(3), 307-319.

    Kvaale, Haslam, & Gottdiener. (2013). The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review, 33(6), 782-794.

    Laner, M. (1976). The medical model, mental illness, and metaphoric mystification among marriage and family counselors. The Family Coordinator, 25(2), 175-181.

    Lilienfeld, Ritschel, Lynn, Cautin, & Latzman. (2013). Why many clinical psychologists are resistant to evidence-based practice: Root causes and constructive remedies. Clinical Psychology Review, 33(7), 883-900.

    MacDonald, C., & Mikes‐Liu, K. (2009). is there a place for biopsychosocial formulation in a systemic practice? Australian and New Zealand Journal of Family Therapy, 30(4), 269-283.

    Meyer, A., Bowden Templeton, G., Stinson, M., & Codone, S. (2016). teaching research methods to mft master's students: A comparison between scientist-practitioner and research-informed approaches. 38(3), 295-306.

    Patil, Tejas, & Giordano, James. (2010). On the ontological assumptions of the medical model of psychiatry: Philosophical considerations and pragmatic tasks. (Editorial). Philosophy, Ethics, and Humanities in Medicine, 5, 3.

    Patterson, J., Miller, R., Carnes, S., & Wilson, S. (2004). Evidence‐based practice for marriage and family therapists. Journal of Marital and Family Therapy, 30(2), 183-195.

    Penttila, M., Jaaskelainen, E., Hirvonen, N., Isohanni, J., & Miettunen, M. (2014). Are we reinforcing the anti-medical model? Reply. British Journal Of Psychiatry, 205(6), 499-500.

    Pies, R.W.. (2017). Hearing voices and psychiatry’s (real) medical model. Psychiatric Times. 34.

    Scott, Helen. (2010). The medical model: The right approach to service provision? Helen Scott questions the medicalisation of mental distress, along with the use of labels to define illness, and argues that lip service is paid to service-user choice. Mental Health Practice, 13(5), 27-30.

    Schwartz, S., Lilienfeld, S., Meca, A., Sauvigné, K., & Kazak, Anne E. (2016). Psychology and Neuroscience: how close are we to an integrative perspective? Reply to Staats (2016) and Tryon (2016), 71(9), 898-899.

    Searight, H. (2016). The biopsychosocial model: "Reports of my death have been greatly exaggerated". Culture, Medicine and Psychiatry, 40(2), 289-298.

    Shah, P., & Mountain, D. (2007). The medical model is dead – long live the medical model. British Journal of Psychiatry, 191(5), 375-377.

    Shyman, Eric. (2016). The reinforcement of ableism: Normality, the medical model of disability, and humanism in applied behavior analysis and ASD. Intellectual and Developmental Disabilities, 54(5), 366-376.

    Sprenkle, D. (2003). Effectiveness research in marriage and family therapy: Introduction. Journal of Marital and Family Therapy, 29(1), 85-96.

    Springer, Paul R., & Harris, Steven M. (2010). Attitudes and beliefs of marriage and family therapists regarding psychotropic drugs and therapy. Journal of Marital and Family Therapy, 36(3), 361-375.

    Thyer, B., & Pignotti, A. (2011). Evidence-based practices do not exist. Clinical Social Work Journal, 39(4), 328-333.

    Van Dyke, David J., & Hovis, Ryan. (2014). Systemic critique of the DSM-5: A medical model for human problems and suffering. Journal of Psychology and Christianity, 33(1), 84-89.

    Wade, D., & Halligan, P. (2017). The biopsychosocial model of illness: A model whose time has come. Clinical Rehabilitation, 31(8), 995-1004.

    Wakefield, J. (2013). The DSM-5 debate over the bereavement exclusion: Psychiatric diagnosis and the future of empirically supported treatment. Clinical Psychology Review, 33(7), 825-845.

    Weston, W. Wayne. (2005). Patient-centered medicine: A guide to the biopsychosocial model. Families, Systems & Health, 23(4), 387.

    Wickramasekera, Ian, Davies, Terence E., Davies, S. Margaret, Deleon, Patrick H., & Kenkel, Mary Beth. (1996). Applied Psychophysiology: A bridge between the biomedical model and the biopsychosocial model in family medicine. Professional Psychology: Research and Practice, 27(3), 221-233.

    Wong, P. (2010). the future of humanistic/existential psychology: A commentary on david Elkins’s (2009a) critique of the medical model. Journal of Humanistic Psychology, 50(2), 248-255.

    Yakeley, J., Hale, R., Johnston, J., Kirtchuk, G., & Shoenberg, P. (2014). Psychiatry, subjectivity and emotion - deepening the medical model. The Psychiatric Bulletin, 38(3), 97-101.