Models of Mental Health: A Critique and Prospectus

Relevant readings elsewhere on Serendip include:

• "She Blinded Me with Science": A Critical Analysis of the Scientific Model of Health
• (mis)MANAGED (don't) CARE: Is managed health care really a necessary evil for physicians?
• Of Two Minds: An Anthropologist Looks at American Psychiatry (book review)
• Healing the Soul in the Age of the Brain, book excerpt
• The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures (book review)
• Making the Unconscious Conscious, and Vice Versa: A Bi-directional Bridge Between Neuroscience/Cognitive Science and Psychotherapy
• Diversity and Deviance: A Biological Perspective
• Culture as Disability

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).

Objectivity

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).

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.

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.

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