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Editor's Introduction to The Medical Model of Mental Illness
Sohan L. Sharma, Ph.D.
Perimeter Of The Medical Model
by Sohan Lal Sharma, Ph.D.
Copyright 1998, Sohan Lal Sharma
Considerable interest and controversy has arisen during the past few years over the concept of the medical model. The concept of the medical model has acquired a certain degree of currency and is now discussed in introductory texts and articles on abnormal psychology while at the same time the implications of the concept are almost totally neglected. In failing to recognize the implications of the concept, the issues of the controversy have been largely obscured in the derived meaning of the term "medical model." Discreet aspects of this concept have been discussed in a global or uni-dimensional fashion, resulting in considerable confusion. Such confusion has been described as "the blind man and the elephant" phenomenon (Brown and Long, 1968). The purpose of this communication is to analyze various parameters of the medical or illness model and its implications through the study of (a) its historical development; (b) the logical fallacy inherent in the concept, (c) the institutional and structural developments that grew out of this concept; (d) the medical model and its implications in community psychiatry, and (e) conclusion.
DEVELOPMENT OF THE "MEDICAL MODEL'' CONCEPT
Perhaps the most cogent significance of the medical model concept is found in its historical development. The term does not have a "scientific" derivation as is often implied (McKeachie, 1967). Rather, it is derived from socio-historical developments, in a somewhat similar fashion to the derived meaning of the term "white collar" in the field of sociology, laden with moral and value judgment (Sharma, 1968). Several recent articles vividly demonstrate this aspect of the medical model (Dain, 1964; Foucault, 1965; Grob, 1966; Leifer, 1969). At the risk of oversimplifying a major socio-historical development, the medical model might be described as a fallout from the scientific era.
With the advent of the scientific and industrial revolution, those who showed deviant behavior, emotional distress, and personal troubles increasingly sought the services of a physician rather than a cleric. The expectation evolved that the new scientific knowledge was more effective than theology in controlling such deviances (Dain, 1964). The physician to whom such deviants were referred naturally declared such people ill or sick in their minds, because their thoughts and actions differed from others around them (Szasz, 1959, 1961b). During this period, the sickness concept was regarded as progressive and humanitarian, for earlier such deviants and disturbed were considered "possessed" and were subject to witch hunts and brutality (Szasz, 1961b). Sanction for the control and management of such people thus passed from the clerical-theological realm to the medical realm. This was, however, clearly a social development and not a scientific discovery.
The term mental illness or sickness was first used only metaphorically to distinguish and explain deviant behavior and conduct which had no concomitant signs of physical dysfunction. The physician to whom such patients were referred described them as acting "as if" they were ill or sick (Szasz, 1961). In this context, the phrase, "as if" denoted only the metaphoric quality of illness, since no concrete evidence of illness was found. During the 16th century, Teresa of Avila* was first credited with invoking the
+++++++++++++++++++++++++++++++++++++++++++++ *Some have credited Johann Weyer as the first to use the term "mentally ill" during the 16th century (Zilboorg, 1941). +++++++++++++++++++++++++++++++++++++++++++++concept of (mental) illness. "A group of nuns was exhibiting conduct which at a later date would have been called hysteria. By declaring these women to be infirm or ill, Teresa was able to fend off the Inquisition" (Sarbin, 1967). First used metaphorically, "mental illness" then became a rubric for medical classification. Mental illness was then classified as a disease entity. Mild emotional disturbances were declared neurosis, to indicate that the person was suffering from a disease of the nerves. The more serious disturbances were labeled psychosis, or disease of the psyche (Szasz, 1961).
With this brief background in perspective, the illness or medical model may now be defined. Szasz was the first to use the term (Szasz, 1961a). He and other historians have shown that during the past two centuries psychiatry developed as a branch of medicine to deal with deviant aspects of human behavior and relationships which, because socially unacceptable, were viewed as "ill" or "sick." Psychiatry, being an outgrowth of medicine, attempted to comprehend and explain man's interpersonal relations and emotional distress in much the same way as any other physical disease with which a physician dealt. Thus the conceptual model, in light of which social and interpersonal relations came to be understood and treated, was the same as for that of physical illness. Because the emotionally disturbed individual was declared ill or sick, it was assumed that the same or similar physicalistic qualities could be attributed to his interpersonal behavior and emotional reactions (Szasz, 1961b). Thus, it became possible to comprehend personal distress and social deviance in the same terms as those applied to physical illness (Foucault, 1965; Grob, 1966; Szasz, 1961b). Although the phenomenon to be understood was human social behavior, emotional upsets, and life game, it was cast and couched in physio- bio-chemical terms. Such a conceptualization of social relations, interpersonal behavior, and personal distress may be called a medical or illness model (Sharma, 1967).
To achieve this end, viz. to conceptualize a man's relationships and turmoils, much of the vocabulary and conceptual lexicon of physical disease was transposed to psychiatry and psychology, namely, patients, disease, cure, symptom, diagnosis, treatment, prognosis, etiology, acute, chronic, etc. It should be obvious from the foregoing discussion that the medical model is a conceptual framework which can be used in any setting. For instance, a psychotherapist in private practice, working outside a medical setting, may conceptualize his client's troubles according to the medical model, i.e. as a sickness, rather than the game model, or the social role model.
THE LOGICAL FALLACY OF THE CONCEPT
Many logical problems and contradictions begin to emerge when the medical or illness model is employed in the field of psychology. Firstly, the original model used to generate "the model for mental illness took its structure from such phenomena as Syphilis of the brain or delirious conditions, intoxication, etc., in which a person may manifest certain disorders of thinking and behavior. It was believed that all so-called mental illness was of this type. Mental illness is thus regarded as basically no different from physical disease. The only difference between mental and bodily disease is that the former, affecting the brain, manifests itself by means of mental symptoms, whereas the latter, affecting other organ systems, for example, the skin, liver, and so on, manifests itself by means of symptoms referable to those parts of the body (Szasz, 1963a). The implications of such logic are, of course, that the disturbances of thought and behavior, etc., are attributable to diseases of the brain, i.e. a neuro-physiological entity, rather than a disorder of the mind, as contended in the medical model. The mind is, in fact, an abstract concept (Ryle, 1949; Szasz, 1966a); which cannot be ill or sick except in an abstract metaphorical sense. Hence, the first logical fallacy or confusion arises when an abstraction is equated with a physical entity. This enigma may be stated as follows: How can an abstract concept and a physical entity be treated in equivalent operational terms as required within the framework of the medical model? Confusion arising from such a conceptualization has been vividly discussed by Szasz (1961).
Moreover, it can be seen that if mental illness is like physical illness, which occurs in an entity, the body, i.e. a physical object, then mental illness must occur in an entity, the mind. The concept of mind, however, is acknowledged to be an abstraction; whatever else it may be, it is not a physical entity (Ryle, 1949; Szasz, 1966a). How, then, can a mind, i.e. an abstraction, be ill or sick in the same way as a physical entity (Szasz, 1966a)? If the illness or medical model is to be used, we must indeed first reify an abstract concept, and then treat such intangible non-entities as character neurosis as tangible disease entities. In so doing, the comprehension and solution of human problems can be subject only to reductionistic and indirect approaches. This is evident in the numerous scholarly endeavors which attempt to comprehend social and interpersonal relations and group behavior by studying the biological or physiological substratum. It becomes obvious that in such a context where psychiatrists and psychologists continue to pursue an illness model, with its inherent irrelevancies and inconsistencies, the real worth and effectiveness of their professional contribution to social and human well-being must continue to be in doubt.
The use of medical model creates a further logical problem, in defining the conceptual system to be used for "mental health." A concept of mental health is necessary, since the medical model implies an illness-health dimension. Should standards be used comparable to those employed for physical health? For the advocates of the medical model, the concept of mental health has created peculiar difficulties. It can, in truth, neither be defined, nor can common agreement be reached that such a phenomena as mental health exists. This is dramatically evident in the first of the ten volumes of the Joint Commission on Mental Health (Jahoda, 1958; Hartung, 1965). The best efforts seem to resolve the issues by simple reiteration of the idealized Protestant, middle-class values or by citing some form of exemplary human virtues, endeavors, and achievements, and collectively labeling these as "mental health." It has also been defined by corollary, i.e. behavior of the poor and lower classes is viewed as undesirable with such subgroups being earmarked for mental health services (Hersch, 1967; Rae-Grant, 1966). To call something "health" which is physically oriented, while at the same time using moral standards and social class as criteria for judgment, obviously leads to all forms of logical difficulties.
It has been argued that the polarization of mental health models, viz., the medical model vs. non-medical model (such as psychological, social dysfunction, social- competence, etc., models), is faulty (Brown and Long, 1968; McKeachie, 1967); that we should indeed follow multiple models and that the illness model should be employed on a pragmatic basis, or that we should use the medical model when it serves our purpose, while at other times we should discard it (McKeachie, 1967). Such a view, however, fails to take into account the inherent fallacy of such a model. The logic of the medical model is rather the basic issue in question. We cannot, on the one hand, continue to believe that mental and emotional disturbance should be treated like a physical disease, while on the other hand, and at the same time, attempt to develop non-medical models, or assert that emotional disturbance is not like physical illness and must be conceptualized and handled differently. Such inconsistency is irreconcilable, for any measure of acceptance of the medical model, with its circumscribed meaning, excludes the possibility of compromising any alternative non-medical model.
INSTITUTIONAL AND STRUCTURAL DEVELOPMENTS
Historical developments that occurred as a result of the view that the emotionally disturbed are sick or ill have also seen the concomitant growth of multiple institutions which have become the operational embodiments of the medical model. Hundreds of state hospitals, V.A. hospitals, and other public and private psychiatric hospitals are only a few examples of the structural and institutional behemoths created on the basis of such thinking. Other institutions charged with the care of the emotionally and behaviorally disturbed, hitherto called retreats, rest homes, etc. (Foucault, 1965), have also metamorphosed into hospitals. Such institutions in the medical tradition require a physician administrator for management and policy formation. They have developed the status and employee hierarchical structure, as well as the working atmosphere, and the ideological mold of any hospital. These institutions and structures, in turn, have generated their own peculiar vested interest, manifest in institutional reluctance to discharge patients* (Szasz, 1960b; Rappeport, et al., 1967), in vying for an ample share of public monies by developing effective strategies for obtaining such financial support. Such strategies include the creating of proper images of the institution and its inmates and propagandizing on the 'shortage of trained personnel," the kinds of specialists needed to interface with inmates, kinds of services and modes of delivery, the type of activities, relationships, and jobs the inmates need and the definitions of roles and status of the staff with regard to the inmates.
+++++++++++++++++++++++++++++++++++++++++++++ Such reluctance obviously has multiple determinants and is vividly discussed by Rappeport (1967). +++++++++++++++++++++++++++++++++++++++++++++
Traditionally such vested interest propaganda has been accepted by the public, as well as the inmates, and staff. Only perhaps in the last decade the role and place of such institutions in a society, and their effect on the inmates, have come under close scrutiny. Most appraisals of such institutions have been negative. Some observers have even dubbed them as "concrete and mortar relics" (Hobbs, 1964) of the past, which are cut off from the mainstream of social life, often remotely located from needed social settings and having, in fact, a dehumanizing influence upon the inmates. It has indeed been argued that the mentally ill should not be sent to such hospitals. Rather, a preventive approach, comparable to public health programs, with emphasis on primary prevention, is recommended. Hospitals and similar institutions, it has been seen, should be used for secondary prevention. These latter developments have also occurred within the framework of the medical model and have provided the rationale for what was to become known as community psychiatry. The development of such institutions in the context of community psychiatry are discussed later in this paper.
Many other facets of (institutional) control and power have come about through dominance of the medical model. Since illness, whether mental or physical, can be detected and cured only by a physician- psychiatrist, the legal-institutional powers have come to be vested in the physician or psychiatrist. Such powers extend into many institutions of society. For example, under the U.S. Immigration Law, a psychiatrist can prevent those whom he interprets to be mentally ill from entering the country. Even though the criteria for judging such immigrants as mentally ill is obscured (Ridenour, 1961), yet from time to time these powers have been exercised freely (Szasz, 1966b; Greenland, 1966). On the basis of such judgment, many immigrants have been denied permission to land on the shores of this country.
The power to involuntarily commit a person to a state institution is also based on the judgment of mental illness. Since emotional disturbances are defined as illness, which are caused by an agent rather than purposive, they may be treated as victims rather than deviants or wrongdoers. This justifies their being treated against their own will. This further justifies stripping them of their responsibility of their action, and under the guise of medical treatment, incarcerating them (Leifer, 1969). This commitment to a mental institution can be obtained at the signature of any two physicians.*
+++++++++++++++++++++++++++++++++++++++++++++ *In some states a certificate by a single physician is sufficient to commit a person. +++++++++++++++++++++++++++++++++++++++++++++
The right of a person to testify in a low court and his ability to defend himself or advise his attorney about his case can also be challenged on the basis of such a judgment by a physician-psychiatrist, who can legally declare a defendant mentally unfit to stand trial (Szasz, 1963b).
Finally, the illness model operates in economic structures of society. In the curing of a (mentally) sick person, only a physician can be legitimately rewarded as recognized by insurance companies, Medicare, or other health schemes. Other professions are usually remunerated only when a physician supervises, takes the legal (institutional) responsibility, or recommends that a "patient" will benefit from the work of an "ancillary" professional.
These continue to be the basic economic- institutional realities. Attempts by other professionals to change such institutional practices are violently resisted by the protagonists of the medical or disease model, as has been evident in the controversy over psychotherapy. Since social and personal distress was defined as illness (like a physical illness) the treatment of mental illness of psychotherapy must be done by the physician-psychiatrist. If non-medical professionals, such as psychologists, social workers, etc., undertake to do psychotherapy, it is maintained that they are trying to do something (treatment) for which they are ipso facto not qualified (Huston, 1954). The confusion and obfuscation generated by the use of medical model has been so great that the premise underlying the controversy were neither confronted nor openly discussed, viz., whether or not psychotherapy is treatment in the same sense as that pertaining to physical disease and requiring physiochemical and anatomical intervention until they were raised by Szasz (1959). The continuation of such conflict and the struggle to maintain the status quo of the institutional and financial arrangements should give us a clear idea about the pervasiveness and entrenchment of the medical model.
THE MEDICAL MODEL AND COMMUNITY PSYCHIATRY
An increasing demand for "mental health" services beginning in the fifties was seen by protagonists of the medical model as one that could not be met by existing techniques employed in one-to-one (dyadic) therapy.*
+++++++++++++++++++++++++++++++++++++++++++++ *Many psychologists and psychiatrists have argued that one-to-one psychotherapy is a perpetuation of the illness model, since it establishes a doctor-patient relationship (Smith, 1966). To break away from this model, group and family therapy, community consultation, etc., should be recommended. +++++++++++++++++++++++++++++++++++++++++++++Therefore, it was advocated that instead of treating the patients when they have become "mentally ill," an approach should be sought which could prevent the occurrence of mental illness. Such a preventive approach was designed after the model of public health or epidemiological approach. Here the germinating ground of mental illness, i.e. the community structures and community relations, would be the focus of study and prevention. The enormous difference between the state institutions and the patient's home community was also seen as an important factor responsible for the lack of cure in mental illness. As this approach gained widespread acceptance (aided considerably by the report of the Joint Commission on Mental Illness, Action for Mental Health, 1961) a shift was made from a clinical to a public health model. Although in essence a social movement, it was launched as a "preventive-psychiatry" movement (Leifer, 1969). The alleged advantages of such an approach to mental illness are vividly discussed by Smith (1968).
When such an emphasis on community psychiatry began to develop in the field of "mental health," it became increasingly obvious that the field of "mental health" is far more closely allied to social sciences and humanities than to the biomedical sciences or medicine. Yet, the conceptual framework of community psychiatry retains its medical model mold. "Mental illness" continues as a disease entity, having causative agents. Now, however, such causes are seen to be inherent in the structure of the community itself which requires help or treatment. The same professions who earlier were the experts on mental illness, now claim expertise in community psychiatry, since this movement is essentially seen to be an epidemiological or community-oriented approach to the same problem of mental illness. With this approach, the medical model has since become somewhat diffused and amorphous, since of necessity it expanded to include many aspects of society. In retaining such a conceptual tradition, most of the developments within community psychiatry movement are but newer forms of the old operational embodiment of the medical model.
In this context of community psychiatry, "most of the new centers are to be located in general hospitals with psychiatric units. The American Medical Association had (at first) opposed most vigorously the federal program establishing the centers, but it now appears that the lion's share of funds will be diverted into construction of beds for private psychiatric patients. A formula representing a 'gentleman's agreement' has been worked out where the allocation of the new beds to the indigent is to be sufficient criteria to qualify a hospital for construction treatment centers in deteriorating areas where prevalence of disturbed behavior is high, and where the trip to the state hospital is one way.
"An even more dramatic kill has occurred in the federal programs for construction of research centers and university affiliated centers in mental retardation. Of the research centers approved to date every last one is in a medical setting! This is not surprising because the regulations were written to require in-patient beds and out- patient services as one of the qualifications for applicants, and administration of the major program was turned over to the Division of Hospital and Medical Facilities of the Public Health Service." (Albee, 1967) It can be seen that the institutional structures within community psychiatry remain akin to their predecessors. Many have observed that "already the plans for comprehensive community mental health centers are following discouragingly tame and conventional paths. Most are hospital-centered - on the old medical model, under medical control. What seems to be happening is that the (mental health) revolution is being frozen in its first phase. This early ossification around the mental-health center idea reflects the thinking of leaders in the National Institute of Mental Health -- and it is deplorable." (Smith, 1968)
With the launching of the community psychiatry movement, the controversy over the medical or illness model is no longer considered a real or relevant issue (Brown and Long, 1968). Dyadic therapy and hospital- or clinic-based treatment have grown in disfavor. Working with the community, civic groups and other organizations has come to be viewed as the prime aim of mental health professionals. These activities, it is contended, fall beyond the scope of the medical model (Brown and Long, 1968). A recent congressional act maintains that the directorship of the mental health clinics should be based on competence rather than professional affiliation. This is all seen as removing professional bias with regard to the power position in the mental health field. Many positions earlier earmarked for physicians are now open to other professionals. For these reasons the central issue now is ostensibly that of leadership rather than medical affiliation (Brown and Long, 1968). However, a recent survey of the "staffing patterns for all budgeted positions in 129 approved federal staffing grants shows that eight out of ten centers have a psychiatrist as director, one out of ten a psychologist, and one out of ten a social worker" (Carter and Teague, 1967). This would suggest that the conceptual system, financial support preference, and power positions within the community psychiatry movement are still dominated by the medical model.
It is also argued that with the launching of this movement, state hospitals and similar institutions have become outmoded. The closing down of such institutions is frequently advocated and anticipated in the near future. In fact, some have even advocated that a closing date be established for such institutions (Albee, 1967). This would free us from the shackles of the medical model. However, with the continued dominance of community psychiatry through the medical model approach, the closing of such institutions would not take us very far on the road to freedom from the medical model. The prevalence of the medical model within the community psychiatry movement would indeed further the development of institutions hardly different from the existing mental hospitals. Such new institutions, of course, would not be brick and mortar structures but those of steel and glass (Hobbs, 1964).
The problem of manpower and professional skills in mental health continues to be a confounding one. Although the cry about shortage of trained professionals in the field of mental health has become almost proverbial, the reasons for such a shortage have rarely been openly examined. "When disturbed and disturbing behavior is currently explained by a conceptual model which attributed causation to disease or to some form of illness" (Albee, 1968), two serious manpower problems arise. First, "the largest amount of funding for training and research is funneled into biomedical programs. The biomedically- oriented programs, demanded by a disease model, support complex laboratory research that have but little relevance to the ideological problems of disturbed people" (Albee, 1968). These training programs are producing professionals who, after being trained at public expense, do not work primarily with those serious chronically disturbed people who are the responsibility of the tax-supported institutions" (Arnhoff and Shriver, 1967). More than two-thirds of all the psychiatrists supported by federal funds since 1947 are currently in private practice working under private auspices (Albee, 1968). Second, "the conceptual model used sets the framework for the kind of professional manpower needed to staff the institutions, whether of the state hospitals or of the community mental health centers. Since in community psychiatry and other psychiatric establishments a medical model of mental disorder is used, we cannot produce a fraction of the medical and paramedical people the model demands. The suggestion is clear that we are in a manpower cul-de-sac because of the conceptual model we use" (Albee, 1968).
A further question should be raised concerning underlying assumptions about the manpower situation. Proclaimed goal of the new movement involves working with the institutions and community organizations of society such as school systems, public assistance, parole boards, etc., in the epidemiological and public health tradition; secondly, the intention is to work with certain subgroups, viz., dropouts, unemployables, the misrelated, multi-problem families of the lower classes, etc., which are considered the germinating ground of mental illness. Why such problems and their alleviation and solution should not be placed under the direction of city planners, union leaders, the local organizers, and the poor themselves, is not clear. Not only these groups are not so critically short in supply, but they directly interface with community institutions and the high-risk population. The problem of manpower shortage could thus be directly alleviated by employing such skills. It is only when a physician-psychiatrist or a similar professional claiming expertise in mental illness is employed to manage these institutions and groups that a manpower shortage occurs. The present enigma is why these programs should be structured in a hospital-type setting under a physician's direction. Apparently, the answer is that such groups and institutions have been defined and labeled as sick or ill.
Another trend in the manpower problem is to train the layman to be the helper of the professional. Trained laymen are considered potentially as competent as professionals for specific work in the community. The professional's job is then to train them. This is proffered as a solution to the manpower shortage problem. Yet in the context of the community psychiatry movement, what can such a professional (medical) person teach a layman, when the professional himself knows but little about the community institutions, their organization and struggles, and even less about the existential reality, the lives, hopes, and fears of those whom he purports to help? As recent studies suggest, the chasm between the professional and his client is deep (Harrington, 1962). Indeed, the training of the professional is most deficient in the very areas where he is presumed most competent. The professional in this regard has thus arrogated a responsibility requiring knowledge and know-how in human-social situations and groups about which he is ill- prepared. This dilemma is resolved by the professionals by viewing these institutions, situations, and groups as sick or ill and requiring "treatment."
The medical model serves many functions in the present-day society. First, by medicalizing the problems and the behavior of the individual it removes the field of psychiatry (and clinical psychology) from its social matrix. If, for example, a social role model of human disturbance was used, then we would have to examine the contributions and the failures of the society, its institutions, its rewards and punishment systems in generating such disturbances. Within the context of the medical model such issues can hardly be raised. Indeed, the medical model helps preserve the status quo. Second, it obfuscates the differences between different kinds of sufferings and disability, between physical and social behavioral events, between the body and the behavior, between biochemical disturbance and moral, ethical, and interpersonal conflicts (Leifer, 1969). Third, it helps understand the dual role of the psychiatrist. On the one hand it views him as any other physician who diagnoses and treats disease and illness (mental) by dispensing pills, shock, and other forms of (talk) treatment. It defines the professional identity of a psychiatrist as that of a physician. On the other hand it obscures the psychiatrist's social role as a guardian or policeman for bourgeois behavior. His daily operations consist of rectifying disturbed and disturbing behavior, mending troubled marriages, testifying in court with regard to the meaning and responsibility of individuals' behavior, hospitalizing people against their will, etc. In short, his social role as the agent of the society who legitimizes certain form of behavior, and condemns other as ill, is concealed by the model.
"If human behavioral function and malfunction were viewed in terms of sociological rather than medical and biological models, we would be obliged to abandon the idea that the psychiatrists function as do other physicians to diagnose, treat, and prevent illness. Conversely, if we could fully explain psychiatric function in sociological terms, we would be tempted to replace the medical model of the psychiatric patient with a sociological model. It would not be logical to insist that only physicians are qualified to deal with phenomenon that we do not regard as illness" (Leifer, 1969).
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