Hearing “medical model” being used used pejoratively is quite tiresome. I have heard it used that way for the past thirty years, usually to take a shot at psychiatrists. I thought I would illustrate how this goes and what I disagree with by responding to a recent article authored by the British Psychological Society on how the system of care for psychotic disorders should be changed. My interest is not in provoking an argument since I think that these errors are obvious. The target audience is also relevant here and it is described as “service users, their friends and families, journalists, policymakers, mental health workers and the public.” As such this is really a political document very similar in nature to the documents generated in the US by SAMHSA or treatment guidelines generated by other special interest groups like managed care companies. That being the case, I will not spend any time on the technical aspects of psychosis alluded to in this paper. As a political document it requires active refutation or the suggestions might be adapted as wholesale measures. I don’t know if British psychiatry is any more successful in doing that than the American counterparts, but judging from what I have read in editorials – I doubt it. Let me start out with a couple of the authors’ statements about the “medical model”.
"At least in the UK, most mental health services are currently based on the ‘medical model’ – the assumption that experiences such as hearing voices indicate illness and result from some sort of problem with the brain. (p. 103). This idea is also enshrined in mental health law and is the basis for compulsion. In the past many professionals have also believed that people experiencing distressing voices or paranoia are unlikely to recover without treatment (usually medication). This belief has led to a perceived ‘duty of care’ to provide treatment, and a tendency to view someone who does not want the treatment being offered as lacking in insight. As this report has shown, both of these assumptions are unfounded." (p. 103 from Reference 2)
And:
"In the past services have been based on what might be called a ‘paternalistic’ approach – the idea that professionals know best and that their job is to give advice. The ‘patient’s’ role is to obey the advice (‘compliance’). This now needs to change. Rather than giving advice, those of us who work in services should think of ourselves as collaborators with the people we are trying to help." (p. 104 from Reference 2)
The authors definition of a “medical model” looks at three dimensions. The first is the assumption that psychotic experiences are due to a brain problem. That is partially true. They limit themselves to what they describe as “idiopathic” causes of psychosis and ignore specific psychotic states and etiological factors. They also exclude medical illnesses that are clearly associated with psychotic symptoms. That happens to be the area that psychiatrists are trained to recognize and treat. Trivializing psychiatric diagnosis as a list of symptoms that most clinicians do not refer to anyway is certainly consistent with the authors’ main points of contention, but fortunately that is not reality. Finally, the diagnostic manual that they criticize has numerous categories that have been researched strictly as psychotic disorders (and anxiety and mood disorders) caused by social etiologies rather than brain problems per se. Early in my career, I reviewed the predominately Scandinavian literature on brief psychoses or brief reactive psychoses so that I could provide necessary prognostic information to patients and their families. More clear evidence that significant psychotic symptoms can spontaneously remit without any medical intervention. That information is a critical part of any medical approach to a spontaneously remitting illness.
Secondly, they go on to say that this also means that “professionals” believe that people are unable to recover without treatment. I don’t know about other professionals but psychiatrists since the time of Kraepelin have known that people recover without treatment, although in Kraepelin’s day they considered asylum care alone to be treatment. Like many illnesses people can recover without treatment and the literature on brief psychosis is further evidence. Psychiatrists have also known that specific types of psychosis (catatonia for example) have very grim prognoses without treatment. Some of the earliest studies showed that malignant catatonia had an 80% mortality rate at the turn of the 19th century. By the turn of the 20th century the mortality rate approaches 1% or less with modern treatment. So the second part of the definition is clearly wrong.
Finally, the authors use “paternalism” to characterize the role of physicians. This is a charge that frequently accompanies the so-called medical model often amidst the associated charge of authoritarianism. It is also incorrect. Medicine is based on the informed consent model of care. Any psychiatrist is more aware of this than most other physicians. Informed consent is based on the idea that the patient is provided with adequate information to make a risk-benefit decision and the patient and physician collaborate on the patient’s decision. I have these conversations every day and many times a day. Doing nothing, being referred somewhere else, and being denied the agreed upon care by a managed care company are all additional possibilities. These conversations can occur with patients who are actively bleeding out on the floor and refuse to allow a trauma surgeon to intervene due to impaired judgment from psychosis. In that particular situation surgeons are likely to remind anyone involved in the care that they would be assaulting the patient if they intervened and did not have informed consent. Similar situations occur with people who have various forms of treatable but life threatening illnesses (operable cancer, impending paralysis, uncontrolled diabetes mellitus, etc) who were unable to make decisions in their best interest due to the effects of psychosis.
So - the authors’ definition of a medical model is wrong in 2 ½ of 3 dimensions. That is not a good starting point for a proposal to go beyond the “outmoded medical model”. It is always good to know what the model really is before declaring it outmoded. I think a lack of scholarship and experience in these matters in a common characteristic of people who criticize the “medical model” in psychiatry. Of course it is generally not a scholarly endeavor. For anyone interested in educating themselves in what a real medical model might look like I would suggest reading Systematic Psychiatric Evaluation (Reference 1) or any other guide to psychiatric evaluation. Take a look at Appendix A and B for the quick story. The fact that models like this one are widely emulated by nonphysicians may speak to their utility in understanding and treating psychosis and other mental disorders.
How do the authors do on their characterization of psychosis? They seem to touch on the high spots. Mention of hallucinations, delusions, and formal thought disorder are all there. They are obviously heavy on phenomena that would not typically come to the attention of psychiatrists, people who experience hallucinations and delusions or some grey zone phenomena that are not quite psychotic symptoms. But what about the central feature of psychosis that generally comes to the attention of psychiatrists (the ones within the “medical model”)? It turns out the authors have little to say about judgment or insight. They have nothing to say about the conscious state of the individual. These are the distressing and often life threatening aspects of the illness. This is the aspect of psychotic illness that causes friends and family to state that they no longer recognize the person due to the disruption of their personality characteristics. Are we really to believe that psychiatrists are having casual conversations with people intellectually curious and not bothered by hallucinations and delusions? Are we really to believe the affected person may not have experienced a profound change in their conscious state that makes them unrecognizable to their friends and family and unable to work or perform their basic life activities? Are we really to believe that change in conscious state may not possibly represent an acute danger to the person affected or their loved ones? Only people who have not been seriously affected by psychotic states and people who are not responsible for assessing and treating those states can make those statements. Those people generally do not need to see psychiatrists.
The authors claim that a “lack of insight” can result in a person being detained for mental illness. That does not happen where I practice. I have to document “behavioral evidence” rather than a lack of insight and treatment refusal can also not be used as a basis for detaining someone. In the USA, there is a strong financial incentive to discharge people from hospitals as soon as possible. The businesses and governments who manage these facilities welcome treatment refusals. The patient can be discharged immediately with no follow up demands. From a business perspective that is "cost-effective care". If any paternalism exists, it is at a societal level. Society is the proper arbiter of how its most vulnerable citizens should be treated. Should they be forced into treatment or allowed to die with their rights on? Psychiatrists have no choice but to follow society's lead. If psychiatrists have no vested interest in forced treatment, one of the critical questions is why it exists in the first place? The obvious answer is that it is a far from perfect approach to help families get their loved ones treated and even then families are routinely disappointed. Hospitals and courts can still have their own interpretations of these laws that will save them money but not provide necessary treatment. In the end there is still no medical paternalism.
There are two other sections in this paper that merit commentary – dangerousness and etiologies of psychosis. After their selective and inaccurate characterization of psychiatric assessment the authors drop this bomb:
"Some psychologists are reaching the conclusion that psychosis is often no more and no less than a natural reaction to traumatic events. For example one recent paper suggested that ‘there is growing evidence that the experiences service users report … are, in many cases, a natural reaction to the abuses they have been subjected to. There is abuse and there are the effects of abuse. There is no additional ‘psychosis’ that needs explaining’." (p 42 from Reference 2)
That is a very interesting observation to psychiatrists who screen all of their new evaluations for trauma history and post-traumatic stress disorder (PTSD). Instead of a “recent paper” what if I am a psychiatrist seeing 500 new cases per year and I screen everybody I see for psychosis, PTSD, childhood adversity and other forms of psychological trauma. What if over the space of 4 years and 2,000 new evaluations I observe that about 30% of my patients have significant childhood adversity or psychological trauma, about 5-10% have PTSD related to that trauma and about 5% have psychotic symptoms totally unrelated to previous trauma. I pose that hypothetical because it would be the common experience of most psychiatrists. The issue of trauma being a cause for symptoms should also lead to the examinations of previous errors postulating trauma as an etiology for symptoms most notably the Multiple Personality Disorder (MPD) fiasco and the associated phenomenon of Satanic Ritualistic Abuse (SRA). I would recommend against even using highly qualified statements about this as a possible etiology for psychosis without ample evidence. Although research bias is a frequent accusation in the area of psychopharmacology research, there is no reason to suspect that favorite theories in psychosocial research are less bias producing.
The authors fall back on the statement about mental illnesses not implying dangerousness. In the vast majority of cases that is true. It is also true that the population with the most significant illnesses need to be evaluated for suicidal and aggressive behavior. Tragedies that occur as a result of impaired judgment and altered conscious states from psychotic disorders are commonplace. People with these problems can be successfully treated and violence and suicide can be prevented. It is not enough to suggest that people with mental illnesses may be stigmatized by any connection with violence. People with psychotic disorders and aggression are among the most stigmatized people in our society. The solution is not to deny that this problem exists but to identify this as a treatable problem and develop an appropriate public health response. There is also a very strong bias in the American legal system to punish rather than treat anyone with a psychosis who commits a crime. Escaping punishment as a result of the not guilty by reason of insanity defense (NGRI) is one of the most consistent urban legends in America. This defense is hardly ever a success and even then it is likely that the patient involved will spend more time in a forensic prison/hospital than they would have if they were criminally sentenced without the NGRI defense.
The authors are certainly wrong about any “medical model” of psychosis or mental disorders that I am used to seeing. My medical model is the model of Engel and Chisholm and Lyketsos informed by Kandel and others. There are very few places it can be practiced in the United States because business interests run the field of psychiatry and medicine. American managed care companies and governments can certainly reduce psychiatric assessment to a series of checkmarks in the electronic health record and documentation that may be unreadable.
A business model of rationing is not a medical model by any stretch of the imagination. That business model is also not one that will prove to be receptive to any enlightened model of community care. The best evidence of that is that the ACT (Assertive Community Treatment) Model invented by Stein, Test and others in 1974. This model consists of active outreach, crisis intervention and housing, medical and psychiatric care, vocational rehabilitation, and peer counseling with a focus on helping individuals maintain stable housing in the community. There is no insurance company that I know of that supports this level of care. The ACT Model is cost shifted to state governments and they strictly ration who gets that level of care. With regard to Cognitive Behavioral Therapy there is no insurance company that I know of that consistently supports research recommended course of therapy for the conditions that have long standing indications – the anxiety and depressive disorders. What is the likelihood that it will be supported for the treatment of psychotic disorders and grey zone conditions?
I will hold my remaining remarks on the treatment implications of this paper. This blog contains extensive commentary on that issue and the real limitations on comprehensive assessment and treatment.
None of those limitations are due to a “medical model.”
George Dawson, MD, DFAPA
References:
1. Margaret S. Chisholm, Constantine G. Lyketsos. Systematic Psychiatric Evaluation. A Step-by Step Guide to Applying The Perspectives of Psychiatry. 2012 The Johns Hopkins University Press. 243 pp.
2. The British Psychological Society. Understanding Psychosis and Schizophrenia. Edited by Anne Cook. Available on the web site of the British Psychological Society.
George Dawson, MD, DFAPA
References:
1. Margaret S. Chisholm, Constantine G. Lyketsos. Systematic Psychiatric Evaluation. A Step-by Step Guide to Applying The Perspectives of Psychiatry. 2012 The Johns Hopkins University Press. 243 pp.
2. The British Psychological Society. Understanding Psychosis and Schizophrenia. Edited by Anne Cook. Available on the web site of the British Psychological Society.
