Chapter Five
As a result of its complex historical development, psychiatry became established as a branch of medicine. Mainstream conceptual thinking in psychiatry, the approach to individuals with emotional disorders and behavior problems, the strategy of research, basic education and training, and forensic measures—all are dominated by the medical model. This situation is a consequence of two important sets of circumstances: medicine has been successful in establishing etiology and finding effective therapy for a specific, relatively small group of mental abnormalities, and it has also demonstrated its ability to control symptomatically many of those disorders for which specific etiology could not be found.
The Cartesian-Newtonian world view that had a powerful impact on the development of various fields has played a crucial role in the evolution of neuropsychiatry and psychology. The renaissance of scientific interest in mental disorders culminated in a series of revolutionary discoveries in the nineteenth century that firmly defined psychiatry as a medical discipline. Rapid advances and remarkable results in anatomy, pathology, pathophysiology, chemistry, and bacteriology resulted in tendencies to find organic causes for all mental disturbances in infections, metabolic disorders, or degenerative processes in the brain.
The beginnings of this “organic orientation” were stimulated when the discovery of the etiology of several mental abnormalities led to the development of successful methods of therapy. Thus, the recognition that general paresis—a condition associated, among others, with delusions of grandeur and disturbances of intellect and memory—was the result of tertiary syphilis of the brain caused by the protozoon Spirochaeta pallida was followed by successful therapy using chemicals and fever. Similarly, once it became clear that the mental disorder accompanying pellagra was due to a vitamin B deficiency (lack of nicotinic acid or its amid), the problem could be corrected by an adequate supply of the missing vitamin. Some other types of mental dysfunction were found to be linked to brain tumors, degenerative changes in the brain, encephalitis and meningitis, various forms of malnutrition, and pernicious anemia.
Medicine has been equally successful in the symptomatic control of many emotional and behavior disorders the etiology of which it has not been able to find. Here belong the dramatic interventions using pentamethylenetetrazol (Cardiazol) shocks, electroshock therapy, insulin shock treatment, and psychosurgery. Modern psycho-pharmacology has been particularly effective in this regard with its rich armamentarium of specifically acting drugs—hypnotics, sedatives, myorelaxants, analgesics, psychostimulants, tranquilizers, antidepressants, and lithium salts.
These apparent triumphs of medical research and therapy served to define psychiatry as a specialized branch of medicine and committed it to the medical model. With the privilege of hindsight, this was a premature conclusion; it led to a development that was not without problems. The successes in unraveling the causes of mental disorders, however astonishing, were really isolated and limited to a small fraction of the problems that psychiatry deals with. In spite of its initial successes, the medical approach to psychiatry has failed to find specific organic etiology for problems vexing the absolute majority of its clients—depressions, psycho-neuroses, and psychosomatic disorders. Moreover, it has had very limited and problematic success in unraveling the medical causes underlying the so-called endogenous psychoses, particularly schizophrenia and manic-depressive psychosis. The failure of the medical approach and the systematic clinical study of emotional disorders gave rise to an alternative movement—the psychological approach to psychiatry, which led to the development of dynamic schools of psychotherapy.
In general, psychological research provided better explanatory models for the majority of emotional disorders than the medical approach; it developed significant alternatives to biological treatment and in many ways brought psychiatry close to the social sciences and philosophy. However, this did not influence the status of psychiatry as a medical discipline. In a way, the position of medicine became self-perpetuating, because many of the symptom-relieving drugs discovered by medical research have distinct side effects and require a physician to prescribe and administer them. The symbiotic liaison between medicine and the rich pharmaceutical industry, vitally interested in selling its products and offering support to medical endeavors, then sealed the vicious circle. The hegemony of the medical model was further reinforced by the nature and structure of psychiatric training and the legal aspects of mental health policies.
Most psychiatrists are physicians with postgraduate training in psychiatry—and a very inadequate background in psychology. In most instances, individuals who suffer from emotional disorders are treated in medical facilities with the psychiatrist legally responsible for the therapeutic procedures. In this situation, the clinical psychologist frequently has the function of ancillary personnel, subordinate to the psychiatrist, a role not dissimilar to that of the biochemist or laboratory technician. Traditional assignments of clinical psychologists are assessment of intelligence, personality, and organicity, assistance with differential diagnosis, evaluation of treatment, and vocational guidance. These tasks cover many of the activities of those psychologists who are not involved in research or psychotherapy. The problem to what extent psychologists are qualified and entitled to conduct therapy with psychiatric patients has been subject to much controversy.
The hegemony of the medical model in psychiatry has resulted in a mechanical transplantation of medical concepts and methods of proven usefulness into the field of emotional disorders. The application of medical thinking to the majority of psychiatric problems and to the treatment of emotional disorders, particularly various forms of neuroses, has been widely criticized in recent years. There are strong indications that this strategy has created at least as many problems as it solved.
Disorders for which no specific etiology has been found are loosely referred to as “mental diseases.”1 Individuals who suffer from such disorders receive socially stigmatizing labels and are routinely called “patients.” They are treated in medical facilities where the per diem expenses for hospitalization amount to several hundred dollars. Much of this cost reflects enormous overhead directly related to the medical model, such as costs for examinations and services that are of questionable value in the effective treatment of the disorder in question. Much research money is dedicated to refining medically oriented research that will eventually discover the etiology of “mental diseases” and thus confirm the medical nature of psychiatry.
There has been increasing dissatisfaction with the application of the medical model in psychiatry. Probably the best known and most eloquent representative of this movement is Thomas Szasz. In a series of books, including his Myth of Mental Illness (1961), Szasz has adduced strong evidence that most cases of so-called mental illness should be regarded as expressions and reflections of the individual’s struggles with the problems of living. They represent social, ethical, and legal problems, rather than “diseases” in the medical sense. The doctor-patient relationship as defined by the medical model also reinforces the passive and dependent role of the client. It implies that the solution of the problem depends critically on the resources of the person in the role of scientific authority, rather than on the inner resources of the client.
The consequences of the medical model for the theory and practice of psychiatry are far reaching. As a result of the mechanical application of medical thinking, all disorders that a psychiatrist deals with are seen in principle as diseases for which the etiology will eventually be found in the form of an anatomical, physiological, or biochemical abnormality. That such causes have not yet been discovered is not seen as a reason to exclude the problem from the context of the medical model. Instead, it serves as an incentive for more determined and refined research along medical lines.
Thus, the hopes of organically-minded psychiatrists were recently rekindled by the successes of molecular biology.
Another important consequence of the medical model is a great emphasis on establishing the correct diagnosis of an individual patient and creating an accurate diagnostic or classificatory system. This approach is of critical importance in medicine, where proper diagnosis reflects a specific etiology and has clear, distinct, and agreed-upon consequences for therapy and for prognostication. It is essential to diagnose properly the type of an infectious disease, because each of them requires quite different management and the infectious agents involved respond differently to specific antibiotic treatments. Similarly, the type of tumor determines the nature of the therapeutic intervention, approximate prognosis, or danger of metastases. It is critical to diagnose properly the type of anemia, because one kind will respond to medication with iron, another requires cobalt treatment, and so on.
A good deal of wasted effort has been poured into refining and standardizing psychiatric diagnosis, simply because the concept of diagnosis appropriate for medicine is not applicable to most psychiatric disorders. The lack of agreement can be illustrated clearly by comparing the systems of psychiatric classification used in different countries, for example in the United States, Great Britain, France, and Australia. Used indiscriminately in psychiatry, the medical concept of diagnosis is vexed by the problems of unreliability, lack of validity, and questionable value and usefulness. A diagnosis depends critically on the school to which the psychiatrist adheres, on his or her individual preferences, on the amount of data available for evaluation, and on many other factors.
Some psychiatrists arrive at a diagnosis only on the basis of the presenting complex of symptoms, others on the basis of psychodynamic speculations, still others on a combination of both. The psychiatrist’s subjective evaluation of the psychological relevance of an existing physical disorder—such as thyroid problems, vital disease, or diabetes—or of certain biographical events in the past or present life of the patient can have a significant influence on the diagnosis. There is also considerable disagreement concerning the interpretation of certain diagnostic terms; for example, there are great differences between the American and European schools about the diagnosis of schizophrenia.
Another factor that can influence the psychiatric diagnosis is the nature of the interaction between the psychiatrist and the patient. While the diagnosis of appendicitis or a hypophyseal tumor will not be appreciably affected by the personality of the doctor, a psychiatric diagnosis could be influenced by the behavior of the patient toward the psychiatrist who establishes the diagnosis. Thus, specific transference-countertransference dynamics, or even the interpersonal ineptness of a psychiatrist, can become significant factors. It is a well-known clinical fact that the experience and behavior of a patient changes during interaction with different persons and can also be influenced significantly by circumstances and situational factors. Certain aspects of current psychiatric routines tend to reinforce or even provoke various behavioral maladjustments.
Because of the lack of objective criteria, which are so essential for the medical approach to physical diseases, there is a tendency among psychiatrists to rely on clinical experience and judgment as self-validating processes. In addition, classificatory systems and concerns are frequently products of medical sociology, reflecting specific pressures on physicians in the task imposed on them. A psychiatric diagnostic label is sufficiently flexible to be affected by the purpose for which it is given—whether for an employer, an insurance company, or forensic purposes. Even without such special considerations, different psychiatrists or psychiatric teams will frequently disagree about the diagnosis of a particular patient.
A considerable lack of clarity can be found even regarding such a seemingly important question as differential diagnosis between neurosis and psychosis. This issue is usually approached with great seriousness, although it is not even clearly established whether there is a single dimension of psychopathology. If psychosis and neurosis are orthogonal and independent, then the patient can suffer from both. If they are on the same continuum and the difference between them is only quantitative, then a psychotic individual would have to pass through a neurotic stage on the way to psychosis and return to it again during recovery.
Even if psychiatric diagnosis could be made both reliable and valid, there is the question of its practical relevance and usefulness. It is quite clear that with a few exceptions the search for accurate diagnosis is ultimately futile because it has no agreed-upon relevance for etiology, therapy, and prognosis. Establishing the diagnosis consumes much time and energy on the part of the psychiatrist, and particularly the psychologist, who must sometimes spend hours of testing to make the final decision.
Ultimately, the therapeutic choice will reflect the psychiatrist’s orientation rather than a clinical diagnosis. Organically-minded psychiatrists will routinely use biological treatment with neurotics, and a psychologically-oriented psychiatrist may rely on psychotherapy even with psychotic patients. During psychotherapeutic work, the therapist will be responding to events during sessions rather than following a preconceived psychotherapeutic plan determined by the diagnosis. Similarly, specific pharmacological procedures do not show a generally agreed-upon relation between diagnosis and choice of the psychopharmacon. Frequently the choice is determined by the therapist’s subjective preferences, the clinical response of the patient, the incidence of side effects, and similar concerns.
Another important legacy of the medical model is the interpretation of the function of the psychopathological symptoms. In medicine, there is generally a linear relationship between the intensity of symptoms and the seriousness of the disease. Alleviation of symptoms is thus seen as a sign of improvement of the underlying conditions. Therapy in physical medicine is causal whenever possible, and symptomatic therapy is used only for incurable diseases or in addition to causal therapy.
Applying this principle to psychiatry causes considerable confusion. Although it is common to consider the alleviation of symptoms as an improvement, dynamic psychiatry has introduced a distinction between causal and symptomatic treatment. It is thus clear that symptomatic treatment does not solve the underlying problem but, in a way, masks it. Observations from psychoanalysis show that intensification of symptoms is frequently an indication of significant work on the underlying problem. The new experiential approaches view the intensification of symptoms as a major therapeutic tool and use powerful techniques to activate them. Observations from work of this kind strongly suggest that symptoms represent an incomplete effort of the organism to get rid of an old problem—and that this effort should be encouraged and supported.2
From this point of view, much of the symptomatic treatment in contemporary psychiatry is essentially antitherapeutic, since it interferes with the spontaneous healing activity of the organism. It should thus be used not as a method of choice but as a compromise when the patient explicitly refuses a more appropriate alternative, or if such an alternative is not possible or available for financial or other reasons.
In conclusion, the hegemony of the medical model in psychiatry should be viewed as a situation created by specific historical circumstances and maintained at present by a powerful combination of philosophical, political, economical, administrative, and legal factors. Rather than reflecting the scientific knowledge about the nature of emotional disorders and their optimal treatment, it is at best a mixed blessing.
In the future, patients with psychiatric disorders having a clear organic basis may be treated in medical units especially equipped to handle behavior problems. Those in whom repeated physical checkups detect no medical problems could then use the service of special facilities where the emphasis would be psychological, sociological, philosophical, and spiritual, rather than medical. Powerful and effective techniques of healing and personality transformation addressing both the psychological and physical aspects of human beings have already been developed by humanistic and transpersonal therapists.