The medical model

Our understanding of ‘madness’ and anguish has changed and developed over many generations. When I look at this process something that strikes me is how each framework has its own strengths and limitations, places where it was helpful and others where it was destructive. There’s also a kind of pendulum swing from polarized positions – all mental illness is caused by genetics, all mental illness is caused by trauma, until finally in many of the debates the reality has been found to be somewhere in between. Both nature and nurture shape us. Attempts to find a way to comprehend and respond to bizarre or distressing experiences seem often to originate in an attempt to move away from the destructiveness of the framework that came before. I’m not too hard on the medical model for this reason. It has strengths! One of them is the idea that madness could be understood. That it could be studied, researched, comprehended, and possibly even treated. When madness was understood as a spiritual or moral failing, people suffered. A medical approach was at the time, filled with hope.

Another thing I like about the medical model is the way it is being used to demand better resources for people with a mental illness. There is talk about a medical apartheid, where money available to support people who have diabetes or are recovering from strokes is compared to the money available to support people who have schizophrenia or postnatal depression. It IS outrageous that there is not yet the funding to develop better testing so that people with mental illnesses are not exposed to medications to which they will have an allergic reaction. It is appalling that perceptions such as ‘people with mental illnesses are never going to get better anyway’ slows the development of quality resources. I’m happy that our ideas about sanity have become much more sophisticated than the two categories of crazy and sane.

In my opinion, the medical model also has some major limitations. One of them is the inability to distinguish between illness and injury. We do not have a language to describe psychological injury in the way that we do physical injury. So for those who have been psychologically wounded by trauma, abuse or neglect, they are diagnosed with a mental illness. Our entire mental health system in some ways is predicated on the idea that there is something wrong with the victims.

Our mental health system has become a catchment for hurting people, and it tells them that there is something wrong with them because they are wounded. In my experience, people who have been mistreated react in entirely predictable ways, and develop difficulties in the areas that were damaged – such as navigating relationships, coping with intense emotions, experiencing chronic shame. There is no place in ‘abnormal psychology’ for these reactions, they are the normal reactions of human beings to these kind of circumstances, in greater or lesser degrees. For those most catastrophically wounded, so many areas of life are affected that they often receive multiple diagnoses, the labels pile up giving the impression of a case of the most hopeless overwhelming sickness and deeply discouraging the person who carries them around. We don’t do this when people have been physically wounded. As Dr Middleton, Australian psychiatrist put it:

If an individual were to be dragged out of the wreckage of a train crash and dispatched to the nearest hospital emergency department he could perhaps be diagnosed with ‘compound fractured tibia-fibular disorder’, ‘respiratory distress disorder associated with pneumothorax’, ‘hypofusion, hypotensive disorder’, ‘renal shock disorder’, ‘tachycardia’, ‘endocrine stress disorder’ or ‘post abrasian skin integrity disorder’ etc. Alternatively, such an individual could be seen as (barely) surviving a major physical trauma that impacted on all bodily systems and where particular physical defences automatically became operative from the point of trauma… We can view the survivors of emotionally deprived and severely abusive childhoods as suffering from multitudinous DSM-IV diagnostic entities: post-traumatic stress disorder (PTSD), borderline personality disorder, dissociative disorders, somatization disorder, affective disorder, drug and alcohol related disorders, sexual dysfunction etc., or we can view them as the survivors of a psychological train wreck in which no psychological system was unaffected and in which whatever psychological defences that were available were pressed into service to ensure survival.

Research suggests that while Depression can appear at random without any clear cause, people are certainly more vulnerable to it after experiencing major life stress such as the death of a family member. The trend is easy to chart – the more of these stressors, the more likely it is that someone will develop a major depressive illness. Once again, if we are dealing with situations where most people who experience a sequence of catastrophic life events will develop depression, isn’t the obvious conclusion that depression is a pretty normal and common human response to certain situations?

Then we have the issue of treating emotional pain as a medical problem. Part of what it is to be human is to be capable of being hurt. Those humans who do not ever suffer, never feel fear or sorrow or grief, we have other words for them and they not examples to be lived up to. Yet with our medical model, people in pain can only access services if they have an illness label of some kind, as though to hurt is to be sick. In crude terms, mental health becomes synonymous with being happy, and mental illness with being sad or hurt. This scares me. It is not only normal, but mentally and emotionally healthy to react to certain situations with a deep sorrow, with anguish, grief, fear, and wrenching pain. To be shattered, heartbroken, heart sick, soul sick, desolate and distraught. Happiness in the face of profound loss is not a healthy human response. But the language of mental illness makes it hard to say to someone – there is nothing wrong with you! And here, let me help.

Please don’t misunderstand me, I’m certainly not saying that all mental illnesses are a response to emotional trauma. I’m not suggesting that we leave people to tough it out alone. I’m not saying that the medical model doesn’t fit exactly some of what some people experience. But in situations where people are wounded, not sick, where their reactions are normal, although deeply distressing, and where they are made to feel that there is something wrong with them for simply being human, I’m distressed that we don’t have a language nuanced enough to capture these ideas. The medical model feels to me a little like pleading guilty in return for a chance at parole when you are innocent. People must first self identify as being ill before any care or comfort can theoretically be offered. There are only services for the sick.

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