I agree with your article, but less of it coheres with my experience. A Colorado medical school professor as recently as 2022 told me that I have a "chemical imbalance" inside of my brain during a video consult. She is now tenured. A more recent interaction with a PMHNP also stated I have "too much dopamine" and that I could "literally die if you don't take vraylar". (I'm still waiting to spontaneously "die" months later; any day now, sigh).
I believe what fuels much of the disillusionment is that these categories are taught as if they're A). homogeneous, B). static, C). a-contextual, D). overdeterministic or unidirectional. And it's because all of science holds the same assumptions with everything they theorize. E.g. Physicists demand spacetime is perfectly homogeneous, that all "laws" are deterministic, static, and a-contextual and hence generalizable. And when philosophers point out these are instead "first assumptions" the scientist responds with "Well that sounds too philosophical for me so it's not my problem!". Whereas biologists will unapologetically claim nothing living is ever homogeneous, not even "identical" twins, nor are evolutionary processes "purely" deterministic, nor are mutations unidirectional nor a-contextual. Living bodies are also not static (aging is real, circadian rhythms change, values change, habits too etc). And no metabolic process follows a straight line. So why hasn't institutional psychiatry banned these words (homogeneity, static, a-contextual, overdeterministc/unidirectional) yet? What kinds of brains are rising to the ranks of professor to regurgitate these specific assumptions? I disagree it's the general public causing them. Rather, the first time i ever learned of the word homogeneity was in a psychometrics class about "crisply measuring mental disorders", as it were, "carving nature at it's joints".
Thank you, Awais, for a very thoughtful discussion of this much maligned concept of "the medical model." You are spot-on in identifying a misplaced "essentialism" as the chief culprit in the misguided arguments against the "medical model." (Please note that Ludwig Wittgenstein warned us of this trap in his Philosophical Investigations).
In a piece I wrote over 7 years ago regarding "hearing voices" [1], I noted that there is no single, written-in-stone, "essential" definition of the "medical model." Nevertheless, to the extent the term is useful in clinical psychiatry, we can identify its six central features:
1) In so far as human emotion, cognition, and behavior are mediated by brain function, there is
always an inherent biological foundation to dysfunctional states, such as clinical depression,
psychosis, etc
2) Valid psychosocial and cultural explanations of human experiences do not nullify (or contradict)
the biological foundations of these experiences
3) Conversely, biological explanations of human experiences do not negate (and often complement)
valid psychosocial and cultural explanations and formulations
4) Biological factors are always part of a comprehensive differential diagnosis of serious emotional,
cognitive, and behavioral disturbances—even if, upon careful analysis, psychosocial or cultural
explanations prove more relevant or informative
5) That certain human experiences or perceptions (e.g., “hearing voices”) have a discernible “meaning,”
symbolism, or psychological significance for the patient does not mean they have no
neuropathological etiology
6) All somatic and psychological treatment modalities—whether medication or “talk therapy”—have
meaningful (and sometimes measurable) effects on brain function and structure
It should be clear that there is nothing "reductive" in this understanding of the "medical model", and I believe these features--while not defining an "essence"--are useful, heuristic starting points for the understanding of how psychiatrists think about illness, disease, etc.
Thank you for this brilliant discussion. I have become more attracted to psychosocial approaches to mental health problems (e.g., housing, counseling, social supports) over the years and have even seen my daughter benefit from such programs as provided by family members and a local non-profit organization. If my daughter had a place to live in peace with access to food and medical care under a biopsychosocial model, and daily activities to give her life meaning, with friends and acquaintances who accept rather than judge or punish behavioral symptoms by interpersonal rejection or through a carceral system, without guns or other weapons (including those introduced by police officers as first responders), then we might have something approaching a utopian solution for persons with serious mental illnesses. But politicians and members of the public who complain about an over-reliance on medications would reject initiatives to bring such psychosocial supports to scale when they found out they cost far more than pills.
Yes, people aren’t very rational, are they? But why aren’t they? For one thing, it’s difficult for everybody to hold complex, multi-causal ideas in their heads. It certainly is for me! I think people learn some complex ideas in school, but in real life, everything inevitably gets simplified.
Besides that, there are all the influences on our thinking. For instance, the pharmaceutical companies are still a giant magnet distorting ideas about brain chemistry and such.
Another thing: I heard in a podcast someone say that in her coursework she was taught that “parents are never to blame.” A shockingly, obviously wrong statement—we all know that parents are often one of the causes of their children’s psychological problems. But from a practical standpoint—especially if you’re working with young people—you risk getting embroiled in family power dynamics if you start talking about abusive or neglectful parents. Better just ignore the facts.
Or take the reality of incest and other sexual abuse. It’s been denied for a long time. Even now, it seems nearly impossible for most people, including therapists, to talk about it. Most (many?) books on therapy don’t even mention it, even though it’s very common and everyone knows how damaging it is. Or sibling abuse. Who takes that seriously? Or dissociation of various kinds. How many therapists are taught about dissociation in depth? These matters are just too disturbing for most people to handle, and psychologists are just people.
And if psychologists don’t get it right, how can you expect patients to develop sophisticated ideas of the multi-causal nature of reality?
Hi Awais, I think you make many important points about medicine and the scope of its practice. There is a presupposition here, though—one that is almost unquestionable these days, for fear of being labeled pseudoscientific or the like. It's that significant mental or emotional suffering (thresholds being defined by the DSM) **is** an 'illness'. The idea of 'mental illness' seems to be a literal oxymoron to me. One way to conceptualise our mind is that it is a result of what 'our brains does'. Walking is one of the things our legs do. However, we don't have 'walking illnesses'. It's a selectional restriction in linguistics to talk about walking being 'ill'. We obviously can have leg injuries, cardiovascular illnesses, neurological illnesses, etc., but we don't talk about 'walking illnesses'. And yet, we frame psychological suffering as a 'mental illness' and not a 'neurological illness'. I can understand this from the point of view that psychological suffering is poorly characterised as a 'neurological illness'. But that doesn't mean that the frame of 'illness' is the most useful or accurate for psychological suffering. To me, this is the most powerfully and implicit 'medical model' involved here. It's the idea that psychological suffering is a medical issue. I'm curious—what do you think is the best argument that the framing of psychological or emotional suffering as 'illnesses' is well conceived, rather than just being *one* possible metaphor amongst other alternatives? Thanks so much.
“Would she be disappointed when she learns that the psychedelic revolution means jack shit for those who experience “financial deprivation, poor education, racial discrimination”?”
This! I live in the bay area and I don’t know many people who can afford psychedelic therapy with a licensed clinician at the rates people charge here unless they work in tech or are wealthy. It has horrified me to watch people go to these retreats, not integrate properly with licensed professionals, and come out with huge grandiose egos. An example of this is the recent OSU commencement speech by Chris Pan. My commencement speaker was Dan Rather and thankfully he was not high on Aya when he wrote it.
I agree with your article, but less of it coheres with my experience. A Colorado medical school professor as recently as 2022 told me that I have a "chemical imbalance" inside of my brain during a video consult. She is now tenured. A more recent interaction with a PMHNP also stated I have "too much dopamine" and that I could "literally die if you don't take vraylar". (I'm still waiting to spontaneously "die" months later; any day now, sigh).
I believe what fuels much of the disillusionment is that these categories are taught as if they're A). homogeneous, B). static, C). a-contextual, D). overdeterministic or unidirectional. And it's because all of science holds the same assumptions with everything they theorize. E.g. Physicists demand spacetime is perfectly homogeneous, that all "laws" are deterministic, static, and a-contextual and hence generalizable. And when philosophers point out these are instead "first assumptions" the scientist responds with "Well that sounds too philosophical for me so it's not my problem!". Whereas biologists will unapologetically claim nothing living is ever homogeneous, not even "identical" twins, nor are evolutionary processes "purely" deterministic, nor are mutations unidirectional nor a-contextual. Living bodies are also not static (aging is real, circadian rhythms change, values change, habits too etc). And no metabolic process follows a straight line. So why hasn't institutional psychiatry banned these words (homogeneity, static, a-contextual, overdeterministc/unidirectional) yet? What kinds of brains are rising to the ranks of professor to regurgitate these specific assumptions? I disagree it's the general public causing them. Rather, the first time i ever learned of the word homogeneity was in a psychometrics class about "crisply measuring mental disorders", as it were, "carving nature at it's joints".
Thank you, Awais, for a very thoughtful discussion of this much maligned concept of "the medical model." You are spot-on in identifying a misplaced "essentialism" as the chief culprit in the misguided arguments against the "medical model." (Please note that Ludwig Wittgenstein warned us of this trap in his Philosophical Investigations).
In a piece I wrote over 7 years ago regarding "hearing voices" [1], I noted that there is no single, written-in-stone, "essential" definition of the "medical model." Nevertheless, to the extent the term is useful in clinical psychiatry, we can identify its six central features:
1) In so far as human emotion, cognition, and behavior are mediated by brain function, there is
always an inherent biological foundation to dysfunctional states, such as clinical depression,
psychosis, etc
2) Valid psychosocial and cultural explanations of human experiences do not nullify (or contradict)
the biological foundations of these experiences
3) Conversely, biological explanations of human experiences do not negate (and often complement)
valid psychosocial and cultural explanations and formulations
4) Biological factors are always part of a comprehensive differential diagnosis of serious emotional,
cognitive, and behavioral disturbances—even if, upon careful analysis, psychosocial or cultural
explanations prove more relevant or informative
5) That certain human experiences or perceptions (e.g., “hearing voices”) have a discernible “meaning,”
symbolism, or psychological significance for the patient does not mean they have no
neuropathological etiology
6) All somatic and psychological treatment modalities—whether medication or “talk therapy”—have
meaningful (and sometimes measurable) effects on brain function and structure
It should be clear that there is nothing "reductive" in this understanding of the "medical model", and I believe these features--while not defining an "essence"--are useful, heuristic starting points for the understanding of how psychiatrists think about illness, disease, etc.
Regards,
Ron
Ronald W. Pies, MD
1. https://www.academia.edu/79032733/Hearing_Voices_and_Psychiatry_s_Real_Medical_Model?uc-sb-sw=38597480
https://www.psychiatrictimes.com/view/hearing-voices-and-psychiatrys-real-medical-model
Also see: Shah P, Mountain D. The medical model is dead – long live the medical model. Br J Psychiatry. 2007; 191:375-377.
Thank you for this brilliant discussion. I have become more attracted to psychosocial approaches to mental health problems (e.g., housing, counseling, social supports) over the years and have even seen my daughter benefit from such programs as provided by family members and a local non-profit organization. If my daughter had a place to live in peace with access to food and medical care under a biopsychosocial model, and daily activities to give her life meaning, with friends and acquaintances who accept rather than judge or punish behavioral symptoms by interpersonal rejection or through a carceral system, without guns or other weapons (including those introduced by police officers as first responders), then we might have something approaching a utopian solution for persons with serious mental illnesses. But politicians and members of the public who complain about an over-reliance on medications would reject initiatives to bring such psychosocial supports to scale when they found out they cost far more than pills.
Yes, people aren’t very rational, are they? But why aren’t they? For one thing, it’s difficult for everybody to hold complex, multi-causal ideas in their heads. It certainly is for me! I think people learn some complex ideas in school, but in real life, everything inevitably gets simplified.
Besides that, there are all the influences on our thinking. For instance, the pharmaceutical companies are still a giant magnet distorting ideas about brain chemistry and such.
Another thing: I heard in a podcast someone say that in her coursework she was taught that “parents are never to blame.” A shockingly, obviously wrong statement—we all know that parents are often one of the causes of their children’s psychological problems. But from a practical standpoint—especially if you’re working with young people—you risk getting embroiled in family power dynamics if you start talking about abusive or neglectful parents. Better just ignore the facts.
Or take the reality of incest and other sexual abuse. It’s been denied for a long time. Even now, it seems nearly impossible for most people, including therapists, to talk about it. Most (many?) books on therapy don’t even mention it, even though it’s very common and everyone knows how damaging it is. Or sibling abuse. Who takes that seriously? Or dissociation of various kinds. How many therapists are taught about dissociation in depth? These matters are just too disturbing for most people to handle, and psychologists are just people.
And if psychologists don’t get it right, how can you expect patients to develop sophisticated ideas of the multi-causal nature of reality?
Hi Awais, I think you make many important points about medicine and the scope of its practice. There is a presupposition here, though—one that is almost unquestionable these days, for fear of being labeled pseudoscientific or the like. It's that significant mental or emotional suffering (thresholds being defined by the DSM) **is** an 'illness'. The idea of 'mental illness' seems to be a literal oxymoron to me. One way to conceptualise our mind is that it is a result of what 'our brains does'. Walking is one of the things our legs do. However, we don't have 'walking illnesses'. It's a selectional restriction in linguistics to talk about walking being 'ill'. We obviously can have leg injuries, cardiovascular illnesses, neurological illnesses, etc., but we don't talk about 'walking illnesses'. And yet, we frame psychological suffering as a 'mental illness' and not a 'neurological illness'. I can understand this from the point of view that psychological suffering is poorly characterised as a 'neurological illness'. But that doesn't mean that the frame of 'illness' is the most useful or accurate for psychological suffering. To me, this is the most powerfully and implicit 'medical model' involved here. It's the idea that psychological suffering is a medical issue. I'm curious—what do you think is the best argument that the framing of psychological or emotional suffering as 'illnesses' is well conceived, rather than just being *one* possible metaphor amongst other alternatives? Thanks so much.
“Would she be disappointed when she learns that the psychedelic revolution means jack shit for those who experience “financial deprivation, poor education, racial discrimination”?”
This! I live in the bay area and I don’t know many people who can afford psychedelic therapy with a licensed clinician at the rates people charge here unless they work in tech or are wealthy. It has horrified me to watch people go to these retreats, not integrate properly with licensed professionals, and come out with huge grandiose egos. An example of this is the recent OSU commencement speech by Chris Pan. My commencement speaker was Dan Rather and thankfully he was not high on Aya when he wrote it.