The Medical Model of Psychopathology

The following is the introductory section of my chapter “The Medical Model of Psychopathology” for a forthcoming (2026?) academic volume “Handbook of Dimensional Models of Psychopathology,” edited by Christopher Conway & Robert F. Krueger, to be published by Oxford University Press.

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What is the “Medical Model”?

“As the issues have become caught up in interprofessional disputes and public controversies, the term “medical model” has taken on different meanings. Like “law and order” and “neighborhood schools,” “medical model” has become a slogan for use in public debate—more an epithet for attacking one's enemies or a rallying cry for gathering one’s followers than a term of precision for furthering intellectual discussion or scientific discovery.” Gerald L. Klerman, 1977

Already in the 1970s, “medical model” was a fraught term in the context of mental healthcare. The psychiatrist Gerald Klerman noted in 1977 that the term had evolved into a slogan used more for rhetorical impact than scientific clarification. As Klerman described it, for psychiatrists it symbolized a unifying concept essential for defending the medical identity of psychiatry as a profession and the existence and accessibility of mental health services within the broader healthcare apparatus of medicine. Cognitive and behavioral therapists used it to contrast their focus on observable behaviors with the psychoanalytic emphasis on unconscious conflicts. For public activists, the term was a reminder of the superficial efforts of the medical community to address problems that were fundamentally social in nature. For psychologists and social workers, it represented efforts at gatekeeping professional prestige and privilege. Sociologists saw the application of the medical model to psychopathology as form of control of socially deviant behaviors. For many within and outside the profession at that time, it stood for biological treatments like electroconvulsive therapy and psychosurgery. Finally, for biologically oriented psychiatrists of the 1970s and 1980s, it encapsulated a rallying cry for a return to the roots of scientific medicine and mainstream medical practices, bolstered by the development of new pharmaceutical treatments (Klerman, 1977).

These contradictory connotations of the term persist to this day. Little has changed in these intervening decades and the term “medical model” remains charged as ever, serving as a vehicle for critique as well as defense. Shah and Mountain note,

“The term ‘medical model’ is frequently used in psychiatry with denigration, suggesting that its methods are paternalistic, inhumane and reductionist. This view has influenced mental health organisations, which in certain areas advocate a departure from the medical model, and contributes to the difficulties in leadership being played out between politicians, professionals and patients.” (Shah and Mountain, 2007)

In contrast, proponents have used the concept of medical model as a way of establishing psychiatry’s medical identity. For them, the fundamental idea behind the medical model in psychopathology is the value – and even necessity – of extending the concepts of general medicine to the study and treatment of mental disorders. The sentiment is expressed by Guze (1993) as follows:

“… psychiatry will most likely thrive and progress if it follows the general strategy, and uses the concepts, of general medicine, in clinical practice and in research. Diagnosis, pathogenesis, etiology, natural history, treatment, and epidemiology are all medical concepts and suggest clinical strategies and research for psychiatric disorders.” (Guze, 1993)

This aspiration to mimic general medicine is important because our notion of medical model for psychopathology will depend on our understanding of the medical model as it applies to rest of medicine (Nesse and Stein, 2012; Huda, 2019; Huda 2021). Arguably, many in the psychiatric community have understood the framework used within general medicine in an overly narrow manner – one that implicitly takes psychiatric disorders to be etiologically similar to conditions such as infectious diseases and autosomal dominant genetic disorders rather than multifactorial complex medical syndromes (Kendler, 2019).

Many limitations of the medical model of psychopathology, as commonly understood, spring from this overly narrow understanding and can be remedied by appreciating the complexity involved across medicine. Furthermore, medicine is conceptually and scientifically dynamic. “Medical model” is not a static conceptual framework but is itself evolving and adapting in response to developments within medicine as well as critiques from outside. Consider, for instance, the American Psychological Association dictionary definition of the medical model: “the concept that mental and emotional problems are analogous to biological problems—that is, they have detectable, specific, physiological causes (e.g., an abnormal gene or damaged cell) and are amenable to cure or improvement by specific treatment.” (APA, 2018) This definition is highly inadequate. Instead of “biological problems,” it would be more accurate to say that the medical model considers mental and emotional problems to be analogous to problems encountered in general medicine. The second, and more serious, error here is that it immediately restricts the range of possible options to “detectable, specific, physiological causes,” when, in reality, medicine deals with a very wide range of problems including situations where physiological changes are not always detectable, and changes are not always specific. Causes in medicine are often environmental or traumatic, and highly influenced by social factors, which is why public health interventions can be so effective.

Due to the current dominance of DSM and ICD, it may be tempting to use “medical model” to refer to a model that privileges categorical classifications, and this may be contrasted with dimensional and idiographic approaches. As we will discuss subsequently in this chapter, however, there is no reason to think that the medical model of psychopathology is unable to accommodate dimensionality, given how common dimensional phenomena are in general medicine.

Shah and Mountain (2007) propose that the medical model should simply be understood as “a process whereby, informed by the best available evidence, doctors advise on, coordinate or deliver interventions for health improvement.” Klerman (1977) identified three components of the medical model: the application of the sick role to the mentally ill, the concept of disease in mental illness, and the expansion of mental health care to noninstitutionalized individuals. He argued for the role of societal negotiation in defining and managing mental illness. Among contemporary commentators, Huda (2019) uses the term medical model to refer to a system that physicians use in clinical or research practice to identify clinical problems, make predictions as to outcomes and responses to treatment of these clinical problems.

For our purposes, it would be reasonable to understand the medical model as referring to a model of practice that is analogous to the practice of general medicine in the following ways:

1. Classification and diagnosis play a central role in the assessment and treatment of mental disorders.

2. The notion of “mental disorder” is thought to legitimately (but not exclusively) fall under the category of “medical disorder.”

3. Causal explanations posit a crucial role for physiological and neuroscientific mechanisms, while recognizing multi-level causality.

4. Treatment modalities such as pharmacotherapies and neuromodulation are considered to be a vital part of the clinical armamentarium.

Understanding “medical model” in this manner allows us to avoid the denigratory connotations discussed previously, while at the same time recognizing distinctive areas of emphasis.

The boundaries of “medical model” are fuzzy and its contents overlap with those of adjacent disciplines such as psychology and social work. This fuzziness of boundaries is to be expected given the historical development of the mental health professions. In the 18th and 19th centuries, the oversight of asylums was primarily assigned to physicians, a decision influenced significantly by the professional absence of other disciplines who could’ve assumed that responsibility. Burns (2006), Bynum (2008), and Huda (2019) suggest that since professional alternatives such as psychologists or social workers did not exist in the 1800s, this led to physicians assuming the role of asylum superintendents by default, leading to the subsequent dominance of the medical perspective on psychopathology. Later in the 20th century, psychological treatments such as psychoanalysis and cognitive therapy were also initially developed by physicians given their dominance in the clinical role. This historical context is critical in understanding why our clinical and scientific understanding of psychopathology is inevitably enmeshed with the medical approach. The prominence of the medical approach in the study and treatment of psychopathology is arguably a product of historical circumstances and not something that arises intrinsically from the nature of psychiatric conditions. In most healthcare systems, at least in the Western world, mental health services currently exist as part of the broader medical system. Primary care physicians (and allied professionals, such as nurse practitioners) often assume the responsibility of providing medical care for common disorders such as depressive and anxiety disorders, co-existing with psychiatrists as well as non-medical specialists such as psychologists and psychotherapists. Reimbursement for psychological assessments and treatments is also typically governed by health-related compensation through private insurance or government programs. In order to meaningfully talk about the “medical model,” the discussion in this chapter will focus on aspects that are comparatively more specific to psychiatry, but this should not be misunderstood to imply that medicine and psychology do not overlap or that psychotherapies are excluded from the medical model.

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See also:

People Are Stumbling From One Misguided Narrative About the Medical Model to Another

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References

• American Psychological Association. (2018). APA Dictionary of Psychology. https://dictionary.apa.org/medical-model (accessed Oct 11, 2024)

• Burns T. (2006). Psychiatry: A Very Short Introduction. Oxford University Press.

• Bynum W. (2008). The History of Medicine: A Very Short Introduction. Oxford University Press.

• Guze, S. B. (1993). The future of psychiatry and the medical model. The Journal of Nervous and Mental Disease, 181(10), 593-594.

• Huda, A. S. (2019). The Medical Model in Mental Health: An Explanation and Evaluation. Oxford University Press.

• Huda, A. S. (2021). The medical model and its application in mental health. International Review of Psychiatry, 33(5), 463-470.

• Kendler, K. S. (2019). From many to one to many—the search for causes of psychiatric illness. JAMA Psychiatry, 76(10), 1085-1091.

• Klerman, G. L. (1977). Mental illness, the medical model, and psychiatry. The Journal of Medicine and Philosophy, 2(3), 220-243.

• Nesse, R. M., & Stein, D. J. (2012). Towards a genuinely medical model for psychiatric nosology. BMC Medicine, 10, 1-9.

• Shah, P., & Mountain, D. (2007). The medical model is dead–long live the medical model. The British Journal of Psychiatry, 191(5), 375-377.

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