By Dr David Laing Dawson
We are all guilty of using language badly, without clarity of definition. We talk of concepts as if they are physical entities. Words that denote complex relationships, even systems of abstract thought, can become epithets, mindless accusations. Over time some words we use take on meaning quite opposite to their original meaning. Usually, behind every shift in meaning lies the politics of power and ingrained attitudes.
What are we talking about when we use terms like medical model, disease model, biological model, bio-psycho-social model, holistic model?
Maybe that is not the real question. Because often when people use those terms they are really expressing attitudes and power positions, or railing against someone else’s attitude and power position.
So instead I will ask the question, what do these terms in their original form and intent mean?
Let’s take the “medical model”. This really speaks of the relationship between doctor/healer and patient/sufferer. It has been pointed out that this particular social contract predates the disease model by many centuries, and that in most or all cultures someone is assigned, earns and accepts the role of “doctor/healer/shaman”. It speaks of a set of guidelines, expectations regarding this relationship, a set of responsibilities and privileges assigned to each (doctor and patient) within the unspoken but generally well known and accepted contract. It is the contract you want your doctor to fulfill when you go to her as a patient with chest pain or a psychotic family member. The doctor’s side of the contract is succinctly explained in the Hippocratic oath, though all the nuances of this contract could fill a large book.
We know that for chronic illness the medical model requires adjustment: the doctor takes a little less responsibility, the patient more, and allied health professionals, and family members share the burden and some of the responsibility.
We also know that for some situations the same medical model that works so well for acute illness can be dangerous when applied to something like addictions. For when the doctor reaches for her prescription pad, she is fulfilling her social contract with this patient to do her “utmost to relieve suffering” – but simple relief of suffering may not bode well for an addict, no matter how much he or she is demanding it.
Physicians in this part of the world have adopted the “disease model”, a scientific and systematic approach to their patient’s illnesses. It is a model, as described before, that implies cause and effect, determined by evidence and science, and an attempt to alter or correct the primary or necessary cause of the distress (e.g. bacteria) and to alleviate symptoms and suffering by understanding their pathogenesis, their mechanisms. This is not all biological in nature: the prescription of antibiotics to kill the germs (biology, reductionistic), the prescription of aspirin to quell the fever (symptom relief from evidence and understanding the mechanism of fever), the advice of bed rest and fluids (holistic health) and the letter excusing someone from work for a few days (definitely a social intervention), to say nothing of reassurance and explanation (cognitive/psychological intervention).
Those who rail against the “medical model” are almost always railing against not the concepts or methodologies of modern medicine but about the status and power of the doctor.
A biological model is reductionistic. It is a focus on biological impairments, mechanisms and pathways that lead to symptoms and distress.
The bio-psycho-social model (which has been called the three legged stool) attempts to add and understand the influences of cognition/emotion and social environment to the problem at hand.
Fair enough, but in practice we want to find, if it exists, the necessary cause of the distress, the illness, the disease. This could be biological. It could be a bad marriage. The bio-psycho-social model reminds us of this, and that all spheres may be playing a role.
Though in truth I would like it to be renamed the bio-socio-psychological model, because it seems clear to me, in my amateur studies of ethnology, evolution, societies, social groups, and human behaviour, that we are primarily biological beings, driven by instinct and biological mechanisms, that secondarily we are social beings, our behaviours and thoughts modified by the social imperatives of our cultures, societies, families, and only lastly are we psychological beings, with our behaviour, to some small extent, driven by thought, reasoning, logic, compassion, understanding. Usually our thoughts are used to simply rationalize or justify those behaviours driven by biology and social imperatives.