On Models, Concepts, Power, and Politics – Part II

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.

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9 thoughts on “On Models, Concepts, Power, and Politics – Part II

  1. The words: “Usually, behind every shift in meaning lies the politics of power and ingrained attitudes” got my attention. I really wonder about the mental health system’s use of privacy legislation. What power dynamic is being exercised and what ingrained attitudes does this use (or according to Harriet Lefley, ‘misuse’) really reveal.

    Could it be that the system does not want family involvement and if so why? And is the ingrained attitude that families are actually the cause of serious mental illness?

    Recently, I had some questions about my son’s treatment by a psychiatrist. I was told “I would be glad to discuss with you and your family if your son is in agreement and provides me with written permission and verbal clarification as to the information/details that can be shared. I appreciate families are concerned about the wellbeing of their family members but must also respect patient privacy.”

    Contrast this to my experience when my mother had terminal cancer. In the eight months before she died, I had many conversations with the doctor and nurses and it was never stated that she needed to give written permission and verbal clarification as to the information/details that was shared.

    Why are the families of the seriously mentally ill treated differently?

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  2. You raise a good point Kathleen. One wonders if this is really is to do with the restrictions in the legislation regarding mental illness and that the doctors may fear a law suit. I remember a well known senior doctor at CAMH years ago say” That doctors must obey the law” and then followed it up with ” But we have not been sued yet. There is fine line between being inappropriate and actually trying to help someone stabilize. Families should surely be included in the circle of care as you were Kathleen with your mother. Families one suspects are still being blamed for the illness one senses. lawyers may be even worse than doctors regarding the blame game.

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  3. “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”

    When people rail against “the status and power of the doctor”, the reason is often connected to their personal experience of a particular doctor’s methodologies. For example, if a psychiatrist in a hospital discharges a patient who is still psychotic to the family home without listening to the concerns of the family caregiver (and this has been happening for decades and is still happening), the psychiatrist is using his or her status and power to over-rule the family caregiver. The caregiver does have a legitimate objection that cannot simply be dismissed as unjustified resentment of the psychiatrist’s status and power.

    Similarly, psychiatrists often cite “confidentiality’ as a reason for refusing to talk to the family caregiver about the treatment plan, medications or concerns about potential violence; yet studies show that more than half of psychiatrists who have refused the family caregiver access to information have not actually asked the patient if he or she would like their family caregiver included. In these cases, the psychiatrist’s methodology needs questioning. Yet because of the relative inequality of their status and power, it is difficult for the family caregiver to challenge the psychiatrist to change this situation.

    Regarding the bio-social-psychological spectrum of care, that is accepted standard of care today. Unfortunately we still have psychiatrists who still do only the “bio” and a very narrow understanding of the “bio” at that. For example, if a psychiatrist prescribes medication and then does nothing about a 60 -100 pound weight gain in the next few months, that psychiatrist’s methodology is substandard and unacceptable and needs to be challenged. Sudden obesity is a serious health concern that a good doctor does not ignore. The underlying cause for sudden obesity is possibly the medications, possibly that the person is lying on the couch sleeping all day, possibly that the person has lost hope, and often a combination of all of these. The psychiatrist should probe the full bio-social-psychological range of possible reasons for the sudden weight gain and give helpful advice, encouragement and references to other professionals – such as psychologists, nutritionists and leaders of psycho-recreational programs. It is legitimate to question the methodology of psychiatrists who don’t seem to care about the patient’s overall health beyond being stabilized on medications, and to ask if that lack of care might be related to the status and power of the psychiatrist relative to these other professionals and to the patient.

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    1. I think you are describing substandard care and have every right to rail against it. In fact, if the social contract inherent in the “medical model” was being fully honoured then the sudden obesity should be of great concern to the doctor. And I think you are right about many doctors hiding behind “confidentiality” to avoid dealing with families. I don’t think it’s right or good but I have some sympathy for these doctors as I know first hand how exhausting some family meetings can be, and how much skill is required to ensure that when an angry (possibly very ill) teenage boy is in the same room with mother, step-father, older sister, possibly biological father and his wife as well – how much skill is required to bring about a constructive outcome.
      David Dawson

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      1. Sorry Dr. Dawson, but I don’t share your sympathy for any doctor who neglects to ask the patient if he or she would like their family caregiver included before citing “confidentiality” and refusing to talk to the family caregiver. A doctor who is exhausted after a 50-minute meeting with the ill person, the family caregiver and various other family members could see this as a positive experience from which to learn how exhausting it is for the family caregiver who is “on duty” continuously, day and night for years, without adequate information about the treatment plan, medications. potential violence or other necessary information. The doctor could use his or her experience of attempting to bring about a constructive outcome in a room with various family members to better understand the challenges to the family caregiver who is also trying to bring about a constructive outcome in the family home with the ill person and many other family members involved – step-father, older sister, biological father and his wife, other children – who are often not educated about the illness, do not always share the same views, and lack the formal skills to work effectively as a team. It must also be noted that the doctor is financially compensated for this exhausting meeting. By contrast, the exhausted family caregiver — often financially burdened from care giving — receives no pay at all, either for attending this meeting or for any other service rendered. In light of the above facts, a doctor who discharges a psychotic person to the family home without first consulting with the family caregiver is either deliberately cruel (for which there is no excuse) or perhaps just lacks insight into the family caregiver’s needs The prescription for this lack of insight should be the requirement to undergo a 50-minute meeting in a room with the ill person, the family caregiver, and various other family members that leaves the doctor exhausted!.

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    2. Patricia Jane, I would appreciate knowing where you found the source about over half of psychiatrists not asking the patient whether information can be shared. I have experienced many times where the misuse of privacy has been used to shield the service provider from accountability, yet have never seen someone charged with breach of privacy. My relative freely gives permission, yet the psychiatrist will ask the family member to leave the room when he is prescribing medication. Yet family members need this information, so that they can encourage the patient to take the medication and how to take the medication. I am wondering if the psychiatrist is contravening the health care consent act. The lives of families would be improved if there was transparency and honesty about the use and misuse of privacy legislation. I would like to see this whole area investigated. Some professionals play fast and loose with their interpretation of privacy legislation.

      Some of the medical profession may be loath do “deal” with families, but it may better inform their practice if they knew the realities that families have to “deal” with from overt discrimination, unasked for judgements, lack of empathy from professionals, lost income, canceled vacations, disrupted family life, seeing public money spent on everything but psychotic illnesses, observing the many glitzy “we are wonderful” projects to enhance the ego, having the profundity of the illness diminished to “mental health issues”, seeing public funding intended for clients wasted on feeding staff, irresponsible allocations of public dollars to ambitious CEO’s who want to try a program because it worked someplace else, the lack of voice at the decision making table or on the treatment team and the ultimate anguish, having to see the patient suffer negative outcomes because the psychiatrist did not listen to the family. Families who endure these experiences have dignity and grace.

      The truth is that the way families are often treated is a social injustice.

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      1. Kathleen, as usual, never speaks with forked tongue in her writing about the inglorious state of our old fashioned, out of date current mental illness system. The use of the name Mental Health System describes the hitch in the system.

        We have adopted this nomenclature to satisfy the political wishes of those who deny the existence of mental illnesses. The word-abusers of sociology have dominated the academic literature on human behavior for decades. They have muddied the waters of otherwise clear scientific explanations on behalf of serious brain diseases.

        Now we must untangle the fanciful from the truth if we are to defeat schizophrenia, manic depression, autism and other neurological curses of humankind.

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  4. The sting of family blaming that is always lurking just below the surface of hospital emergency psychiatrists destroys families’ hope at the very onset of a treacherous journey into the bizarro maze of our mental illness system.

    I found myself so distraught by the atmosphere in the tiny room with my son and a stranger psychiatrist, that I caught myself working harder to show that I was not the “schizophrenogenic” mother he clearly assumed I must be. That was my first discouraging attempt to save my son from the madness which gripped him.

    This was just the beginning of my search for help which led to my son’s eventual suicide. The current misunderstanding about neurological diseases had done its job.

    It is time for the system to escape Freud’s pie-in-the-sky assumptions about serious brain diseases and follow the scientific path to amelioration and a cure for chronic brain diseases.

    After all, it is 2016.

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    1. Your trailblazing is an inspiration, June. Let’s cut to the chase and not get distracted by the BS. We need more caring competent psychiatrists, more hospital beds, and family inclusive services and supportive housing.

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