It’s a bitter, exhausting and sometimes controversial debate, often taking place on X (formerly Twitter) and nearly always ending in name-calling and ridicule: which is the right way of approaching mental ill-health and distress? Is one model or approach better than the other? Which model speaks for those with lived experience, and, crucially, who ends up speaking over us?
In the toxic landscape of the pro vs anti medical model debate, it’s sometimes hard to see through all the fog. So, what actually is the medical model – and what is it not?
Why does the anti vs pro-medical model debate exist? What’s the backdrop?
The anti-medical model movement is much interlinked with the anti-psychiatry movement, although the two are not quite the same – you can be opposed to the use of the medical model in mental healthcare without being against psychiatry as a discipline altogether. Both movements originate from the same source: the campaign against psychiatry that took place in the 1960s, which coincided with the cruel and punitive treatment of people in psychiatric hospitals and the excessive use of electroconvulsive shock therapy occurring during the 50s and 60s. The movement was fuelled (amongst others) by the works of five key figures, three psychiatrists – R. D. Laing, David Cooper, and Thomas Szasz – as well as sociologist Erving Goffman and philosopher Michel Foucault, who each (to varying degrees) believed that mental ill-health was the result of social (rather than biological) factors, and that the medical model was therefore ineffective as treatment.
Today, those who are anti-medical model include survivors of psychiatric abuse and iatrogenic harm, alongside people working in the ‘psy disciplines’, such as psychiatrists, psychologists, psychoanalysts and occupational therapists. Disabled people have historically been (and continue to be) at the forefront of the anti-medical model movement, and were integral to the formation of the Social Model of Disability (an alternative to the Medical Model of Disability) throughout the 60s and 70s. The pro-medical model crowd is often made up of the same professionals, those who have been helped by psychiatry, and those who have been harmed by it.
There is so much toxicity between those who are pro-medical model and those who are against it that many people within lived experience communities avoid the topic altogether. Professionals, both pro and anti-medical model, feel that they are entitled to speak on behalf of us; some survivor influencers feel that they are entitled to speak for all of us. We have reached a point where compassionate discussion feels impossible; before conversation has even begun, shame is weaponised by both sides of the debate to ridicule and silence one another; when it is used by professionals against survivors, shame is particularly harmful because it replicates (and utilises) the innate power imbalances between “staff” and “patient” – it is, in essence, an abuse of power. Simultaneously, X has become a hive of misinformation, and the medical model debate has not sidestepped this; we must acknowledge how damaging misinformation can be and strive to call it out when we see it, unpick it, and challenge it.
So what actually is the medical model?
The medical model, sometimes called the ‘biomedical’ model, is a method for conceptualising and responding to mental ill-health and distress. It functions on the assumption that like physical illness, mental ill-health is caused by physical, biological or ‘organic’ factors (such as genetic defects, chemical imbalances or brain abnormalities) and can therefore be understood in terms of diagnoses, disorders and diseases. Under the medical model, treatment for mental ill-health normally includes talking therapies such as CBT or DBT and the use of psychotropic medication, which aims to change the brain’s chemistry and resolve chemical imbalances. In the UK, the medical model is by far the predominant approach to understanding mental ill-health (and has been since a systematic approach to ‘mental illness’ was established), although alternatives are slowly becoming more accepted. Despite the existence of these alternatives, however, the medical model and its associated ‘treatment’ options are often the only offering when trying to access care for mental ill-health, distress, or trauma, and information about non-medical model approaches can sometimes be difficult to access, or feel as though it is reserved for ‘professionals’.
And what is it not?
First and foremostly, it’s not the only way of understanding mental ill-health and distress, and it is not, therefore, the ‘right’ way – it may be the ‘right’ way for some individuals, but it isn’t the ‘right’ way for all. Like its alternatives, the medical model is a theory, and should be recognised as such; presenting it as fact undermines those who have been harmed or failed by it and overlooks the wealth of evidence (or, as many argue in these debates and especially when it comes to the chemical imbalance theory, the lack of solid evidence – see this post by H. Spandler at Asylum Magazine) that suggests the medical model is not always – or in some cases ever – effective, and is misleading to those of us who end up accessing mental healthcare over the course of our lives.
In the same vein, the medical model is not working; mental health in the UK isn’t improving, it’s worsening. Facts and statistics provided on Mind’s website indicate a clear increase in the number of people experiencing mental health problems over the last 30 years – and research published in March this year suggests that less than half of those who accessed the NHS’ talking therapy treatment programme for adults – which relies on a medical model approach to mental ill-health – had actually ‘recovered’.
Why might the medical model not be the best way of understanding mental ill-health?
The reality is that the medical model is limiting by definition. Traditionally, the model has not strived to account for the impact of socioeconomic factors on a person’s individual sense of security, hope and wellbeing, and although more recent interpretations of the model (such as psychiatrist George Engel’s 1977 biopsychosocial model) have been increasingly holistic, mental ill-health and distress are still viewed under the lens of disorder, and categorised through the use of diagnoses.
Understanding distress as a ‘disorder’ compresses a complex array of behaviours, mechanisms and responses into a singular diagnostic term, prompting the employment of a specific treatment ‘pathway’. Often, diagnoses fail to encompass the whole experience of a person living with mental-ill health and distress (and therefore fail to meaningfully explore why someone is experiencing distress), which can leave the individual feeling unseen and invalidated, and frequently leads to a situation where someone receives multiple different diagnoses over the course of their treatment in an attempt to find one that ‘fits’ – or several that ‘fit’ – most cohesively. Different courses of treatment – ‘pathways’ – are suggested for different diagnoses. These pathways can be extremely reductive (not factoring in the needs, circumstances and individualities of each person) and, when someone ends up with multiple diagnoses, they can counteract one another; for instance, a treatment pathway for someone given a diagnosis of Borderline Personality Disorder (BPD – a widely rejected diagnosis within the survivor movement) might suggest a ‘hands-off approach’, whereas a treatment pathway for Anorexia Nervosa (AN) might suggest a ‘hands-on approach’. What happens when a person is diagnosed with both AN and BPD?
Finding fault within an individual – rather than within the systems in society that operate to educate, support and prevent harm – means that when systems fail, they aren’t held to account. When these systems aren’t held to account, nothing improves, and individuals continue to suffer.
Why do some people think the medical model is harmful?
The medical model of psychiatry has long been associated with power imbalances and iatrogenic harm. Although person-centred care is becoming more commonplace in some areas of mental healthcare it is not yet a certainty, and the medical model has previously minimised (and continues to minimise) the voice of the person living with mental ill-health and distress. Treatment is done ‘to’ and not ‘with’, and decisions about care are ultimately made by professionals; they have the right to the final say. Those living with mental ill-health, trauma and distress have limited power to challenge decisions that are made about them, continually causing innate power imbalances and leading to inadvertent or advertent iatrogenic harm.
Many who find the medical model harmful feel that it serves to blame an individual for their mental ill-health (what’s wrong with you?) over acknowledging the systemic injustices and inequalities in our private lives and more widely in society that can lead to distress. This not only reinforces an individual’s shame and distress, but also creates a breeding ground for compassion fatigue in mental healthcare services, where staff and professionals are taught to understand the people they work as being ‘faulty’, and thus at fault; blame and responsibility is shifted solely onto the individual experiencing mental ill-health. When professionals and staff view us in this way, it can reduce their ability to empathise with us or even see us as human, which can lead to cruel and degrading treatment.
Medical model treatment approaches can be harmful, too. Some survivors and people with lived experience find therapies such as DBT and CBT to be degrading, humiliating and retraumatising, and there is evidence to suggest that in some cases the use of psychiatric medication – which is often prescribed without the informed consent of the receiver – may do more harm than good. Over the last few years, journalists have uncovered systemic harm and abuse at inpatient mental health hospitals across the UK, with common themes including the overuse of restraint, the overuse of sedative medications and a lack of compassion.
Why do some people find it helpful?
Although it could be easy to see the medical model in black and white terms as essentially ‘bad’, the reality is that not everyone experiences it in this way; many people find the medical model extremely helpful. In fact, people who have used mental health services working within the medical model sometimes describe these services as life-changing or even life-saving.
Some people who receive mental health diagnoses experience them very positively, finding them to be a helpful way of understanding what they are experiencing, allowing them to access appropriate support and giving a name to their distress. People who find comfort in diagnoses often speak about feeling validated by diagnoses, and being able to find community with others who have the same diagnoses as a result. For instance, in a blog post for Mental Health Today, mental health writer Mark Brown acknowledges that some people experience “diagnoses as useful in building their own meaning.”
Psychotropic medication is often widely valued by those who take it. People describe antidepressants or antipsychotics as necessary in enabling them to function on a day-to-day basis, and feel that finding the right medication has been revolutionary in terms of their wellbeing.
To be pro-medical model, or not to be pro-medical model?
The truth is that there is no definite, clear-cut way of understanding and responding to mental ill-health and distress, as much as it would make the world so much simpler if there was. The pursuit of one ‘correct’ model can often obscure the fight for informed choice in mental healthcare, as described by Akiko Hart for Asylum Magazine. Nobody has the right to decide what works for someone accessing care besides the person accessing that care; you can’t shame or bully someone into believing that their mental ill-health is caused by chemical imbalances in the same way that you can’t shame or bully someone into believing their mental ill-health is caused by trauma. We must listen to those who are experiencing distress, meet them at their level, and respond to individual needs and beliefs; we have to be balanced, and we have to be nuanced.
We can do better than this, and in order to move forward – towards a place where mental healthcare is appropriate and available for all – we need to work with one another, even when we fundamentally disagree. A middle ground exists, and there is so much power within it.
Background reading
https://pmc.ncbi.nlm.nih.gov/articles/PMC6312522/
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61789-9/fulltext
https://livingwithschizophreniauk.org/information-sheets/the-anti-psychiatry-movement/
https://onlinelibrary.wiley.com/doi/full/10.1002/symb.84
https://pubmed.ncbi.nlm.nih.gov/33289576/
https://pubmed.ncbi.nlm.nih.gov/23664634/
https://pmc.ncbi.nlm.nih.gov/articles/PMC6312522/
https://pmc.ncbi.nlm.nih.gov/articles/PMC6875848
https://www.bps.org.uk/member-networks/division-clinical-psychology/power-threat-meaning-framework
https://www.3brainsintelligence.com/post/gabor-mate-the-myth-of-diagnosis-in-psychiatry-it-s-simply-a-circular-argument?srsltid=AfmBOorIUvkUuRtaurzXSEWRUZxjcujsg8TaT0sdOfNJLuRPykOXkn-l
https://www.madintheuk.com/2023/04/power-threat-meaning-framework-critique/
https://www.mentalhealthtoday.co.uk/blog/diagnosis/challenging-narratives-the-power-threat-meaning-framework
https://commonslibrary.parliament.uk/research-briefings/sn06988/
https://www.madinamerica.com/2022/08/trauma-survivors-speak-out-against-dialectical-behavioral-therapy-dbt/
https://asylummagazine.org/2022/09/chemical-imbalances-or-problems-in-living-you-dont-decide-by-h-spandler/
https://asylummagazine.org/2018/06/pursuing-choice-not-truth-debates-around-diagnosis-in-mental-health-by-akiko-hart/