Medical Model vs Social Model of Disability
The medical model of disability problematizes a person’s impairment as “disability” in the realm of normal versus abnormal modes of functioning and stresses medical interventions to restore or enable “normal” functioning. The medical model places agency in the hands of medical professionals under a “best interests” paradigm where decisions are made through medical lenses to determine the so-called “best outcome” for the patient, without much regard for the patient’s will, preferences or even opposition to treatment.
While moral treatment was prevalent in the Bedlam model of treating psychosocial conditions in the nineteenth century, the medical model was accelerated with the growth of the eugenics movement at the start of the twentieth century, further enabled by the introduction of neuroleptics and other psychoactive medications theorised to “correct” the chemical imbalances in the brains of mentally disordered patients. Inhumane treatments such as insulin therapy, electro-convulsive therapy (which is still used today) and psychosurgery (such as lobotomies) are emblematic of a medical profession that neither cared for patients nor respected their personhood or rights as neurodiverse individuals.
The legacy of medical model thinking can still be seen in the treatment of mental disorders via a heavy reliance on psychopharmaceutricals (such as antipsychotic medication) that have a large side-effect profile and are based on unproven theories about the biological basis of psychosocial conditions.
Contemporary disability rights rose out of a history of atrocities, abuses and demonization of those with disabilities. The era of institutionalization, stretching from the early 1400s to as recent as the late 1960s, was marred by a systemic failure to address the needs of the disabled, and, in most cases, pushed those with disabilities to the very fringes of society; housed in conditions akin to torture—cruel, inhumane and degrading punishment. The approach for much of disability history has been punitive and discriminatory against disabled peoples, excluding them from societal participation and status among equals.
Despite improvements in treatment approaches, disabled peoples are still treated as beneficiaries instead of active participants, subject to colonisation and arbitrary medicalisation by a vast army of professionals. Over the past three decades, disabled people and their allies have been advocating for greater rights in the backdrop of historical oppression and marginalization, as a response to the over-medicalized and individualist accounts of disability. Disability was conceived historically as religious (divine punishment), moral (karmic), and biological failings on the part of the disabled individual, leading to over five centuries of social oppression, cultural stigmatisation, and imbedded environmental barriers.
The social model of disability provides a basis for understanding disabling barriers as the main challenge to disabled peoples, while acknowledging that impairment does indeed take part in affecting quality of life. Notably, disabled peoples are conceived as an oppressed group, where the problem is not located in the disabled person (as per the medical / individual model) but rather in oppressive social forces. Carlos Thomas has tried to develop the social model to account for impairment effects:
…once the term “disability” is ring-fenced to mean forms of oppressive social reactions visited upon people with impairments, there is no need to deny that impairment and illness cause some restrictions of activity, or that in many situations both disability and impairment effects interact to place limits on activity. (Source)
While medical model thinking depersonalises individuals and focus on a medical solution to “disability,” the social model of disability, which arose out of the disability rights advocacy movement, acknowledges a person’s impairments as a limitation to their ability, while characterizing “disability” as the result of the interaction between persons with impairments and environments that produce physical, attitudinal, communication and social barriers.
The social model therefore reconceptualises disability as limitations resulting from the environment impacting a person’s livelihood and quality of life, which can be altered to accommodate persons with impairments to enable them to participate in society on an equal basis with others. Agency is placed firmly in an impaired person’s hands, negating the paternalistic and restrictive elements of the medical profession.
In practice, the social model has yet to materialise as the dominant model, as public mental health authorities continue to oppress persons with psychosocial conditions through a combination of punitive and discriminatory laws that are constructed with a “best interests” paradigm in mind and a medical model that pathologises difference and dissent. Notably, the United Nations Convention on the Rights of Persons with Disabilities (CRPD) has officially adopted the social model of disability and enshrined rights for persons with disabilities on par with all other persons in the community.
Corker conceives of dis/ability as being in relation to other objects of a system, one which modernist materialism has constructed as “impairment” and “non-impairment.” Research literature shows that the impact of impairment as a physical, sensory or cognitive function, and the impact of social barriers, are difficult to distinguish in theory; in practice, it is the interaction of individual bodies and social environments that produce disability.
The initial conceptualization of community-based rehabilitation (CBR) rose out of an acknowledgement that conventional delivery of disability-related services was inadequate for many in the developing world and that a strategy for service provision would be required to achieve the objectives of improving “the quality of life of the majority of the world’s disabled people,” namely, “those who live in absolute and relative poverty in urban and, especially, rural areas in developing countries.”
Medical model thinking is enshrined in the liberal term “people with disabilities,” and in approaches that seek to count the numbers of people with impairment, or to reduce the complex problems of disabled people to issues of medical prevention, cure or rehabilitation. Social model thinking mandates barrier removal, anti-discrimination legislation, independent living and other responses to social oppression. From a disability rights perspective, social model approaches are progressive, medical model approaches are reactionary. (Source)
The contestation between dis/ability in practice and in policy remains firmly in the scope of Western theorists and Eurocentric norms. If we begin with the premise that all people are equal and that human rights are indivisible, inalienable and interrelated, then the deprivation of liberty, of choice, and of conscience is thus an inherently immoral, illegal, and illegitimate use of force by state parties.
It is this premise that must inform the disability debate as even highly developed countries with well-established public discourses on the role of disabled peoples in society pursue strategies that seek to legitimate involuntary treatment of disabled peoples in institutions. UN member states, including developing countries, have an opportunity to move the disability debate forward and create frameworks for equity on the basis of a post-social, post-medical, and post-institutional model of disability. This rests on a much-needed acceptance that the brutal colonization of disability by an over-medicalized profession has led to centuries of violent oppression.
And it is from this history of oppression that the issue at stake becomes elucidated; the very liberty of an entire generation of disabled peoples. As Perlin eloquently summates:
At this point, legally, there can be little question that the ball game is over. The Supreme Court’s decisions in Washington v. Harper, Riggins v. Nevada, and, most recently, Sell v. United States, make it clear that: a qualified right to refuse medication is located in the Fourteenth Amendment’s due process clause; the pervasiveness of side effects is a key factor in the determination of the scope of the right; the state bears a considerable burden in medicating a patient over objection, and the least restrictive alternative mode of analysis must be applied to right-to-refuse cases.
Medical institutionalism has historically marginalized and eroded the rights of disabled peoples, not only in low to mid income countries as research has indicated, but also, on a well-documented basis, in modern, industrialised and democratic states. Arbitrary denial of legal capacity, entrenchment of cognitive approaches, rampant forensification, mass detention, psychiatric medicalization and the involuntary treatment of persons with disabilities in facilities without independent oversight have led to widespread abuse, cruel, inhumane and degrading treatment amounting, in some cases, to torture.
The active denial of legal capacity, and arbitrary restrictions on liberty, security and integrity of disabled peoples are in direct and explicit contravention to international law and convention, and have pervasively undermined the basic dignity, rights and equality to those whose interests it claims to serve. Legislation such as the Mental Health Act (England and Wales), Guardianship Act 1987 (New South Wales, Australia), and the Mental Health (Compulsory Assessment and Treatment) Act 1992 (New Zealand), to name a few, overtly and inexcusably violate fundamental tenants of international human rights law.
In contrast, member states in the EU have demonstrated progress towards harmonizing policy with international convention. As published in the New England Journal of Medicine, Applebaum concedes that there are “no formal practice guidelines from professional societies for the assessment of a patient’s capacity to consent to treatment.” The Australian discourse around non-consensual treatment remains resoundingly statist and casually dismissive of international human rights obligations, despite being a signatory and claiming ratification under the UN CRPD.
As Drew et al. and their many contemporaries highlight, the rampant abuse of disabled peoples, including those with psychosocial and related disabilities, often by those in the medical profession who claim to act in their best interests, has necessitated a resounding and uncharacteristically unified response in the form of a renewed advocacy base in the non-governmental sector.
While the medical sector has scrambled to reclaim some form of legitimacy, the decades old argument between the right to refuse and right to access camps has been, with some great difficultly and finality, resolved by process of international agreement, domestic ratification and proactive representation. The historical threshold for medicating disabled peoples against their will, at times with untested, untried and inhumane procedures, to an extent far beyond that of those for biophysical conditions, no longer passes for ethical medicine.
The closest-to-viable mode to a neoliberal solution would be the consumerist / empowering model. The professional is viewed as a service provider to the client and their family, and the client decides what services are or are not appropriate. Unlike the medical / expert model, the client is not a passive recipient.
The Empowerment model avoids emphasis on or direction toward cure. It focuses not on their label/s but their personhood regardless of the label/s that are experienced as integrated into, containing or constraining that personhood.
The imposition of solutions made by professionals can be less than benevolent where the client has no choice and is unable to exercise basic human rights; this is evidenced by the motivation behind the biomedical model, which seeks to establish a “perfect world [that] is a world without disability.” Notably, “the biomedical model results in categorical devaluation” of persons with disabilities by perceiving disabled peoples as their impairment. Furthermore, medical models view disabled peoples as requiring “fixing” with the political goal of entrenching the medical model as the sole legitimate basis for policy making, much like the Eugenics projects of the early twentieth century.
In the Economic Model of Disability, responsibility attribution is shifted to employers (to not discriminate), similarly, the Consumerist model ensures that decision-making responsibility remains with the client and their family and not subject to “professional tyranny.” From a market-oriented perspective, the purchase of services is based on a contractually equitable relationship, where the client can sever the relationship with compensation if the services are not to the client’s preference. The professional as a service provider role should understand their role as a “consultant, coach and resource provider” ensuring that the decision-making is carried out by the client and their family. This is visualised below:
|Situation||Charity Model||Medical Model||Social Model||Rights-based Model|
|Young women using a wheelchair||“What a pity, this beautiful woman is bound to a wheelchair, she’ll never be able to marry, have children and care for her family.”||“Oh, this poor woman, she should go to a doctor and discuss with him if there is a therapy which could enable her to walk again, like everybody else.”||“The community really should build ramps in front of public buildings, so that persons like her can participate in social life.”||“When she gets a job, her employer will have to build accessible rooms. This is her right!”|
|Man with an intellectual disability||“Look at this poor confused man; he seems to be mentally retarded, it would be better for him to live in a fostered home, where somebody will take care of him.”||“Perhaps there is some medicine or treatment which could improve his perception. He should try a psychiatrist.”||“It’s a good solution that he lives with his brother, so he is surrounded by non-disabled people.”||“Where does he want to live? Let’s go and ask him!”|
|Parents with a hearing-impaired daughter||“It must be very sad having a child and knowing that she will never be able to live on her own.”||“I’m sure in a few years there’ll be a hearing aid available which will make this child able to hear better.”||“We should all learn sign language, so that we can communicate with this child and all other hearing-impaired people.”||“When this child grows up, she’ll study at university, if she wants to.”|
Community Treatment Orders (CTOs) in Victoria, Australia
With the introduction of Community Treatment Orders (CTOs) in 1986 in Victoria, medical treatment for psychosocial conditions have been securitised under the Mental Health Act. Police, paramedics and medical personnel are given extensive powers to detain, assess and treat persons with psychosocial conditions or appearing to have psychosocial conditions, in a manner that violates common law presumptions of innocence and negates limits on detention that are well-established within the criminal system of justice.
While CTOs are civil instruments of law, they authorise deprivations of liberty normally associated with criminal convictions or findings of guilt in criminal courts. Detention in hospital facilities via a treatment or assessment order can feature elements of chemical, emotional or physical restraint and even seclusion, which parallels the approach used by penal institutions to impose solitary confinement as a security measure against physically violent inmates.
Arguably, there are more stringent standards of evidence for criminal matters (“beyond reasonable doubt”) in the context of any deprivation of liberty compared to the civil standard of “balance of probabilities.”
CTOs were designed in response for the push to advance de-institutionalisation and it was thought that persons with psychosocial conditions could be managed in the community with greater respect for their autonomy, although this has not been the case, given the implementation of compulsory treatment regimes. CBR was thought to increase patient autonomy, while offering a pathway of symptom and pathology management through mandatory treatment regimens to prevent a “revolving-door” phenomena often claimed by psychiatrists and others in the medical sector who are in favour of compulsory treatment.
The oft-heard position from the medical sector is that CTOs allow a degree of freedom that would otherwise be restricted by in-patient detention of persons with serious psychosocial conditions. However, this has little support from actual evidence, as there is no empirical basis to assume that those who are treated on CTOs would otherwise be treated in hospital settings. Randomised studies conducted on the efficacy of CTOs demonstrate that they have little effect on clinical outcomes.
Nonetheless, the argument is still used by compulsory treatment proponents to create an illusion of autonomy while resituating agency into the hands of medical (often psychiatric) staff.
The Mental Health Act (2014) is the newest iteration of mental health laws designed to enforce compulsory treatments on persons with mental illness. Mental illness is specifically defined in the Act as a “significant disturbance of thought, mood, perception or memory” and excludes intellectual disabilities.
Despite the insistence of Parliament that the Act serves to protect the rights of consumers, the introduction of advance directives, second psychiatric opinions, nominated persons and a statement of rights have not, in any meaningful way, addressed the issue of substituted decision making by authorised psychiatrists against the wills and preferences of a person found to have a mental illness. The authorised psychiatrist holds all the agency in the service-provider-consumer relationship and engages in an almost adversarial approach that pathologises opposition to compulsory treatment itself as a symptom of mental illness (or lack of insight).
While the Act operates in a supposedly civil arena, the overriding power of the authorised psychiatrist to impose compulsory treatment in the community with the threat of hospitalisation (i.e. detention) is enforced in a way akin to the role of parole officers in the criminal justice system. What crime has a mentally ill person committed (assuming they are not a forensic patient)? Is the opposition to or non-compliance to medical treatment a crime? Not in the strictest sense, but the punitive penalties imposed by the Act does result in quasi-criminal outcomes for mentally ill persons.
Medical treatment in the context of compulsory treatment not only encompasses forced medication (via psychopharmaceuticals), but is often accompanied by invasive testing (blood screening for medication plasma levels) or injection regimes (of antipsychotic depot medication), an invasion of privacy (by members of an assertive care team supervising treatment) and mandatory meetings with public mental health authorities. The Act also empowers the police to enter the homes of persons under compulsory treatment and transport them to a mental health facility.
Convention on the Rights of Persons with Disabilities (CRPD)
The Convention on the Rights of Persons with Disabilities (CRPD) is the only disability-focused international human rights convention. General comments and guidance from the committee specifically refer to the incompatibility of substitute-decision making regimes, involuntary commitment or detention in mental health facilities and compulsory treatment in the community.
The CRPD reconceptualises disability using the social model of disability and further builds on this model with the human rights-based model of disability, which situates persons with disabilities as autonomous individuals with rights and freedoms and not as welfare cases or problems that need to be “fixed” by medical authorities. Accessibility is framed as a right or an option that persons with disabilities can elect to engage, with the obligation for providing these services through progressive realization resting in state bodies.
Following on the model established by the International Covenant on Civil and Political Rights (ICCPR), negative rights are immediately applicable and enforceable and state parties have an immediate obligation to grant these rights. To this end, the Committee on the Rights of Persons with Disabilities has recommended that Australia immediately withdraw its interpretative declaration and repeal all legislation that permits involuntary commitment, substitute decision making (i.e. Guardianship Orders) and compulsory treatment in the community.
The need for strong social protection systems to be inclusive of those who are often forgotten in policymaking, including those with psychosocial and intellectual disabilities, is undoubtedly relevant for provision of support services. However, the tension between right to refuse and right to access proponents continues to not only medical institutions, where disabled peoples are often subject to discrimination, abuse, stigmatisation, and an arbitrary restriction of rights.
It is worth noting that the “traditional disability-welfare approaches under the medical model de facto promoted inequality among the diversity of persons with disabilities by adopting legislation that benefited certain groups of persons with disabilities while excluding others.” This includes the deprivation of legal capacity faced by disabled peoples and their struggle to accessing their right to social protection.
Ultimately, this responsibility lies with state parties, who, under international obligations to comply with human rights laws and convention, must ensure that policy implementation does not violate disability rights, where legal capacity, consent to treatment, and inclusivity are paramount to the individual dignity, autonomy and the principles of non-discrimination.
While the cruelty of such practices as seclusion, restraint (chemical, physical, emotional), sedation, the arbitrary denial of legal capacity, violation of physical and mental integrity, and other forms of non-consensual medicalization continue to pervade in clear defiance of the international community’s commitment to uphold human rights principles for disabled peoples, the need for greater oversight, advocacy, representation, and compliance monitoring of State Parties is greater now than ever.
This is reflected in the Report of the Special Rapporteur on the rights of persons with disabilities. With the signing and ratification of the CRPD and inclusion of disabled peoples in decision-making processes at the international level, there may be cause for celebration as the rights-based approach replaces the medical model, especially on issues pertaining to the right to security of the individual, autonomy and self-determination.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.