Researchers Critique the Medical Model, Propose an Alternative

Researchers from Poland detail a thorough critique of current medical model approaches to mental health and propose a shift to humane care.

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In a new article, researchers lay out a cogent critique of current practices in mental health care and propose a paradigm shift based on existing, successful alternatives.

The authors were Radosław Stupak, and Bartłomiej Dobroczyński at Jagiellonian University, Poland, and the article was published in the International Journal of Environmental Research and Public Health.

Despite the overwhelming increase in psychiatric services, there has been no improvement in outcomes for people diagnosed with mental illness, according to Stupak and Dobroczyński. Rather, outcomes have only worsened since the dawn of the medication era. For instance, the number of people taking long-term prescriptions continues to rise, as do the suicide rate and the rate of disability due to “mental illness.”

The overwhelming focus on biology in mental health research, the authors write, “has failed to address the primary goal psychiatric research should serve—helping patients. The progress in neuroscience does not seem to translate into better treatments, and new drugs are no better than those discovered by accident in the middle of the 20th century and work on the same underlying principles.”

They note that the United Nations has recently focused on critiques of biomedical psychiatry, particularly in the work of UN Special Rapporteur Dainius Pūras.

For instance, Pūras wrote, in his report on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, that “mental health systems worldwide are dominated by a reductionist biomedical model that uses medicalization to justify coercion as a systemic practice and qualifies the diverse human responses to harmful underlying and social determinants (such as inequalities, discrimination, and violence) as ‘disorders’ that need treatment.”

That is, biomedical explanations of distress encourage people to see their emotions as random sputterings of imbalanced chemicals in the brain, rather than as the natural response to trauma and other social factors like poverty or racism, or even situations like stressful work or problems in romantic life—all of which have been shown to lead to distress far more than any hypothesized chemical has.

“One particularly worrying consequence of this,” Stupak and Dobroczyński write, “is the fact that some people with psychiatric diagnoses may even lose the ability to understand their mental states as something that is directly connected to the lives they live.”

If someone sees their distress as due to workplace harassment, for example, they may try to change jobs. But if they think that their “broken brain” is the problem, they may feel powerless to ever escape that distress—and focus on treating their “mental illness” with drugs rather than changing that problematic life situation.

Perhaps even more importantly, when society views distress as an individual biomedical problem, then issues like social inequality, structural racism, student loan debt, etc., can all be put on the back burner. More funding will go to individual medical care—usually drugs—and less funding will be used for fixing structural, societal problems. Thus, the cycle continues.

“Understanding psychiatric disorders as primarily consequences of various life circumstances and their meanings for individuals would require a radical reshaping of mental health care,” Stupak and Dobroczyński write.
Psychiatric Drugs

One important shift, according to the authors, is in the way we view psychiatric drugs. These drugs do not act in a specific, identifiable manner on known biological processes. Instead, psychiatric drugs have widespread effects across multiple systems in the brain and body. Researchers do not know which of these many effects—if any—can ease various forms of distress.

Instead, the authors suggest, psychiatric drugs should be viewed in much the same way as coffee or alcohol. These drugs have effects, but they are broad and work differently for different people. They also have damaging effects when used long-term. Finally, the best way to understand these drugs’ effects is through qualitative research—asking people what they find helpful about the drugs, why they use them—rather than through clinical trials.

This is because clinical trials force the effects of the drugs into narrow boxes—symptom reduction as defined by a particular measure, for instance. However, the actual effects of the drugs are widespread, and what a person finds helpful might not be captured by that measure. Moreover, the harms of the drugs are also difficult to capture via a simple checklist, especially when these harms may involve identity confusion or other deeply phenomenological states that are hard to objectively rate.

Therefore, Stupak and Dobroczyński suggest that the drugs be used only in the short-term: “Certainly, in some circumstances, pharmacologically induced sleep, for example, is better than no sleep at all, but that does not necessarily mean that prolonged use of hypnotics, sedatives or neuroleptics is indispensable or beneficial. Drugs could be then primarily used as short-term solutions helping to overcome specific temporary difficulties, in a somewhat similar way as one can drink a cup of coffee to fight fatigue or have an alcoholic drink to relax.”

Likewise, drugs like ketamine or psilocybin may enhance therapeutic interactions when used to induce hallucinogenic states. But instead, their effects are being reduced to biological mechanisms, the pharmaceutical industry is marketing them at low doses that don’t achieve those mind-altering states, and they’re being delivered without accompanying therapy. Taking a hallucinogenic, mystical experience and reducing it to a biological effect—removing the reason that people actually want to use the drug—may be why the results from ketamine trials, for example, have been so underwhelming.

The authors write:

“Generally, our thinking about using psychiatric drugs could follow the principles of harm reduction, as in the case of illicit drug use, not only in the cases of withdrawing but as a guiding principle. Drugs should be used voluntarily (as all other services—otherwise speaking of “service users” is merely a linguistic distraction; someone who is treated against their will is neither a ‘user’ nor a ‘consumer’) and rely on an actual informed consent.”
Diagnostic Labels

Their final critique involves the use of diagnostic labels. According to the authors, psychiatric diagnoses are vague, ambiguous, and subjective. Two people with the same diagnosis often have widely varying experiences and “symptoms.”

Moreover, diagnostic terminology and biological explanations actually increase stigma, including the desire for distance from the person with a diagnosis and perceiving the person with a diagnosis as being more dangerous and having less control. As a result, even mental health workers are less empathetic when they believe biomedical diagnostic labels. By contrast, explanations that are environmental—you feel distressed because of something that happened to you—and normalize distress as a natural reaction leads to less stigma and discrimination.

Stupak and Dobroczyński write, “Diagnoses could be considered to be the primary source of stigma, self-stigma, power imbalances within the psychiatric system and an excuse for forced treatment and violations of human rights that effectively produce second-class citizens.”

Instead of diagnoses, the authors suggest a more humanistic framework (such as the Power Threat Meaning Framework) could be used, but even just a simple focus on the person’s specific experiences, rather than trying to fit them into a diagnostic label, could be better.

“We should be asking questions such as: what has happened to you? How did it affect you? What sense did you make of it? What did you have to do to survive? instead of going over symptoms checklists to arrive at a diagnosis.”

They suggest that this approach may help empower people to view themselves as active participants in improving their lives—in stark contrast to the biomedical view, which inspires hopelessness and the fear that their “brains are broken” and they can never change.

Reshaping Mental Health Care

So how can mental health care be reshaped and improved? According to Stupak and Dobroczyński, the solution is already in front of us. It simply involves combining a number of approaches that have already been shown to be effective but which mainstream psychiatry has ignored:

  1. Open Dialogue
  2. Soteria houses
  3. Individual and group psychotherapy
  4. Checking for adverse reactions to psychiatric medications and services to help people discontinue the drugs
  5. Self-help and peer-run services for continuous support
  6. Services to support housing, everyday activities, and employment

They write that Open Dialogue approaches are the best solution if a person is in crisis or for the first instances of serious distress. According to the authors, Open Dialogue provides immediate help, has a social network perspective, and enables dialogue. This approach includes all members of the distressed person’s social system and tries to engender dialogue so that the system can find new ways of working together to meet everyone’s needs. Diagnostic labels are less important, and the identified problem is viewed as a dysfunction in the social system, not in an individual.

Open Dialogue approaches, particularly those in Finland, lead to powerful improvements in people with psychosis, including recovery outcomes, often with minimal use of psychiatric drugs. Unfortunately, there are few approaches like this in the US.

Soteria houses may provide the more intensive, residential-style care that some people need. Consistent with Open Dialogue, Soteria focuses on “being with” the person in distress, rather than a hierarchical “treating them.” It also emphasizes the interpersonal and systemic nature of distress rather than a “disease” model. But Soteria also provides housing and full-time help for people who are in severe distress.

For people who need less intensive care, individual and group psychotherapy can be provided. The authors particularly emphasize trauma-informed therapy, but the focus should be on allowing the person to choose the modality and intensity of therapy that works best for them.

Based on the research into common factors of therapy, they write, “It may seem that, in reality, the possibility to have a comfortable, caring, respectful conversation with another person is what is most important and helpful in a vast majority of cases.”

When it comes to psychiatric drugs, people need to be given fully informed consent about the risks and potential benefits, and they should not be administered against a person’s will. In addition, for people who choose to take psychiatric drugs, constant screening for adverse effects needs to occur. Finally, the medical system should make helping people withdraw from the drugs a priority.

Peer-run services, including self-help groups and clubhouse-type centers, could help people work toward recovery. According to Stupak and Dobroczyński, these should be independent and as non-hierarchical as possible, rather than co-opted into the medical “treatment” model. They can provide a way for people to help each other make meaning of their distress and work toward personal recovery.

Finally, a truly humane mental health care system would help people live independently by providing housing, supporting employment, and providing income support.

Stupak and Dobroczyński write that all of these components already exist—they are simply not being utilized by the current system. Therefore, reshaping mental health care by structuring it according to these six solutions would be more effective, better promote recovery and social inclusion, and be more consistent with a human rights approach, such as that described by Pūras and the UN.

The authors emphasize that involuntary treatment is at best a paternalistic approach to people with a disability, and at worst—as the UN has stated—a violation of human rights. They argue that if people no longer have to fear coercion and punitive action if they interact with the healthcare system, then forced or involuntary “treatment” will no longer be necessary.

They write:

“We feel that in a system in which people do not have to be afraid that they will be abused, involuntary treatment will not be necessary. The situations that lead to the use of force often stem from an inappropriate attitude of staff and serve discipline purposes only, and the use of restraints sometimes leads to death. In general, we think that any form of involuntary treatment in mental health could only be justified in very specific circumstances, such as treatment of people convicted for serious crimes—for the duration of the sentence—and should be avoided at all cost or even made impossible.”

 

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Stupak, R., & Dobroczyński, B. (2021). From mental health industry to humane care: Suggestions for an alternative systemic approach to distress. Int. J. Environ. Res. Public Health, 18(12), 6625. https://doi.org/10.3390/ijerph18126625 (Link)

16 COMMENTS

  1. Thanks Peter.

    “Alternative” options will always include psychiatry and will be based on the paradigm of psychiatry. Psychiatry is really our governments, it is political. Absolutely NOTHING
    medical nor caring about it.

    Perhaps a few actually care and definitely care about their own families, but being a mensch within your privileged community does not make you a nice person to the needy.

    • Conventional mental healthcare, i.e. synthetic drugs and talk therapy, is crooked as hell. Psychiatrists aren’t taught how to even look for the proven physical causes of psychiatric disorders. Their synthetic drugs are designed to be just an attempt to suppress patients’ symptoms. They’re just chemical straightjackets. Drugging people brings in huge profits for the American Psychiatric Association and their business buddies, the drug companies, but cures no one. These 2 groups have been fighting restorative mental health care for about 80 years. King County (Seattle area) proved that the drug approach has a recovery rate of .0005%. In 2003, only 5 patients out of 9,304 recovered by being given these drugs. The problem isn’t that mental illnesses are incurable – the problem is that that drugs aren’t designed to cure anyone. –Linda from Facebook “A Dose of Sanity,” also 3 videos on Youtube at “Linda Van Zandt’s Mental Health Recovery Channel,” and author of “The Secrets to Real Mental Health.”

  2. I agree with most of this, largely good recommendations for change. However, an issue – that I eventually learned is another systemic problem with the “mental health” industries – should be mentioned. “The dirty little secret of the two original educated professions,” is how an ethical pastor described the psychological and psychiatric crimes, with which I’d dealt.

    This “dirty little secret” is basically that the psychological and psychiatric industries have “partnered” with many (or all?) of the mainstream religions. And they function as the child abuse and rape covering up arm of the mainstream religions.

    And this is the vast majority of today’s “mental health” industry’s business, given that “the prevalence of childhood trauma exposure within borderline personality disorder patients has been evidenced to be as high as 92% (Yen et al., 2002). Within individuals diagnosed with psychotic or affective disorders, it reaches 82% (Larsson et al., 2012).” But, absolutely, this has been a problem with the psychological industry, at least since Freud, as well.

    https://www.madinamerica.com/2016/04/heal-for-life/
    https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo

    Another aspect of this “dirty little secret” is likely also that psychology and psychiatry are, obviously, “partnered” with the mainstream medical doctors. And they function to cover up malpractice for the mainstream doctors.

    These “partnerships” with other professions – which result in systemic “mental health” industry crimes and cover ups – should be brought out into the open. How do we end these “partnerships,” and this “dirty little secret of the two original educated professions?”

    “Stupak and Dobroczyński write that all of these components already exist—they are simply not being utilized by the current system.” I think the problem is they are not being funded by the current system.

    Funding needs to be taken away from psychiatrists who have been doing nothing but drugging people, via “15 minute med checks.” And that funding needs to be redirected to psychiatrists who work to withdrawal people from the psych drugs. I do agree funding is needed for Open Dialogue, Soteria Houses, Hearing Voices groups, and other peer run programs.

    As a legitimately concerned mother, who was attacked and drugged, to cover up the abuse of my child, for a pastor. I personally believe funding – to someone other than mainstream psychologists, psychiatrists, or any other DSM “bible” believers – is needed for child abuse survivors specifically. Since the psychological and psychiatric professions, et al have been betraying child abuse and rape survivors for many decades, if not centuries, and this is all by DSM design.

    https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

    I also agree “Services [and funding] to support housing, everyday activities, and employment” are needed. And I believe forced treatment – with any drug – should be made illegal.

    As to “Checking for adverse reactions to psychiatric medications.” Until the psychiatric industries can admit to the fact that the ADHD drugs and antidepressants can create the “bipolar” symptoms.

    https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/

    And until they can admit to the fact that the antipsychotics can create both the positive and negative symptoms of “schizophrenia,” via anticholinergic toxidrome and neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Toxidrome
    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    “Checking for adverse reactions to psychiatric medications” will be a job, that is beyond the scope of most psychiatrists’ ability.

  3. Thank You Peter,

    “..and propose a paradigm shift based on existing, successful alternatives…”

    The successful alternatives are definitely available:- Counselling Psychotherapy, Community Support, Meditation, Buddhism, Mindfulness, Peer Group Support, Yoga, Hearing Voices Network, Twelve Step, Emotions Anonymous, GROW.

    Psychiatric Drugs rarely help people to improve (as far as I can see). I would hold Psychiatric Drugs responsible for the years I’ve lost getting myself back together following the damage of drug exposure.

    The vast majority of the so called “schizophrenics” in this contingent have been misdiagnosed BUT are trapped in Long Term Drug Disability:-

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2418996/

    • The thing about this is, Buddhism and other spiritual approaches aren’t “treatment.” I don’t have a knee-jerk negative response to the idea of “alternatives,” but if they are “alternatives,” they should be alternatives to viewing emotional distress as “mental illness” and alternatives to pretending to provide “treatment” in the medical sense for problems that are not medical in nature.

      • I think some Buddhist practices are closer to qualifying as “treatments” than something like “meditation” “mindfulness” or “yoga.” Especially when they are done under the supervision of a “master.”

        But of course, my objection to articles like these is that they stop at the level of environment (which could be called the source of “triggers”) and fail to go beyond that to discover what is being triggered by all those triggers, and what to do about that.

  4. Sadly, some of the “alternatives” mentioned by Fiachra can be just as dangerous and damaging to the brain as do the psych drugs and therapy. Some even cause similar symptoms that the psych drugs and therapy does. The Twelve Step program began by Bill W. for alcoholics may have some helpfulness for some individuals. Steve McCrea is right that Buddhism, etc. is not “treatment” however, the questions might really be, do we really need “treatment” “Treatment” usually assumes illness or the possibility of infection; such as I cut my finger with a knife while cutting up vegetables, then I might apply “treatment” with a “first aid ointment.” Perhaps, the reason, none of this really works is that there is no illness involved. That began to dawn on me as they kept trying drug after drug and then claiming that the didn’t work. Now, obviously, they did not work because they had no need to work. I was not sick at all. It is not that we are never sad, angry, unhappy, etc. We would be human and probably “sick” if we weren’t. Perhaps, this really might be better handled by our specific, unique, individual religious beliefs and orientation, rather than the false medicine of psychiatry, etc. Thank you.

  5. How many zillion times must I point out that if one uses the term “mental health” they are using the “medical model,” which is simply the ascribing of terms such as “health” and “illness” to the mind, which is not subject to physical characteristics?

    • Mental illness/mental health: 0+0=0; 0X0=0. If there is nothing, then one has nothing. Why do you think they keep changing or adding drugs to people’s prescriptions? Well, the answer is there is no such thing as a mental illness and mental health is therefore the biggest lie ever foisted upon a civilization? If our civilization goes the way of Ancient Egypt, Rome, the Mayans, etc. it is because of this evil lie. I am sorry that I ever fell into that trap and I am sorry for all those who have. And, the most evil part of this lie is that the drugs and the therapy is damaging and dangerous and can disable or kill you or worse. All I can say is say no now—even to the smallest bit of therapy. Do not forget that therapy can be as dangerous as the drugs and with the drugs it is terror and torment. And, that is even before the withdrawal. Still, there is some good news. If you make it through the withdrawal, life may a little different than before the drugs. For one thing, you are thankful to be alive. Your mind is clearer and you are drug and therapy free! They say a bad fishing day is better than a good work day. I say a bad day without drugs and therapy is one billion times better than a day on psych drugs and programmed into their evil therapy. Each day the sun shines and I am not on those evil psych drugs or engaging in any form of therapy, I can only smile and thank God for my deliverance. Thank you.

    • A requiem was written for large scale modeling some time ago. See https://journals.sagepub.com/doi/pdf/10.1068/b4103c2 . This continued rant about medical models died failed years ago and still creeps back into the discourse of the novice. Models just don’t cut the mustard nor give license for what is happening in the practice of living a LIFE. There are definitely “alternatives” by which a richer dialogue can emerge from the heads, not just youth but from old heads, too!

  6. I would welcome more articles on this subject!

    I am perturbed, though, by the authors’ withdrawal into the safe space of present time environment when they should be pushing harder on the work begun by the psychoanalysis people.

    There is something right about both of these “paradigms.” Some people who experience what some call “mental illness” do feel, subjectively, that there is something wrong with them. When you go to the extreme of the psychopath, this becomes more obvious (though the psychopath is likely to consider himself the sanest person in the world). Also, the environment does expose us to many stresses that can overwhelm us to various degrees that have as much to do with physiological limitations as they have to do with “mental health.”

    The possibility that both Freud and Jung were onto something should not be overlooked. Did they fail because they were wrong, or because they didn’t look far enough or hard enough into the human mind? We know now how far the human mind can extend. Someone should be talking about it, and someone in academia (besides Jim Tucker’s group) should be investigating it. There IS more to learn about this, you know!

    • I have seen that sometimes a weather forecast model gets it right; but, it’s still very short-term and very limited. They are improving somewhat on hurricane models, but, they can usually on close on the track, not the wind speed, etc. But, what is to be noted about any of these models as that in the end, Mother Nature has her say and overrides all the meteorologists. Actually, there is some similarity with any sort of alleged medical model, albeit there are extremely far less accurate. Mother Nature always overrides these alleged experts “models” and Father Time complete evaporates or eviscerates them. What does it all mean? It means even allegedly real scientists and doctors and the illegitimate psychiatrists who pretend to be God will be reprimanded by a higher power and we humans who put our undying trust in such nonsense should do the same. Please remember astrology is only a model, too. Thank you.

    • Oh – medical model! It’s in the title of the article! Sorry.

      I have different experiences with models. I used to build them for fun when I was a kid.

      Strictly speaking, a “model” is a mathematical approximation of a physical system used for predicting the behavior of the system.

      I don’t think psychiatrists are very good mathematicians, though. And of course, the guys in charge are not to be trusted no matter what “model” you give them to work with. They can (and have) screwed up a Spirit-Mind-Body model! And that’s one of the best ones we have.

      I think models have their place. But they are useless in the hands of most psychiatrists.

      • They don’t really use a scientific “model.” They use a marketing/business model, based primarily on what will convince the “customer” that their “product” is something they should buy. No science is involved, except the “science” of how to convince people to change their minds and do what you want them to do.

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