There is a popular concept on our cultural horizon called the medical model of mental illness; otherwise known as a malady called mental illness that derives from the medical model. Just what is the medical model and is there a separate element under the medical model called the medical model of mental illness? Is there mental illness?
Almost no culture in history has lacked its visual and auditory hallucinators: depending on the culture and sometimes depending the time of the year, people having visual and auditory hallucinations were said to be imbued with the spirit of God or the spirit of the devil. In the seventeenth century, if they were diagnosed with the former, sufferers of hallucinations could be assured of all kinds of pleasant “assisted living.” If the latter, the sufferers received all forms of “physick” from local doctors: blood-letting, leeches, purgatives, and hours of rocking and rolling in contraptions we know today from carnival rides. And the seventeenth-century version of depression was called melancholy.
Four hundred years ago, the medical model was still evolving; today, even decidedly non-medical personnel enjoy free use of the term. Define it, and we at once see it is at variance with what we call mental illness. The medical model, however else it is defined, is that set of procedures in which all doctors (including psychiatrists) are trained and which they must use for all of their professional careers: patient complaint (“Doctor, it hurts when I do this.”); history (“How long has it hurt when you do that?); examination (“Does it hurt here too?”); ancillary tests and procedures (blood and urine specimens, X-rays, MRI, EKG, EEG, biopsy); diagnosis (“It hurts when you do this because.”); recommended treatment (“This will stop it hurting when you do that.”); and prognosis, with and without treatment.
Name a physical ailment you or someone you know has had (brain tumor, heart disease, diabetes, constipation, broken toe), and you can fit it easily into the above scheme. The symptoms for these are often connected with the ailment: frequent headaches, chest pain, distended abdomen, and pain when walking. Diabetes is a bit trickier to diagnose, because it is often not readily apparent by symptoms (dizziness, extreme thirst, lack of energy) or physical exam: ancillary tests (blood sugar, glucose tolerance) are needed to confirm a diagnosis of diabetes.
Now plug in bipolar disorder or schizophrenia into the scheme. What is complaint? Is it auditory hallucinations or complete lethargy? Who is the complainant? Sometimes it’s the patient, sometimes it’s the patient’s family, and sometimes it’s the police. Already we are plunged into a world far different from standard medicine.
Many people will tell us that mental illness and the two horns attached to it (bipolar disorder and schizophrenia) are the result of a chemical imbalance in the brain. Where in the medical model is there a step for examining chemical balance or imbalance in the brain? Best guess would be the “ancillary tests” phase. But such chemical imbalance tests are rare, expensive, and seldom done in a G.P. treatment room and never on initial presentation of the patient. Gradually, we seem to be moving outside the purview of the medical model; yet, we insist that mental illness is medical illness and by treatable by medical specialists called psychiatrists. And only after treatment has begun may we surmise that we have a chemical imbalance: this directly contravenes the medical model.
Strangely and quite unreasonably, we seem to agree that mental illness is a medical malady only after we are receiving treatment: we go from being emotionally miserable and agonized to being relieved. Whither history, examination, ancillary tests? An interesting survey would be to discover at what point the patient learns of this diagnosis of mental illness (or rather any of the dozens of syndromes scattered among bipolar disorder and schizophrenia). We agree we must have had a chemical imbalance only after treatment begins and a medication we are told “targets” specific neurotransmitters ameliorates symptoms. It seems fair to question the validity of a mental illness as a medical malady when diagnosis and treatment stray out of the bounds of the standard medical model.
We like to insist that mental illness is an illness just like diabetes. This statement usually refers to the treatment aspect only: we are treated for mental illnesses and diabetes more or less forever. We’ve never heard anyone, doctor or patient, say that mental illness is just like diabetes because the history, examination, and ancillary tests phases or their results are so similar.
Oh, and by the way: even if we should discount all the preceding and insist that mental illnesses are medical illnesses because they are treated by doctors and because most so diagnosed are treated forever, remember that it is conduct that is being treated. Not the incessant rash under your arms and not the chemical imbalance that a doctor will tell us later is the cause of our misery: patients are diagnosed mentally ill and treated accordingly because their conduct is deemed socially objectionable. It is not socially objectionable to suffer headaches, a chronic cough, and chest pains. It is not socially objectionable to wince in pain when you have broken a bone. It is socially objectionable or stigmatizing to hear voices, to see Satan in the face of your boss or a parent, or feel suicidal.
I do not doubt that many people believe that they have a medical malady called mental illness because a doctor (psychiatrist) has prescribed for them medications that relieve them of their symptoms: whether auditory hallucinations or chronic depression. But I do not doubt that the diagnosis of the various mental illnesses differs drastically from the diagnosis of run-of-the-mill diseases and ailments, as do their treatments. We treat diabetes with insulin, we treat heart ailments with surgery and medication, and broken bones are set and placed in casts. Mental illnesses are treated with medications to alter the chemistry in the brain, to relieve unpleasant feelings and ameliorate unpleasant conduct that we believe emanate from the mind: a metaphor we have created to explain activity in the brain that helps us to be human. And when we start dealing in metaphors, we stray far from a science we call medicine and its exacting set of procedures called the medical model.
