The Limits of the Medical Model in Child Psychiatry
By Nick Child
This paper is a pruned-by-half version of the one published in Clinical Child Psychology and Psychiatry, 5, pp11-21. It is the opening article of CCPP's millennium! The publishers (then) only allowed half the paper to be put up on a web-site. Please read the full version in the journal - it's worth it! Now that it is allowed, I will try to get a full version too.
There's a story behind this paper. In 1984 I began doing a twice a year teaching slot for trainee psychiatrists attached to child psychiatry placements in the West of Scotland. I drew a short straw and got Conduct Disorders to do. I turned this into more of a philosophical exercise, examining a typical chapter of a child psychiatry text-book in the light of other conceptual frameworks and my Basic Model of Human Functioning. Since the trainees seldom did the preparatory reading, I would end up talking through my ideas. For years I kept intending to write it down so I could get them to read that and use the teaching time for discussion instead. Then, the novel and quote I open with, inspired me with a perfect start. Having written down what was by now a well tested argument, I thought it was worth publishing properly. I am very proud of the result and what it represents of my insider- revolutionary work and thinking. The world has not come back at me in an explosion of welcome or criticism, but I believe there are many who see it's worth!
ABSTRACT Good science and clinical practice are based on sound logical thinking. The bioscientific 'medical model' is learned by doctors in their original training, then brought and adapted to the field of mental health by psychiatrists and child psychiatrists. This article uses Conduct Disorder as a test and clarification of the rationale of the otherwise valuable medical model and the limits of its applicability in child psychiatry.
INTRODUCTION In Don Delillo's novel 'White Noise' (1984, Picador), teenager Heinrich answers his father's question about visiting his separated mother in the summer:
'Who knows what I want to do? How can you be sure about something like that? Isn't it all a question of brain chemistry, signals going back and forth, electrical energy in the cortex? How do I know I really want to go and it isn't just some neurones firing or something? You don't know what's you as a person and what's some neuron that just happens to fire or just happens to misfire.'
The medical model (1) is superbly logical in the right place. But Heinrich's speech strikes me as a precise description of a reductionist medical model applied ubiquitously in the wrong place. Just as Heinrich used the medical model as a strategic or psychological defence within a particular interpersonal human predicament, we can be similarly interested in the wrongly applied medical bioscientific framework.
My serviceable recasting of child psychiatry overlaps with his, with family functioning frameworks (Group for the Advancement of Psychiatry, 1996), and moderately also with 'anti-psychiatry' (see Child 1989 and other references below). Here I work through the standard 'text-book' medical headings as they are often applied to Conduct Disorder. Two authors inform this critique: David Taylor's important thinking, for example, set out as the first chapter of a paediatric textbook: 'The components of sickness: diseases, illnesses and predicaments' (Taylor, 1982). And, John Macmurray's humanist philosophy of 'self as agent' and 'persons in relation' (Macmurray, 1957 and 1961). This can be simplified into the language of 'problems of living' (Child 1984), of individuals and their widely varied tasks and problems, with solutions often involving another person or persons, conflict requiring resolution before problem solution. 'Abling' is the characteristic form of medical model help where one person takes responsibility for removing another's problem. The alternative form of help is 'enabling' the other to discover what to do about their own problem. Getting either form wrong can be 'disabling'.
At each stage, having identified where the medical model is misapplied, I indicate a possible non-medical, more appropriate way of thinking about it. All this is from the dominant Western tradition. At least the critique offers a better bridge to other cultures.
BEHAVIOUR OR ACTION The medical model gains its power from a valid bioscientific approach to objectifiable conditions. Disease, the object concerned in medicine, is assumed to be within the individual. So, when doctors move on to look at behaviour as we do in psychiatry, the natural tendency is the Heinrichian one, to see behaviour as a kind of symptom of some condition within the individual. Heinrich could point out that any behaviour or action is served by physiological processes within.
In contrast, a non-medical model might see behaviour as the action or re-action of a person trying to get through life's tasks and solve the problems of living within relationships and interactions in social systems, such as, for children, school, peer group, agencies, and especially, the family. The distinction between behaviour and action can seem obscure. Take going on strike. If a worker reaches the point of taking 'strike action', the one thing that would inflame the striker's passions would be objectification or labelling by bosses or media as 'disordered' or as 'just attention-seeking'.
For the striker, the whole point is to draw more attention to the worker's plight (2). So strikers might be happy to have their actions considered as their way of 'conducting' themselves, and even that their conduct is intentionally 'disorderly'. But they would escalate their protest if they were dismissively labelled as having a 'conduct disorder' requiring treatment to to pacify them. Strikers mean to be attended to; they want their concerns directly addressed. There is a lot more meaning to taking 'action' than the word 'behaviour' conveys. So, if a child's 'behaviour' is a form of 'action', we should raise our thinking and responses from the pseudo-bioscientific to the human.
DEFINITION: DISEASE OR PROBLEM-SOLVING STYLE The definitions of 'conduct disorder' come from the International Classifications of Diseases (ICD) - 'Diseases', note (3). I criticise the plain self-implicated problems of this system of description lying within and effectively promoting an otherwise medical 'disease' model and classification of child mental health problems, as if they were part of the same realm as appendicitis and cancer (4). With six axes and co-morbidity, multiple diagnosis adds even more fog to the already misty business. In addition, the individual focus disconnects the social situation of the behaviour and useful alternative frameworks.
As we, child psychiatrists, ran into these problems, we might have looked outside of medicine to other fields involved in our multi-disciplinary field. But, no, Mount Everest had to be climbed, and it had to be climbed in our own special way! The logic for this lies outside rational science. It lies in professional and political reasons to want to look like 'proper' doctors in a culture and economic system that also values all that, and devalues the skill and intelligence required in the field of mental health. Some aspects of our field require a medical approach. But we should take great care, given the strangeness of a system that has a disease label, hysteria, for a predicament when, by its own definition, there is no disease to be found (5)!
What could we put in the place of the ICD as a framework for our subject? I have found that sensitive and logical thought expressed in ordinary everyday language anyone can understand and use is acceptable and effective for most clinical and service purposes (6). For other purposes such as teaching, research, and service-planning, and to soften the loss of the terminology and model we are so attached to, I suggest that describing 'problem-solving styles' might be an alternative.
We might find that individuals and families can be placed on a spectrum between problem-solving styles that are overorganised - that is, worrying a great deal about nothing very substantial - and problem-solving styles that are underorganised - that is, not worrying effectively over matters of great concern. We might expect correlation between the family style and the styles of the individual members of that family and of people living in the same personal or wider culture. The new labels would have face descriptive validity and would indicate what sort of help would be appropriate - the overorganised need to loosen up, while the underorganised need to tighten up. We might find, in contrast, that the overorganised attract rather overorganised types of help and agency, while the underorganised attract multiple agencies often offering rather disorganised help!
This scheme, the reader may notice, generates new labels for roughly the same spectrum and groupings as the ICD 'neurotic/emotional' and 'conduct' disorders does, and that the help described matches what would be our present standard 'treatments' of those categories of problem. So, psychotherapy helps the overorganised to loosen up, while multi-agency liaison and meetings integrate more effective organisation around the underorganised. This equivalence to ICD, I suggest, validates and makes the 'problem-solving style' alternative categorisation even more appropriate, since it becomes a more transparent framework for the same business and kinds of 'treatment' that we already do.
The new framework removes medical mystique and control. So it may de-centre us doctors within the mental health field, but it does not remove us. Especially given our culture's strong attachment to bioscientific approaches, there will always be a need for a doctor to be around to diagnose 'health' authoritatively, as well as to engage in any bioscientific discourse being raised. For example, to consider the limits of any actual or proposed bioscientific condition being suffered. 'ADHD' is easily the most taxing challenge in this respect (Child 1996)! In the UK, diagnosing health does not preclude doctors' further concern and interest in what the presented problem is about and how to help in other terms than medical.
PREVALENCE - THERE'S A LOT OF IT ABOUT Joining prevalence to diagnosis helps us comfort our patients' otherwise lonely experience of their illness. We can test our rationale here with some calculations. Just as we can work out the number of surgeons needed to treat a given prevalence of appendicitis, so Royal Colleges, managers and government departments need to know how many psychiatrically disordered children there are to plan the number of psychiatrists. So how many more child psychiatrists proportionally are required given that only one in ten, say, of psychiatrically disordered children get to see one? Ten times more. Are the funds for this going to be forthcoming? No. Are the newspaper headlines as bothered about the nine out of ten not being seen as they would be for a similar shortage of surgeons and untreated appendicitis? No. And are child psychiatrists anyway keen and able to help this largest section of those psychiatrically disordered children, the 'conduct disordered' ones? Apparently not, according to our experience and textbooks.
So this is where we strategically pull in the neat alternative meaning of 'psychiatric' as 'multi-factorial multi-disciplinary multi-agency', confusing the single medical discipline with the multidisciplinary field of mental health. To summarise: having laid claim to 'conduct disorders', powerfully dominated the way they are conceptualised, labelled and studied, implied that there should be ten times more of us, child psychiatrists then declare that we are not very good at helping and want to pass the problem to others! There could hardly be a more infuriating strategy designed to promote poor interdisciplinary and interagency relationships and conflict-ridden services to the clients who, as we saw above, need the opposite for a change.
Finally, the child and family in the clinic need to be understood and worked with in terms of their unique 'predicament', not primarily according to the general category and any attached 'off-the-shelf' treatment. Knowing the prevalence is less of a comfort for 'conduct disorder'.
CAUSES OR PERSISTING PATTERNS Like the satisfaction of finding a prevalence, finding causes also gives a doctor a glow of scientific satisfaction. But the satisfaction can be unmerited. Statistical associations have to be explored further to uncover the mechanisms of the associations. In our clinics, we use psychodynamic and family-systems frameworks. Some post-modern approaches propose no causal relationship between problem and solution! Research from early on has shown factors that load the dice of psychiatric disorder, but that what throws them is problematic family relationships. Despite the admirable efforts of many researchers then and since - the quality of whose work thankfully ensures that noone else needs to redo it better - I still think that way of climbing this Mount Everest has been akin to going up backwards on a sledge. Clients and others though wish the non-family relationship factor to be the main and only one to treat, this longing for a disease contrasting with the rest of medicine where there is relief when the absence of one is declared (7).
Granny has often been proved right by the laborious backward-sledging research. We can list many understandable causes of the protest that we call 'conduct disorder' - urban or delinquent areas, unstable families, poor parenting methods. These causes are mainly not in the same realm as the bioscientific. They are the subordinated social and predicament factors. And tautology appears. 'Failure of adjustment' may be used as both the description of the disorder as well as its cause! Within a problem-solving style framework, this tautology would be a human system's pattern of problem-solving generalising or persisting.
At this point, a child psychiatric authority may well launch out to illustrate how an alternative relationship-based family-systems perspective is indeed a most productive theory of 'cause' and an effective practical framework. The antisocial behaviour may be an important factor in keeping the family or parents together, or in distracting the family from more difficult matters. Clearing up these problems leads to the identified patient's symptoms disappearing. But then:
DESCRIPTION - INDIVIDUAL BEHAVIOUR The medical structure pulls us back from a clearly more promising approach to a description of the individual behaviours as if they were symptoms of an internal condition of the patient - stealing, lying, aggression etc. A non-medical approach might integrate cause and description by describing the problems within the family and other system behaviour as a whole (as in the previous paragraph), formulating the functions it all performs.
TREATMENT The scientific rites of diagnosis, prevalence, cause and description, herald the medical model's ceremonial crown, treatment. Treatment of 'conduct disorder', our authority might tautologically tell us, consists of 'alteration of circumstances'. The list of treatments is broad. But none are medical and several are specifically not medical. Whatever it is called, the time-consuming, multi-disciplinary, communicational nature of our work, clearly contrasts with the patterns of treatment in categorically organised medicine.
But what if the 'conduct disorder' is a child's, albeit less than conscious, equivalent of strike action against their predicament? After our treatment, the child returns to that situation. For a child, the situation needs to be modified, or identified as reason for valid protest. Or else the individual work should be aiming to coach the child escalate their strike action. In other words, successful work could be shown in the child 'getting worse'.
Then, echoing the medical model, we may say that family work is indicated 'if assessment suggests that the behaviour is a symptom of a dysfunctional family system'. The logic of including the family or substitute family only if they are deemed to have caused the problem is equivalent to a surgeon's theatre nurses refusing to assist the operation because they did not cause the disease! The family are involved because they live with and are significant parts of the child's life. Theatre nurse and family are to be involved because they are an essential part of the solution.
OUTCOME For treatment to be any more than ritual, we must attend to its outcome. This is a strength of the medical model with its focus on science and cure. But the more inappropriate our model for understanding the nature of the problem, the more the issue of outcome will show it. Outcome in mental health services is not the same as in the more prescriptive fields of medicine. The kind of help we offer is more in the class of advice. It is not traceable in the same way as pills to see if the client has taken it in. Just because they come to our clinic does not mean they have been taking our further advice or treatment. In a drug trial, if a patient did not take their medication, they would not be included in the research as evidence that the treatment did not work, however regularly they attended the research clinic.
In summary the complications for outcome in child psychiatry are that:
the 'therapy' is a mutual enabling process, not a one-way treatment
the individual is not so separable a unit from the (dys)functioning of their family, extended family, or other social context
it is sometimes not clear who the client is
whoever they are, clients may not take in advice or therapy offered
the case may be closed without improvement, but perhaps reopened later when the family does return ready for help
the situation might need to deteriorate or
apparent deterioration might even be a sign of successful work.
For these reasons, outcome and the 'evidence-base' for the likes of 'conduct disorder' require a lot more thought than the standard medical style conclusions on the subject. On both sides, the appointments can be for many other or more covert reasons and outcomes than straightforwardly taking part in therapeutic work. Where medication is proposed for predicaments where the 'behaviour' may be at least partly significant 'action', very careful consideration is required for the complexity, and for the politics and messages we thereby authorise.
Evidence-based medicine and the stringencies of resourcing require us to prove that what we do works to predictable standards (Goodman, 1997). But assuming medical territory where a presumed medical model apparently shows proof of good outcome, makes as many logical mistakes as counting your chickens before checking it's not a fish farm. It is only in recent years that doctors of all kinds have had anything much more to offer than simple humanitarian care and nursing while the patients cure themselves if they can. As its power has grown, the medical model has devalued our less definable human response to human predicaments. A non-medical model might yet prove the power and outcome of more human methods, or at least share more honestly the limits of what any profession can do for so-called 'conduct disorder'.
SUMMARY For any helping profession, some kind of system is important for identifying and assessing a problem, succinctly describing, formulating or labelling it, developing and referring to a body of knowledge about it, planning help and services, and reviewing and monitoring progress and outcome. Frameworks and labels help all this, in gathering people to a valid field, in research, in organising teaching and textbooks, in service administration, in abbreviating communication within the field and in clinical work.
The medical model is the most established version of this system. Poorer versions elsewhere may leave a gap that a medical model can fill more effectively. But this does not make the medical model the best overall framework for 'conduct disorder' or the field of child and family mental health. The other models could be improved rather than displaced.
I am a keen supporter of the medical model in its proper more limited place. 'Conduct disorders' are not best considered within that framework. I have shown where that logic is illogical and why, without mapping its limits in more contentious areas of child psychiatry. The ICD itself recognises the medical model's limitations but, for other reasons, covers its confusion and so compounds it. A more appropriate framework might be problem-solving styles. However, for much of our clinical practice, I hold we only need the 'labels' of ordinary language.
As well as their general contribution, there is still an essential place for a doctor in a multidisciplinary mental health service or research team to carry the authority around this moved boundary. I think of myself more as a doctor with an interest and expertise in thinking or philosophy, psychology, relationships, life and problems of living. If that is also a description of a psychiatrist, then that is fine, except the training would need some changes. I find that recognising the medical model's right place ensures greater clarity and collaboration in clinical practice and service provision, with team colleagues, other agencies, and especially with 'proper' medics, than when psychiatrists seem to claim they work in the same realm as 'real' doctors and that all mental health is to be addressed within a medical model. More logical thinking would serve better science and better services. Problem-solving labels or ordinary language can demystify part of a complex subject so that all and sundry can own it and more easily grasp the nature of the problem and its solutions.
FOOTNOTES 1. My use of 'medical model' is defined well enough by Heinrich's account, but there is a debate to be had about alternative meanings of the term.
2. There is the (bioscientifically) strange notion here of something very palpable being caused by a factor in the future, not in the past. The striker's 'cause', the aim being pursued, has not yet happened. Philosophically, matters of intention are by definition not yet matters of fact. They therefore cannot be studied by the same objective evidence that bioscience calls for.
3. In a British context, I refer to ICD, but the argument is essentially applicable to other diagnostic systems such as DSM.
4. My argument about disease would disappear if we still used the old broad sense of 'dis-ease' rather than the objectified modern one (see Fulford, 1989).
5. To identify the paradox of a disease called hysteria, does not imply that this kind of predicament should not be identified, studied and even otherwise labelled, nor that it is always unrelated to other valid disease categories, nor that we have no responsibilities or methods of helping. See, for example, Warwick (1998).
6. 'Ordinary language wherever possible' requires more exploration than there is space for. In interviewing a child or family, or in a letter to a General Practitioner, usually with copies to the family, I would use (rare) labels like schizophrenia or Asperger's. I prefer talking of 'attentional difficulties' or 'being depressed' than the reifying labels, though medication may be appropriate in both cases. I would not think about or use any of the adjustment, emotional, conduct, or personality disorder ICD labels. On the other hand, for example, it can help clinically to think of 'the picture' being a 'school refusal one', though this term has been obscured in ICD10! 'School refusal' is anyway ordinary English.
7. The unusual desire for a diagnosed disorder is evidence that people's experience of suffering from non-medical predicaments, and their desperation that something professional be done to help, is at least as great as the suffering and desperation from medical diseases. Therefore mental health problems deserve at least as much attention in research and services as somatic illness does. The language of pain, illness, potions, and death is how people in many cultures present and describe their severe mental distress. This also explains why mental health professions have borrowed that language where alternative languages are feeble and systematically marginalised.
Child, N. (1991) 'Quality thinking and a formula they [managers] can't refuse'. Psychiatric Bulletin of Royal College of Psychiatrists, 15, 476-477.
Child, N. (1992) 'Finding a philosophy that fits'. Letter in Journal of Family Therapy, 14, 225-7
Child, N. (1996) 'How true story-telling lost its place'. CONTEXT (Autumn), 28, 34-37
Fulford, K. W. M. (1989) Moral Theory and Medical Practice. Cambridge: Cambridge University Press.
Goodman, R. (1997) 'Child mental health: an overextended remit.' British Medical Journal , 314, 813-814
Group for the Advancement of Psychiatry Committee on the Family (1996) Global assessment of relational functioning scale (GARF): 1 background and rationale. Family Process, 35, 155-172
Macmurray, J. (1957) Self as Agent. London: Faber
Macmurray, J. (1961) Persons in Relation. London: Faber
Taylor, D.C. (1982) 'The components of sickness: diseases, illnesses and predicaments'. Chapter 1 in One Child (eds Apley and Ounsted). London: Heinemann.
Warwick, H.M.C. (1998) 'Cognitive therapy in the treatment of hypochondriasis'. Advances in Psychiatric Treatment, 4, 285-295.
NICK CHILD, MB, ChB, MRCPsych, MPhil, is the Consultant Child and Adolescent Psychiatrist in the Motherwell Team of Lanarkshire's Child and Family Clinics service. His main interests are in 'getting a life', demystification, clear thinking, liberating organisation, multidisciplinary community psychiatry in the peripheries of excellence, and in the fields known as psychotherapy and family therapy.