Category: Psychology

The Psychological Model

The medical versus psychological models of treatment are often discussed during psychological training.  The word “model” refers to the theoretical framework that each profession uses as their guiding principles.  Both medical and psychological models focus on signs and symptoms of illness.  The medical model relies heavily upon independent tests to prove or disprove if a patient is ill.  The psychological model also uses tests to prove or disprove whether a patient is ill.  It is at this point of agreement that the two models diverge.

The chasm that divides one model of treatment from the other is the subjective experience of the patient.  To most medical doctors, if the tests do not reveal a problem, then the patient is often perceived as hypochondriacal or even malingering.  To a psychologist, if the patient believes they have a problem, then they really do have a problem.  The subjective experience of the patient is considered most important, and objective measures less so.  For example, people often claim they are experiencing pain, even though objective tests did not discover damage to the organism.  The psychologist will note that there does not appear to be organic damage, yet the patient remains in obvious distress.  Psychologists are trained in the scientific method, which encourages constant skepticism.  A well trained psychologist should always keep in mind that no test is one hundred percent reliable, and there are always limitations regarding the extent of their validity.  In the example above, there may be actual organic damage to the patient causing their pain, but the current state of the art lacks a test to reliably identify the organic damage.

An obvious limitation to the psychological model is a patient that is unconscious, or their communication ability is compromised to the extent that they are unable to make their needs known to others.  Both medical and psychological models must rely upon objective tests to evaluate these type of patients.  There is no alternative.  When the patient regains consciousness, and is at least vaguely aware of their environment, then their subjective experience again becomes very important.  For example, patient’s who wake from a stroke to discover that they are unable to communicate often manifest great agitation.  Quite often, they are not aware of their own lack of expressive ability and believe others are making a game of pretending to not understand their verbiage.  The objective tests qualify and quantify the extent of damage to their brain, but the subjective experience is that loved ones and staff are playing an elaborate trick.
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The explosion of “alternative” medicine suggests that traditional medicine might be missing something.  Those patients that are attracted to alternative medicine do not completely eschew the traditional medicine model.  Consumers of alternative medicine still believe that substances outside our bodies have curative powers.  They tend to avoid products of traditional pharmaceutical companies in favor of medicinal preparations from other cultures or even antiquity.  The model of treatment is essentially the same, it is merely a change in the manufacturing and distribution of the medicines.  Clearly this group of consumers has health needs not adequately addressed by the traditional medical model, yet it remains to be seen if the “alternative” style of medical treatment is any more effective.

To paraphrase Andrew Still, anyone can find disease, but it takes a healer to find health.  The various qualities and techniques to become a “healer” are still less than scientific.  The failure of traditional and alternative medical models to address the subjective needs of the patient may be the missing link that completes the true healer.  Twenty years of clinical practice have convinced the author that people’s complaints are only loosely based upon reality, and this holds true for the author as well.  Humans have resisted efforts to equate mental and physical health with empirical evidence reminiscent of mechanical laws.  Empirical evidence should be the cornerstone of medical and psychological practice, yet the entire edifice is not created with these laws alone.  Understanding the subjective experience of the patient is a gift, both to the patient and their family.

Independence

Americans prize their independence.  Hollywood earns billions portraying characters that express their independence in an aggressive fashion.  Many Americans loath dependence and equate it with weakness.  Is dependence really equatable with weakness?

The author’s experience with nursing home and hospital patients over the last twenty years may shed some light.  The severely medically ill typically dread becoming a burden on their loved ones.  It is rare to find older adults who readily agree to live with their children.  Rarely does the avoidance stem from ill feelings, as from the aforementioned dread of becoming a burden.  The ailing older American is typically more resistive of living with their children than the children themselves.

Other cultures have less difficulty with dependence.  These patients typically experience less adjustment problems with illness and nursing home placement.  Forced dependence from medical illness is viewed as an unavoidable part of life, rather than stemming from a personal inadequacy.  Just as they may have taken care of ailing friends and relations, there is an expectation that it is a societal necessity to receive care in turn.  In such cultures, the resistance to unavoidable dependence would be taken as askew, and possibly indicative of mental illness.

These notions regarding dependence are focused on physical rather than mental illness.  Quite often long-term mental illness has a significant impact on parenting style and resources.  This impact may be resented by the children as they age; especially as they compare notes with peers whose parents did not suffer with mental illness.  Children of recurrent depressive and bipolar patients are often the least motivated to care for an incapacitated parent.  The very real physical responsibilities of providing care is even more difficult when the parent is uncooperative and apparently unappreciative.  It is nearly impossible for children to fathom the role of mental illness in parenting, as it requires a prospective obtained outside the confines of the family unit.
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In regards to mental illness, there was a disorder termed Dependent Personality Disorder.  This so-called disorder is no longer a part of the diagnostic nomenclature, but its very existence is significant.  Dependent Personality Disorder was confined to the American diagnostic manual of mental disorders, and has never been a part of the international classification of mental illness.  Too much dependence was viewed as a mental illness, and psychologists and psychiatrists were given the task of drawing the line.  Dependence was not only considered a weakness, but possibly a disease that required treatment.

Anthropologists and evolutionary psychologists now consider the the role of grandparents as an advantage unique to our species.  Grandparents living within the family unit were able to confer knowledge and skills to the children that the parents were too busy to provide.  This advantage may be the reason other forms of humanoids became extinct.  Prior to World War II, it was the norm for couples to live with their parents for many years.  Married couples initially depended upon their parents, and in turn, the parents came to depend upon their children.  It may be merely an artifact of simple economics, but the children and grandparents may have benefited in ways that were not reducible to mere income potential.

Dependence is a problem if either party perceives it as a problem.  Dependence is highly influenced by cultural norms.  Dependence stemming from mental illness is often less well received than physical incapacity.  Dependence may be an evolutionary adaptation that secured our species spot at the top of the food chain.  We depend upon others for their knowledge and experience, as well as physical support.  Others depend upon us for the very same reasons.  Perhaps dependence is often perceived as a weakness by those who are afraid of the responsibility.  The responsibility is to not hate those on whom we depend.  It’s very American.