Some of Gerald Klerman’s comments from 40 years ago [an interesting read…, Schizophrenia: Science and Practice, Chapter 5: The Evolution of a Scientific Nosology] could’ve been written yesterday, and you wouldn’t see any difference. After reviewing the oft told history of diagnosis and treatment of psychotic illness and discussing the neoKraepelinian Credo, he turns to the medical model:
The medical model has become a code word for controversy and debate, a slogan with which to rally one’s allies or to castigate one’s enemies. To psychiatrists concerned about defending their health insurance prerogatives, the medical model is an umbrella to justify continued support from Blue Cross, Blue Shield, or Aetna. To psychologists and other nonmedical practitioners anxious to be included under health insurance, the medical model refers to a narrow biological approach to the treatment of psychological problem. To behavior therapists, who apply the methods of B. F. Skinner, the medical model applies to dynamic psychotherapy and psychoanalysis, which they attack for postulating “underlying conflicts” of which symptoms are only manifest behaviors [It is ironic that this extension of the medical model to psychoanalysis would be rejected by a substantial group of nonpsychiatric physicians]. To black militants in an urban ghetto, the medical model is a term of contempt for the futile attempt of the community mental health center to treat social ills by treating individuals, whom the militants regard as victims rather than patients.
That is the way it felt in 1978. I’d never even heard the term medical model of disease as an internist – first encountering it as a psychiatry resident as I was being berated by a behaviorist trainee for believing in it. Klerman goes on to say how he understands the term:
[1] The disease concept. This is a theory of illness that evolved in the eighteenth century and is now held throughout Western industrial civilization.[2] The sick role. As sociologists such as Parsons [1951] and Fox [1968] and anthropologists such as Fabraga [Fabraga et al. 1968] have pointed out, every known society has a category of the “sick role” for a special class of deviance, even non-Western societies that do not have modern notions of biology such as bacteriology or catecholamines. The sick role carries with it a set of rights and prerogatives, and mechanisms are specified whereby this role can legitimately be conferred on certain individuals by another group within society, the “healers.”[3] The health care system. As society becomes more specialized and differentiated, the roles of both the sick and the healer become more complex. In modern industrial society there is a complex health care system that includes various kinds of specialists among healers, such as nurses, doctors, technicians, as well as complex institutions such as hospitals and universities and, recently, fiscal mechanisms such as health insurance and Social Security. In part, the debate over whether or not schizophrenia or anxiety are “diseases” is a conflict over whether individuals exhibiting such behaviors are legitimately to be given the rights and prerogatives of the sick role and whether or not the complex and powerful apparatus of the health care system shall serve their needs…
1978 was a very different time from the days of Emil Kraepelin when psychiatry was still associated with the asylum whose population who could be classified by the syndromes he so carefully described. By 1978, there were a treatments for a broad range of behavioral and emotional conditions that had unclear boundaries and didn’t easily groups treated by psychiatrists, psychoanalysts, psychologists, social workers, etc. Those in non-medical specialties were not reimbursed by medical insurance and were vocal about being excluded. Also, the insurance carriers balked at including these patients in the "sick" role along with those with physical ailments or even the classic psychiatric syndromes. Thus, Klerman’s comments about legitimacy – an issue that was very much on the front burner in those days. Klerman goes on:
Looked at in these terms, mental illness and the medical model are social constructs; they are inventions of modern society that attempt to make sense of and deal with the real phenomena of pain, distress, anguish, and disability experienced by certain individuals. However, to say that the medical model or the concept of mental illness is a social construct is not to say that it is a myth or that it is invalid. All social constructs are not myths and they are not necessarily untrue. After all, “the rights of man,” the electron, and the university are also social constructs. They are not facts given in nature, but rather are complex ideas developed by historical forces and legitimated by consent. The concept of illness is not arbitrary but reflects areas of shared consensus, embodying truths arrived at by rules of evidence.
The application of the medical model to mental illness was an achievement of the nineteenth century, when Philippe Pinel at the Salpetriere was responsible for bringing medical leadership to the asylums. For centuries Western Europe had had institutions for lunatics, but these asylums had not been considered appropriate for medical supervision. Usually they were run by religious orders or were parts of jails or prisons. Furthermore, the courts had not distinguished “madness” and “badness” as clearly as became the norm in the early part of the nineteenth century, as a result of the eighteenth century Enlightenment. This distinction between being mad and being bad was regarded as a major humanitarian gain, motivated by humane and benevolent intents.
The psychiatry of 1978 was also very different from the 2016 version. Psychoanalysts at that time were all physicians and heavily represented in the upper levels of the Departments and Professional Organizations. Schizophrenia was one of the least conflicted areas, but even then, you can see the difference just by looking at the chapter headings of this book.
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Approaches to Understanding Schizophrenia – John C. Shershow
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The Manifest and the Scientific Images – Etiology: The Nature-Nurture Interaction
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Heredity and Environment – Seymour Kety
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A Developmental Theory – Theodore Lidz
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The Evolution of a Scientific Nosology – Gerald L. Klerman
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Biochemical Investigation – Ian Creese and Solomon II. Snyder
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Psychopharmacology – Leo Hollister
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The Patient and the Community – Jonathan F. Boras and Elaine Hatow
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Psychotherapy – Daniel P. Schwartz
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The Surrogate “Family,” an Alternative to Hospitalization – Loren II. Mosher and Alma Z. Menn
Historical and Philosophical Perspectives
Bioscientific Research
Care and Treatment: The Human Dimension
And while Klerman’s chapter was about Schizophrenia, it was also about nosology for the whole of mental illness. Reading this section about the medical model, I doubt that many psychiatrists or physicians would disagree with much of it. It certainly fits my understanding [then and now], though it wouldn’t sit well with psychiatry’s critics – then or now. They would argue that to call something a Disease, you needed a known cause and a biomarker. They would likely see his notion of a social construct as a rationalization or worse, and go on to talk about why it’s harmful to think that way. So on to the critics in 1978 in the next post…
From 1977 to 1980, Gerald Klerman was Administrator of ADAMHA in the Jimmy Carter administration. In that role he was the éminence grise behind the APA’s development of DSM-III. He interacted regularly with Mel Sabshin at the APA and with Robert Spitzer, who chaired the DSM-III task force. That helps to explain the many references to professional guild issues and to insurance reimbursement in his chapter, written in 1978. As much as anything else, DSM-III was created to protect the guild interests of the American Psychiatric Association, and Klerman helped to steer that operation. Remember, these were the days when my peers in general medicine would sneer at reimbursement for psychotherapy, with derogatory comments like they didn’t expect to be reimbursed for their gym memberships, so why should the worried well be reimbursed for attending a psychological gym? DSM-III aimed to give medical respectability to the entire broad range of “behavioral health” disorders. Out of that same era arose the manualized psychotherapies called cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). The former derived from the work of Aaron Beck and the latter was cobbled together by Myrna Weissman and her husband Gerald Klerman. These were represented as standardized and evidence based psychotherapies, with an eye to qualifying for insurance reimbursement. No longer would long term psychotherapy be condemned as a waste of money for the worried well to shoot the breeze with their therapists without process measures or outcome measures. Now, 40 years later, we are still debating their value. I vividly recall a respected psychiatrist colleague dismissing IPT as ‘dollied up social work.” But, with a manual for the treatments and with the diagnostic cover of DSM-III, these developments secured a place under the umbrella of the medical model.
I had been in medicine for a while before I came to psychiatry, and knew many medical models.. There was the Disease Model for conditions with a known pathophysiology. There was the Preventive Model [I should say were the preventive models]. There were many Empiric Models. et cetera. The point was that the word Disease was best understood from its concrete root – dis-ease [what the patient said, how they felt] and ill-ness was the state of feeling ill.
Non-medical people would like for us to understand everything in depth – a Disease Model. I guess we’d like that too, but we don’t. So we have to have ways of dealing with what we don’t know too, thus the pantheon of other ways of understanding – guided by the basic rule [do no harm].
I didn’t find the time to read Klerman myself so far, but I now that he expressed two central tenets when he was chief of US national mental health agency from 1977 to 1980: that “there is a boundary between the normal and the sick”, and that “there are discrete mental disorders”.
I was very surprised to see this rather constructivist approach to mental illness (that I share, at least for some disorders) that contrasts with the above tenets.
As you know, I usually distinguish between disorders as reflective (they cause their symptoms) and formative (they are caused by their symptoms) latent variables or disorders. Intelligence is oft used as an example for a reflective latent variable (changes in unobserved intelligence cause changes in how you respond on observable intelligence tests), measles is a good example for a disorder (if you get measles, you get symptoms of measles as a causal consequence). A formative construct is SES, because the observable indicators (neighborhood, income, disability, etc) determine what your SES is.
What Klerman proposes here is that some mental disorders may be better understood as formative constructs (he calls it socially constructed, with is the same) — but formative latent variables can be highly informative, and I agree with him. SES predicts mortality and morbidity. The APGAR score (that is also a formative construct) also holds high predictive value.
Great references to read up on this in general are:
* Kendler KS, Zachar P, Craver C. What kinds of things are psychiatric disorders? Psychol Med. 2011;41: 1143–1150.
* Borsboom D. Psychometric perspectives on diagnostic systems. J Clin Psychol. 2008;64: 1089–1108.
And I am aware of two recent papers that argue that specific disorders are formative:
* Fried EI, van Borkulo CD, Epskamp S, Schoevers RA, Tuerlinckx F, Borsboom D. Measuring Depression Over Time . . . or not? Lack of Unidimensionality and Longitudinal Measurement Invariance in Four Common Rating Scales of Depression. Psychol Assess. 2016;28: 1354–1367
* Van Rooij AJ, Van Looy J, Billieux J. Internet Gaming Disorder as a formative construct: Implications for conceptualization and measurement. Psychiatry Clin Neurosci. 2016;
Good to see you back here, Eiko. I don’t yet have a good understanding of your work on reflective versus formative latent variables or disorders, so I am unsure about your exposition in the third and fourth paragraphs above. One problem for me is that you move back and forth between disorders and traits – measles and intelligence, for instance, but you give no examples of formative disorders. I am guessing that you would agree that some disorders are reflective disorders (like melancholia and mania and delirium) whereas other disorders are formative disorders (like internet gaming disorder and pathological grief disorder and perhaps even posttraumatic stress disorder). I agree with you and Klerman that the latter group can be thought of as socially constructed.
In your discussion of intelligence, if you say SES and APGAR scores are formative constructs, then why call intelligence a reflective latent variable? How do any of these differ from Percy Bridgman’s operationalism? All three, SES and APGAR and intelligence (or IQ) are instantiated by the operations involved in measuring them. Bridgman would say that the inferred latent variables are just shorthand names for the operations.
Eiko,
Likewise. Welcome. Being less savvy in these matters, I don’t know what SES stands for…
SES. SocioEconomic Status?
Colleagues,
A long time ago ,in a different galaxy , at Hillside Hospital a research assistant Rachel Gittelman and I would talk about problems in psychiatric diagnosis. For her PhD thesis ,she looked into the issue of whether childhood social development had played any role with regard to schizophrenia. This work led to the Premorbid Asocial Scale ,still the best instrument for prognosis in early onset “functional” psychosis. Nobody seems to remember that the revered article by Robins and Guze had the substantive point that the use of their criteria would clearly distinguish poor premorbid from good premorbid schizophrenia into two different disorders . Ignored right through DSM-V .
One day she told me that I was a Kraepelinian which surprised me as I had never read Kraepelin. It also came as a surprise that I was a neo-Kraepelinian. It was even more of a surprise to find out that as a DSM -3 Task Force member my job was to protect the Guild interests of the APA. As I remember our goal was to deal with the well demonstrated gross unreliability of psychiatric diagnosis that was undermining psychiatry as a clinical science. The APA nearly sank that boat except for Spitzer’s tactical adroitness.
Best
Don Klein
Reliability is not the problem, construct validity is.
“Cubs fan” would have a high kappa but it’s not a mental illness (well maybe it was masochism until October 2016).