{"id":69536,"date":"2016-12-16T16:31:58","date_gmt":"2016-12-16T21:31:58","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=69536"},"modified":"2016-12-17T19:00:44","modified_gmt":"2016-12-18T00:00:44","slug":"klerman-1978-on-the-medical-model","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2016\/12\/16\/klerman-1978-on-the-medical-model\/","title":{"rendered":"Klerman 1978: on the medical model…"},"content":{"rendered":"
Some of Gerald Klerman’s<\/font> comments from 40  years ago [an interesting read…<\/a>, Schizophrenia: Science and Practice<\/font>, Chapter 5: The Evolution of a Scientific Nosology<\/a>] 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: <\/div>\n
\n
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.<\/div>\n<\/blockquote>\n
That is the way it felt in 1978. I’d never even heard the term medical model of disease<\/font><\/em> as an internist – first encountering it as a psychiatry resident as I was being berated by a behaviorist trainee for believing in<\/font><\/em> it. Klerman goes on to say how he understands the term:<\/div>\n
\n
[1] The disease concept. This is a theory of illness that evolved in the eighteenth century and is now held throughout Western industrial civilization.<\/div>\n
[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.”<\/div>\n
[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…<\/div>\n<\/blockquote>\n
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:<\/div>\n
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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.<\/div>\n

<\/p>\n

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. <\/div>\n<\/blockquote>\n
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.<\/div>\n
    <\/p>\n
    Historical and Philosophical Perspectives<\/font><\/strong><\/div>\n
  1. \n
    Approaches to Understanding Schizophrenia – John C. Shershow<\/font><\/div>\n<\/li>\n
  2. \n
    The Manifest and the Scientific Images – Etiology: The Nature-Nurture Interaction<\/font><\/div>\n<\/li>\n
  3. \n
    Heredity and Environment – Seymour Kety<\/font><\/div>\n<\/li>\n
  4. \n
    A Developmental Theory – Theodore Lidz<\/font><\/div>\n<\/li>\n
    Bioscientific Research<\/font><\/strong><\/div>\n
  5. \n
    The Evolution of a Scientific Nosology – Gerald L. Klerman<\/font><\/div>\n<\/li>\n
  6. \n
    Biochemical Investigation – Ian Creese and Solomon II. Snyder<\/font><\/div>\n<\/li>\n
  7. \n
    Psychopharmacology – Leo Hollister<\/font><\/div>\n<\/li>\n
    Care and Treatment: The Human Dimension<\/font><\/strong><\/div>\n
  8. \n
    The Patient and the Community – Jonathan F. Boras and Elaine Hatow<\/font><\/div>\n<\/li>\n
  9. \n
    Psychotherapy – Daniel P. Schwartz<\/font><\/div>\n<\/li>\n
  10. \n
    The Surrogate “Family,” an Alternative to Hospitalization – Loren II. Mosher and Alma Z. Menn<\/font><\/div>\n<\/li>\n

    <\/span><\/ol>\n

    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<\/font>, you needed a known cause and a biomarker. They would likely see his notion of a social construct<\/font><\/em> 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…<\/div>\n","protected":false},"excerpt":{"rendered":"

    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 […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-69536","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/69536","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=69536"}],"version-history":[{"count":33,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/69536\/revisions"}],"predecessor-version":[{"id":69603,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/69536\/revisions\/69603"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=69536"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=69536"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=69536"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}