The Medical Model In Mental Health – An Interview With Ahmed Samei Huda

WHAT I'M INTERESTED IN, AND WHAT OUR READERS WILL BE ASKING IS - WHAT IS THE MAIN REASON YOU WROTE THIS BOOK?

I think the main reason is that there are many common criticisms of psychiatry which get repeated, often around diagnosis and treatment, and other criticisms that I didn’t feel particularly able to answer.

I didn’t feel qualified to address these as conceptual forceful criticisms or criticisms in terms of social constructionism, but what I was better able to respond to were criticisms that were framed in such a way, I could answer using scientific research.

There were already some answers to these criticisms, often in brief papers by academics, but there didn’t seem to be anything written from the point of view of the ‘jobbing clinician’ so to speak, who is probably more aware of how these ideas play out in clinical practice, compared with, say a researcher, who has a different focus.

WHEN YOU TALK ABOUT CRITICISMS, WHAT ARE THE COMMON CRITICISMS THAT YOU HAVE COME ACROSS THAT YOU'VE INCLUDED IN THIS BOOK?

Two common criticisms tend to be in the areas of diagnosis and treatment, and a familiar way to criticise psychiatry is to compare the field with that of general medicine.

General medicine, as you know, is portrayed as a kind of near-perfect paradigm of scientific progress and cures; psychiatry, by contrast, is seen as some unscientific speciality with ineffective and dangerous treatments, in comparison.

I thought the best way to address this was to look at these criticisms; for example, how diagnosis in psychiatry compares with diagnosis in medicine. I read many scientific papers on mental health and general medicine, and a lot on the philosophy of classification of mental health problems, general medicine, and pharmacology.

The philosophy books helped me structure the criticisms of psychiatry into questions, and the textbooks and scientific papers helped me answer them.

I hadn’t realised it at the time, but I had begun the background research for this book about two years before I started to write it, in the shadow of the Scottish independence referendum.

By the time I was halfway through writing, the Brexit referendum was getting underway, so my comparison was, ‘is psychiatry part of the continent of medicine?’ It was before the Brexit referendum happened and almost a coincidence of that being in the background.

What I wanted to see was whether there was a big difference in psychiatric diagnostic constructs compared with those seen in general medicine – looking at the common criticisms such as the lack of objective tests in psychiatry, because obviously, we have no way of measuring thoughts or feelings using external devices; the only method we have is by talking to people and observing people.

The book provides a synopsis of problems or conditions that doctors see in the clinic, what the expected outcomes are, what kind of complications to expect, and which treatments are effective.

Common criticisms were ‘whether it was easy to distinguish between people said to be healthy, and people said to be ill,’ and ‘whether there were any clear-cut differences between the various diagnostic constructs.’ Also, ‘how effective and how dangerous are the treatments?’

As I said, the comparison was, ‘how does this compare with general medicine?’ People often use comparisons like, “it’s not like this in physics” or “it’s not like this in chemistry”, but physics and chemistry are entirely different from medicine. Medicine is about people, right?

And the best comparison isn’t whether psychiatric diagnostic constructs are like electrons or water molecules, but more, ‘are they like the diagnostic constructs we use in general medicine?’

SO, ARE THERE EXAMPLES IN GENERAL MEDICINE WHERE A SIMILAR SORT OF CRITICISM WOULD APPLY?

Well, what I find is that people don’t tend to criticise physicians. I think, partly, as doctors, we often don’t think about what we do, we just do it, and in general medicine that seems to work quite well.

Think of it like a car. When you’ve got a car, you just drive it. I remember when I was taught to drive, I learned how to pull the choke and not to flood the engine with petrol. Now, you’ve all got automatic chokes, you don’t have to think about the choke or clutches and gears – once you learn to drive the car you don’t think about how the car works, you just drive the car – and that’s what physicians tend to do. Because it seems to work for them, they don’t think about what’s going on.

In psychiatry, we’re more likely to think about what’s going on. For example, there are often no clear-cut divisions between diagnostic constructs in psychiatry, but that’s something that does happen a lot in general medicine.

You have a category for the connective tissue disorders, you’ve even got a category for mixed connective tissue disorder because you can’t tell which connective tissue disorder it most resembles.

You’ve got high rates of co-occurrence in psychiatry, so you’re not identifying essentialist items that are supposed to be completely separate entities.

In general medicine, if you have high blood pressure, you often have type 2 diabetes, and if you have anxiety, you often have depression, and vice-versa, but because the medics don’t think about these issues nobody criticises them – they say, “well, it just works”. They don’t examine whether it ‘just works,’ but there are assumptions it ‘just works,’ so people don’t look at those broader issues.

Whereas, with psychiatry, because we can’t directly measure thoughts and feelings, we are more aware of these conceptual issues than physicians are. They are more focused on whether they reliably measure the actual blood pressure or not.

YOU'VE NAMED THE BOOK "THE MEDICAL MODEL IN MENTAL HEALTH". WHAT IS THE MEDICAL MODEL?

Another common criticism in how people describe psychiatry is that they often use the term ‘biomedical model,’ but in psychiatry, we have been using the ‘biopsychosocial model’ for decades.

It’s in our curriculum, it’s in the Australian curriculum, it’s in the British curriculum, and I’m pretty sure it’s in the American curriculum as well. That’s something that you can look at and check, but for some reason, people persist and say ‘biomedical model.’

I remember when I was doing my MSc in psychiatry, and we had a psychologist teaching a session. She was explaining what the medical model was, and we were saying, ‘but that’s not where it is – we’re doctors, we use the medical model, we’ve got a better idea,’ but she was entrenched in an idea.

I think the medical model becomes like a cypher – you project onto it your feelings about doctors and psychiatrists, but obviously, every medical model varies with each doctor. One argument might be that the medical model is whatever model that doctor is using. For instance, Freud – that was a medical model because he was a doctor, but the conventional idea of the medical model is, I think, the idea that you try and look at the best available evidence to help that particular person in your clinic; to help them, try and share it with them, and then jointly come to a decision about what’s the best thing to do.

The problem we have in medicine, particularly in psychiatry, is that we are not very good at doing that consensually shared decision-making a lot of the time.

For me, the medical model is primarily about applying the best evidence, and the way we tend to apply the best evidence is to subdivide problems into categories.

We give them diagnostic constructs as a way for us to learn and recall lots of information. It’s like a tree, then a branch, and on the branch, there are leaves. We separate peoples’ problems into different systems, and within each system (such as neurology or cardiology) their different problems are then subdivided into categories.

In reality, they are not subdivided neatly into categories, but we learn this way because it’s easier for our brain. People think categorically, and attached to these categories, these diagnostic constructs; there’s a lot of information about complications, outcomes, treatments, other problems likely to be present, and how you’d recognise it.

What we do when we see people is that we’re very quick, even in general medicine and psychiatry, to have an idea in our head as to what we think the problem is. Then we go through a process of elimination by finding out more – ‘is it what we thought it was, or was it something else?’ – what we call prototype matching, and then we hypothetically deduct whether we were right or wrong.

[The process of elimination (falsification of hypothesis) links to Daniel Kahneman’s System 1 and System 2 thinking, where the System 1 thinking is very much about the heuristics, and then you’ve got the System 2 thinking, where he talks about deductive reasoning or the falsification of hypotheses. If we find that System 2 picks up that our initial diagnosis wasn’t accurate, we should be better at changing it, so that’s a great point.] – Dr Sanil Rege

You can learn more about this these talks:

Pattern analysis and Clinical Reasoning by Prof Gordon Parker

Serendipity and Multidisciplinary learning by Dr Sanil Rege.

Unfortunately, we’re very bad at ditching our initial diagnosis, but we should be better. As for the medical model, this is about trying to find the right evidence to help someone. The medical model is not the only way to help people with their problems, and many times, it’s not the best way.

That’s why doctors usually work in multi-disciplinary teams, because these teams have different models of helping people, and they might meet those needs of people better than we can.

One of the advantages of the medical model – because it uses diagnostic constructs – is that it compresses a lot of information into what I call ‘quantum hyperlinked information seeds,’ because the information is probabilistic, it’s not definite.

When you see one diagnosis, you start thinking about the information associated with it, and the way we use that information allows us to see lots of patients in a relatively short time. We’re not usually reinventing the wheel every time we see someone; we are using evidence from patients that we’ve already studied or researched.

[The concepts described by Samei above are covered in further detail in the following videos that cover how doctors can be prone to errors and biases.] – Dr Sanil Rege

Decision-making biases and doctor error: Anchoring bias by Prof Jill Klein

Decision-making biases and doctor error: Confirmatory bias by Prof Jill Klein

Decision-making biases and doctor error: Overconfidence by Prof Jill Klein

SO ALTHOUGH THE BOOK SAYS 'MEDICAL MODEL' IT DOES NOT MEAN THAT IT ISN'T A BIO-PSYCHO-SOCIAL MODEL?

Yes, in medicine, it’s about identifying the relevant factors for the patient, and particularly, social factors in both general medicine and psychiatry are the biggest determinants of someone’s health status, so these have got to be considered.

For instance, they used to say TB was a social disease because it’s associated with overcrowding, poverty, poor nutrition, and lack of access to services, so you’ve always got to be aware of social factors.

Of course, psychological factors also affect your health status in general medicine. Pain is an obvious example or diabetic control, but, in mental health disorders, you can’t eliminate the mind, so psychological factors are important.

Biological factors also have an effect, and in the individual, there is a different balance of effect. You have to try and consider the relevant factors for each individual and to be aware of a wide range of varieties. Social factors also include the context, the culture.

For example, in Germany, German doctors treating you for low blood pressure give you salt tablets. We don’t even think about that – in Germany, that’s regarded as a problem, but not here.

In Anthony Clare’s book, he talked about a South American tribe where if you had the treponemal infection of your face, you were a member of the tribe because you had the right markings; if you didn’t, you were out of the tribe.

So, we would think of it as an infection; they think of it as a necessary part of their culture. It’s not biomedical, because if you only look at biological factors in psychiatry, even in medicine, you’re going to be very limited.

Hippocrates and Osler, the Canadian physician, both strongly talk about how you need to treat the person, not the disease.

THE RANZCP GUIDELINES NOW INCLUDE THE BIOPSYCHOSOCIAL-CULTURAL-DIET AND LIFESTYLE MODELS. SO HOW WOULD YOU SUMMARISE THE BOOK IF YOU HAD TO?

I would summarise it by saying the medical model is biopsychosocial, and that psychiatry is not so different from general medicine regarding the usefulness and validity of its diagnostic constructs, or in the effectiveness and harmfulness of its treatments. It’s part of the medical continent; it’s not at the centre of medicine.

I would use the metaphor of Norway or Italy, it’s not Germany, Switzerland or Austria, so it’s not the heart of medicine, but still part of medicine; it’s not Britain, detached from the continent by sea.

DO YOU THINK THAT THIS IS SOMETHING THAT POTENTIALLY CREATES A BIT OF CONTROVERSY?

I think it creates controversy because it doesn’t say what some people would like it to say. My book is probably the most thorough way of putting the evidence forward, and I based much of it on the notes in medical textbooks.

However, I think the issue is that it’s not a controversy based on evidence – as I said, a lot of the evidence is already there. It’s about values, and I think there’s a division between patients who have had terrible experiences under psychiatrists in mental health. I can understand perfectly why they don’t like us, don’t want anything to do with us, and just want us to go away.

Then there’s a group of professionals – obviously, there is an overlap because some professionals are also patients – but generally, there’s a group of professionals with a vested interest in trying to get at doctors as much as possible.

Sometimes these are doctors with a particular view of things. Maybe their particular view hasn’t convinced their colleagues because the evidence for it isn’t that great, and it affects them. They might think, “Well, my ideas seem great to me, why don’t they seem great to you?”, and instead of thinking, “Well, maybe my ideas need to be stronger”, they attack people who reject their ideas.

I think one of the things I’ve learned is that for some people it’s not about the evidence – they’ve made their mind up before the evidence, and evidence won’t convince them. I suppose it’s also a bit of politics.

You’ve been spared a bit of this in Australia, but certainly in Scotland and Britain with the two referendums, we’ve had this interesting experience where the evidence is fairly clear, but people aren’t interested in the evidence, they’re interested only in what fits with what they want to believe.

Something like this happens in psychiatry, and there’s a group of professionals who can’t tolerate views that don’t agree with theirs – they’ve made complaints about me for basically disagreeing with them. I don’t think this will resolve any controversy; in fact, simply stating forward a point of view seems controversial to them, that I don’t think the same as them.

WHAT DO YOU THINK WOULD BE THE SOLUTION MOVING FORWARD FOR MENTAL HEALTH AS A WHOLE?

Well, I’ve just been to a lecture where they talked about ethics and psychiatric genetics. One of the interesting things is that I think we need to be more aware of the role of values – why do we say someone is ill?

If we’re saying some people have unusual ideas, then this doesn’t necessarily mean that they are ill. We’ve got to be more aware of the values behind the judgements we make about people, and are those values defendable values? Are they defendable all the time? Some of the time?

We’ve also got to focus on having a more psychosocial understanding of the illness. A lot of social determinants are very important. Psychological factors are very important.

We are increasingly recognising the role of childhood trauma and difficult experiences in treating mental health, and we’ve got to listen to patients more. I think we’ve got to move away from the model of being ‘the expert above.’

There was a reason for this in the past when all we had was leeches and cupping, and it was about the placebo effect and the illusion of omnipotence to improve the patient’s recovery.

Now we need to aim for a different type of placebo effect; Bracken and Thomas would say it’s about focused collaboration with the patient, listening to the patient, and remembering that the whole point is to help the patient.

You’re not going to help unless you can listen and take on board your patient’s point of view – that’s what we need to do more of.

 

That’s fascinating Samei, and thank you for talking with us about your new book. For all our readers, Samei’s book, The Medical Model in Mental Health, is available for purchase.