Hearing Voices and Psychiatry’s (Real) Medical Model
Hearing Voices and Psychiatry’s (Real) Medical Model
“Most psychiatrists and psychologists are taught that engaging the voices is foolish and dangerous and that their content is random and meaningless.”
—Reader’s comment posted on STAT1
Let’s say you are seeing a recently bereaved woman in her 60s, whose husband died suddenly 2 weeks ago. Her response to the loss is consistent with grief, and she doesn’t fit DSM-5 criteria for a major depressive episode. However, she is anxious and alarmed because, as she puts it, “I heard my husband’s voice, clear as a bell, just as I was going to bed—like he was right there in the room with me! Am I going crazy, Doctor?” Since, as a psychiatrist, you are familiar with normal bereavement, you reassure the patient that auditory or visual hallucinations of the deceased loved one are often experienced during acute grief—and that this is not a sign of psychopathology.2
And yet, one of the enduring myths about psychiatrists is that we rigidly apply “the medical model” to persons who “hear voices”; that is, who have the experience of hearing voices in the absence of any relevant external auditory stimulus. Critics charge that by applying the medical model, psychiatrists “pathologize” a rich, psychologically meaningful human experience.3 Thus, in their report on psychosis, the British Psychological Society states, “At least in the UK, most mental health services are currently based on the ‘medical model’—the assumption that experiences such as hearing voices indicate illness and result from some sort of problem with the brain.”3[PDF]
I believe these critics misconstrue the nature of the medical model used in clinical psychiatry—and often overlook the seminal contributions psychiatrists have made to the psychological understanding of “hearing voices.”
What is “the real medical model” in psychiatry?
The late psychiatrist Gerald Klerman once observed that the term “medical model” “. . . has become a slogan for use in public debate—more an epithet for attacking one’s enemies or a rallying cry for gathering one’s followers than a term of precision for furthering intellectual discussion of scientific discovery . . .”4
Indeed, there seems to be no universally accepted definition of the medical model, and one’s ideology clearly colors the definitions we do have. The philosopher Dominic Murphy describes 2 versions of the medical model, which he calls the “strong” and the “minimalist” interpretations.5 The strong version of the model “. . . seeks explanations that cite pathogenic processes in brain systems, just as bodily diseases are explained by processes in other organs.” The strong version is often conflated—or used synonymously—with the so-called “biomedical model,” which “. . . posits that mental disorders are brain diseases and emphasizes pharmacological treatment to target presumed biological abnormalities.”6
In contrast, Murphy describes the minimalist version of the medical model as asserting that “. . . mental illnesses are regularly co-occurring clusters of signs and symptoms that doubtless depend on physical processes but are not defined or classified in terms of those physical processes.”5 This “neo-Kraepelinian” version of the medical model is, roughly, the foundation on which the recent DSMs rest.
But there is a much broader and less “biological” version of the medical model, described by Shah and Mountain.7 They define the medical model as simply “. . . a process whereby, informed by the best available evidence, doctors advise on, coordinate or deliver interventions for health improvement.”7 Clearly, the Shah-Mountain formulation requires no assumptions regarding the etiology or biological character of psychiatric illness; rather, it is a pragmatic description of how physicians properly coordinate with other health care professionals.
While all 3 formulations of the medical model have their virtues, they all omit some central philosophical principles which, in my view, underlie the model most psychiatrists actually use in their clinical work. I believe there are 6 fundamental assumptions in what I call “the real medical model” of psychiatry, namely:
1. In so far as human emotion, cognition, and behavior are mediated by brain function, there is always an inherent biological foundation to dysfunctional states, such as clinical depression, psychosis, etc
2. Valid psychosocial and cultural explanations of human experiences do not nullify (or contradict) the biological foundations of these experiences
3. Conversely, biological explanations of human experiences do not negate (and often complement) valid psychosocial and cultural explanations and formulations
4. Biological factors are always part of a comprehensive differential diagnosis of serious emotional, cognitive, and behavioral disturbances—even if, upon careful analysis, psychosocial or cultural explanations prove more relevant or informative
5. That certain human experiences or perceptions (eg, “voices”) have a discernible “meaning,” symbolism, or psychological significance for the patient does not mean they have no neuropathological etiology
6. All somatic and psychological treatment modalities—whether medication or “talk therapy”—have meaningful (and sometimes measurable) effects on brain function and structure
There is nothing strikingly original in these principles. But it should be clear that this medical model does not empty the experience of “hearing voices” of psychological meaning; nor does psychiatry’s medical model in any way hold that the content of the patient’s voices is “random and meaningless.”