The Medical Model of Mental Health Care

The dominance of the medical model can be traced back to the first half of the twentieth century, in the early years of psychology and psychiatry as it looks today. As they struggled to gain legitimacy, the scientific and medical establishments criticized these new fields, arguing that they lacked clear explanatory models or proofs. Psychology and psychiatry, they argued, must be supported by the “hard science” approach favored by Western medicine. Both explicitly and implicitly, the medical paradigm superseded the psychoanalytic approaches developed by Sigmund Freud and others, which insisted, ultimately, on listening to people experiencing mental distress.

Other, more nefarious factors were also at play in the medicalization of mental suffering. Many of the psychiatrists involved in the drafting of recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) had financial ties to pharmaceutical industries.

Today, the market distortion of mental health care has worsened as health insurance companies insist on lowering costs associated with mental health care. The need to drive down costs and maximize profits pressures mental health care providers and researchers to accept certain conditions and treatments in opposition to others.

When it comes to treatment, the medical model primarily prioritizes Cognitive Behavioral Therapy (CBT), which is often touted as one of the more cost-effective forms of evidence-based practice. CBT emphasizes critical analysis of thought and behavioral patterns, in order to identify opportunities for change. CBT’s central idea is that if we can change our internal experience, we can reduce suffering.

When implemented thoughtfully, CBT can offer people a curious and nonjudgmental therapeutic space that supports them to develop the capacity to think about their thinking. Yet when CBT is not implemented thoughtfully — often impossible over the course of ten publicly subsidized sessions — it can encourage a kind of blindness toward material reality. Rote-delivered CBT offers a highly individualistic focus on mental health care that fails to contextualize suffering and places undue responsibility on the client to shoulder personal responsibility for their recovery.

Interestingly, there is evidence to suggest that when CBT does lead to positive change, it’s linked to unintentional psychoanalytic techniques that emerge in spite of the prejudices of the medical model. This suggests that the evidence base supporting CBT and the medical model more generally is selective and biased in favor of the assumption of the status quo. Even so, there is firm scientific backing for models of care beyond CBT, including psychoanalytic or psychodynamic psychotherapy.

As a short-term, cost-effective therapy, CBT fits neatly within the limits of a severely underfunded public mental health care system. At the same time, CBT’s individualistic narrative places responsibility for overcoming mental suffering disproportionately on the person burdened with that suffering. Consequently, when it doesn’t work, it’s not the system’s fault, but the patient’s.

In the absence of a robust enough public mental health care system, the medical model and CBT can appear to be our only options. Indeed, CBT is the main — and sometimes only — model assessed in Assessing Cost-Effectiveness (ACE) studies into mental health care in Australia.

There Is an Alternative (to CBT)

To paraphrase Mark Fisher, the medical model is so hegemonic that it’s often easier to imagine the end of the world than the end of CBT. Yet there are alternatives. For example, models built on a paradigm known as “relational care” emphasize the interpersonal nature of suffering and recovery.

Relational care emerged from the thinking of certain schools within the British Psychoanalytical Society in the second half of the twentieth century, particularly from the work of English pediatrician and psychoanalyst Donald Winnicott. Relational care models regard mental health care sociopolitically, and insist on considering the ways in which relationships with major people in our lives can create patterns of functioning and dysfunctioning.

Inevitably, this way of thinking leads us to consider the social systems that lead to disadvantage and abuse, helping us to work through the negative impacts that people have on each other. Relational models suggest that individuals absorb the impacts of living within dysfunctional social contexts, shaping their social worlds, and impacting others within them for better or for worse.

As Winnicott wrote in 1947, “There is no such thing as a baby.” Far from denying the existence of babies, what he meant was that a baby cannot exist in isolation. As he argued, given their near total helplessness, a baby’s physical and psychic development is dependent on the “good enough” care provided by a consistently available mother-figure.

Winnicott’s focus on the external world would go on to have a major influence within psychoanalytic thought and eventually, contemporary mental health care. His ideas formed part of the shift away from classical Freudian thinking toward a “two-person psychology,” or relational thinking. This approach to mental health care emphasizes the foundational importance of relationships in the architecture of an individual’s mind.

One of the outcomes of Winnicott’s breakthrough was the development of scientific frameworks — such as attachment theory — that offer formal evidence of how our relationships influence our mental health. This affirms the importance of relationships between children and the adults who raise them, explicating their profound impact on adult mental health and even physical health.

Relational thinking and models of mental health went on to inform several evidence-based treatment models, such as Dynamic Interpersonal Therapy (DIT) or Cognitive Analytic Therapy (CAT). Both therapies are offered within the publicly funded National Health Service (NHS) in the UK, while CAT is used in a publicly funded youth mental health service in Victoria.

Victoria’s Centers Against Sexual Assault

The network of Centres Against Sexual Assault (CASAs) across Victoria is a powerful case in point. The CASAs offer publicly funded, relationally minded mental health care to victims/survivors of sexual assault. The CASA network has a history dating back to 1974, when Women Against Rape — an offshoot of the Women’s Liberation Movement — established the first Rape Crisis Centre in a health care center in Collingwood, in Melbourne’s inner north.

Today, CASAs uphold their historic commitment to feminism (not of the girl boss variety) and are staffed by mental health care workers who integrate intersectional feminist perspectives on sexual trauma with specialist training in trauma therapy. The result is a model of care that places the impact of trauma in its social, political, and interpersonal context. Instead of restricting the focus to the individual who has experienced trauma, this way of working highlights the power dynamics and inequalities that facilitate gendered and sexual violence.

Dr Bree Weizenegger, a specialist trauma psychotherapist based in Melbourne, has studied the feminist trauma therapy offered at CASAs. In qualitative interviews, victim/survivors identified that the explicitly feminist trauma therapy interventions offered by CASAs were effective in supporting their recovery. Specifically, interventions that explored the social context in which sexual assault occurred were found to help victims/survivors reduce self-blame.

For example, deconstructing gendered norms around sex, as well as power discrepancies that favor men over women and gender diverse people, or adults over children, were found to ease the sense of shame and self-blame experienced by victim/survivors. Far from ignoring social realities in favor of the individual, the feminist relational model offered by CASA workers helps victims/survivors to contextualize sexual assault within the external factors that lead to sexual abuse.

According to the 2021 final report from the Royal Commission into the Victorian Mental Health System, people who had used the community mental health (not inclusive of CASAs) system consistently shared their experiences of trauma being under-/unacknowledged. This suggests that, in the absence of a robust enough system (and indeed, major themes of the report point to extreme rationing of resources), workers are restricted to a medical model of care.

Beyond the Medical Model

As limited as the medical model is, to blame it exclusively for Australia’s dysfunctional mental health care system would be reductive — it would be mistaking a symptom for the cause. In reality, the medical model dominates mental health care in this country precisely because it is well-suited to market-driven, profit oriented health care. The so-called free hand of the mental health care market — aided by pharmaceutical and insurance companies — has delivered the medical model a monopoly while stifling less-individualistic competitors.

That’s why adequate funding is only half of the solution to the crisis in Australia’s mental health care system. After all, if funding were doubled tomorrow, it would mainly expand access to CBT and other medical model-approved treatments. While this would be a step forward, a more radical overhaul of the system is needed.

In a publicly funded, robust enough mental health care system, people should have access to a variety of models of care. Working on the principle of informed consent, the mental health care system shouldn’t railroad people into one paradigm or treatment, but instead support them to find mental health care that suits their needs best.

At the same time, mental health care workers should be given the support and training they need to develop the kinds of therapeutic relationships that can affect meaningful change. This may be shy of what we could imagine in a socialist society — but it would represent a definitive break with Australia’s dysfunctional, neoliberal mental health care system and the medical model.