Contrasting Models of Care in Healthcare: Biomedical vs. Psychosocial

There are two contrasting models of care in healthcare: the biomedical model and the recovery-based psychosocial model. These models stem from different perspectives on the human body. The biomedical model, which historically prevailed in Western medicine and psychiatric treatment, views the human body as a biological entity and gives priority to disease, pathology, and remedies. In contrast, the recovery-based psychosocial model sees the human body as a complex microcosm influenced by its surroundings. The chosen approach to care greatly impacts both the treatment provided and patients' journey towards regaining health.

The biopsychosocial model (Engel, 1977) and psychosocial rehabilitation have presented the mental health field with an alternative to the biomedical model. These models prioritize a person-centred and recovery focused approach, acknowledging the influence of social factors in mental disorders. This paper will evaluate and compare the advantages and disadvantages of these care models in three main areas: (i) patient empowerment/disempowerment, (ii) implications for nursing practice, and (iii) outcomes.The biomedical model in psychiatry emphasizes the use of medication to treat mental disorders, attributing them to factors such as chemical imbalances, genetic anomalies, brain structure defects, or neurotransmitter dysregulation.

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This approach distinguishes biological psychiatry from a biopsychosocial approach to mental health care. Engel (1977) criticized the reductionist nature of the biomedical model and argued that it neglects the social, psychological, and behavioral dimensions of illness.

He introduced a model that considers the patient, their social environment, and society's response to illness. This biopsychosocial framework is the basis for recovery-driven psychosocial rehabilitation (Cnaan, Blankertz, Messinger & Gardner, 1988; King, Lloyd & Meehan, 2007).

Unlike the biomedical model, psychosocial rehabilitation emphasizes the subjective aspect of recovery and well-being. Thus, an individual's perception of themselves and their level of wellness may not always align with their symptoms and signs.

There is a discussion about patient empowerment/disempowerment.

Critics argue that the biomedical model undermines patient empowerment by presenting them as passive recipients of treatment based on a diagnosis. The biomedical model restricts personal choice and views disease as a deviation from the biological norm, focusing on identifying causes and remedies for illness. This perspective assumes that symptoms and behavior stem from an underlying pathological cause and emphasizes objective indicators of recovery. Consequently, patients are unable to independently improve their condition and must adhere to diagnosis-specific treatments prescribed by psychiatrists in order to bring about any behavioral changes. It is contended that the negative consequences associated with psychiatric diagnoses (such as stigma, involuntary hospitalization, and long-term medication use) outweigh any potential benefits.

The concept of recovery is viewed as empowering within the psychosocial rehabilitation framework for individuals receiving mental health services (Shah & Mountain, 2007; Callard et al., 2013). This approach highlights a social model of care and prioritizes the patient's strengths over their pathologies (King et al., 2007). Within this framework, there exists a doctor-patient-like relationship between patients, caregivers, and clinicians, akin to the biomedical model.

The main focus is on developing a therapeutic alliance (King et al., 2007) where the patient takes ownership of their recovery, while professionals and services support this process (Mountain & Shah, 2008). The goal of psychosocial rehabilitation is to empower the patient to have control over their illness and well-being, and to maintain a positive sense of self even if symptoms persist (Barber, 2012). This approach differs greatly from the biomedical model, which involves the practitioner managing the illness and considers health as the absence of symptoms or disease (Wade & Halligan, 2004).

The limitations of the psychosocial perspective should also be taken into account. By focusing on self-determination and self-management of mental illness and wellbeing, there is a potential risk of attributing responsibility or blame to the patient when health outcomes are not ideal. This is especially important in mental health settings, where poor health outcomes are unfortunately common (Deacon, 2013). In contrast, the biomedical model allows the psychiatrist to shoulder more of the responsibility, providing some consolation to the patient.

The idea of 'care' versus 'cure' suggests that the biomedical model and psychosocial rehabilitation, while competing approaches, are not entirely separate when it comes to empowering the patient. It is worth noting that contemporary definitions of the biomedical model strive to incorporate recovery-focused treatment methods (Barber, 2012; Mountain & Shah, 2008; Wade & Halligan, 2004). In modern times, the doctor-patient relationship is believed to resemble the psychosocial therapeutic alliance more closely, which is based on engagement and recognition of both partners' skills and knowledge. However, in mental health care, the biomedical model may differ from psychosocial rehabilitation by resorting to compulsion (Mountain & Shah, 2008).

Today's mental health legislation often aligns with the biomedical model, leading to regular disempowerment of individuals with psychiatric diagnoses. Their right to self-determination is frequently overridden by legal powers of compulsion (Thomas, Bracken & Timimi, 2012). Despite some moves towards self-determination within the biomedical model, mental health patients may still be forced into treatment against their will. In contrast, the psychosocial framework supports a community-based approach to care, focusing on 'case management' to empower patients and encourage independence (King et al., 2007).

(i) Implications for nursing practice

While the medical model is beneficial for psychiatrists in recognizing disorders and diseases, it lacks a biological cause or dependable biomarker for any mental disorder (Deacon, 2013). Furthermore, the majority of mental disorders are influenced by and have consequences within a social context (McAllister & Moyle, 2008). Consequently, there is a need to question the suitability of the biomedical model as a nursing model in mental health care settings.

Although the biomedical model is dominant in nursing and psychiatry, there is an increasing recognition of the significance of the interpersonal domain and psychosocial factors in providing care. In an inpatient setting, mental health nurses acknowledge the impact of interpersonal factors on mental distress but still describe their role and nursing interventions as supportive of a medical model. This emphasizes the conflict between conventional nursing concepts and the comprehensive approach demanded by a psychosocial framework.

There are several issues with the utilization of the biomedical model in mental health nursing. The primary goal of this model is to achieve a cure, and nurses who follow it must also work towards this objective. This presents a problem for a field that deals with disorders that may not have an easily identifiable cause and often have poor outcomes (Deacon, 2013). In terms of 'care' versus 'cure', nurses in mental health settings face the challenge of being guided by the medical model, which hinders them from achieving their desired outcome of care, specifically a cure (Pearson, Vaughan & FitzGerald, 2005).

According to Pearson et al. (2005), the biomedical model, which emphasizes disease and categorizing individuals based on their diseases, can depersonalize nursing care. This model may undervalue nurses by prioritizing medical diagnosis and cure over the humanistic aspects of care. Despite its limitations in mental health nursing practice (McAllister & Moyle, 2008), nurses often resort to this model to justify their practice when no other option is present.

Psychosocial rehabilitation is viewed as a viable alternative to the biomedical model and offers benefits for both mental health service consumers and the nurses who care for them (Stickley & Timmons, 2007). Multiple studies support a shift towards a recovery-focused, psychosocial approach rather than the traditional medical model (Engel, 1977; Barber, 2012; Caldwell, Sclafani, Swarbrick & Piren, 2010; Mountain & Shah, 2008). Unlike the biomedical model, the nurse-patient therapeutic alliance plays a central role in the psychosocial framework (King et al., 2007). Therefore, nurses have a more active role in developing, coordinating, and implementing strategies to support the recovery process instead of solely focusing on tasks (Caldwell et al., 2010). Additionally, this care model aligns with nurses' perceptions of their role as caregivers and their beliefs about the causes of mental disorders while also reflecting their attitudes towards best practice (McAllister & Moyle, 2008; Carlyle et al., 2012).

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(i) Results

The biomedical model has been associated with significant advancements in medical care during the 20th century. However, it lacks clinical innovation and leads to poor outcomes in mental health care (Deacon, 2013). Despite its drawbacks, the biomedical model does have strengths. Its main advantage is objective scientific experimentation, which provides a strong knowledge base and applies to various diseases (Pearson et al., 2005; Wade & Halligan, 2004). Evidence-based medicine allows psychiatrists to access unbiased evidence on the safety and effectiveness of their interventions (Thomas et al., 2012). Shah & Mountain (2007) argue that although the biomedical model has successfully developed effective psychopharmacological treatments, it fails to identify the specific elements of effective psychosocial treatments.

The effectiveness of a psychosocial rehabilitation program for patients with severe and persistent mental illness was supported by a study conducted by Chowdur, Dhariti, Kalyanasundaram, and Suryanarayana in 2011. The study indicated notable improvement in functioning levels among all participants across various measured parameters. However, the study did not provide specific information regarding the individual effects of different components of the rehabilitation program, posing challenges in isolating and studying each component's impact. Nonetheless, the limitations of the study should not dismiss the overall advantages offered by psychosocial rehabilitation.

The biomedical model, despite its rigorous study methods and evidence-based core, has been unsuccessful in uncovering the biological basis of mental disorders and reducing stigma. According to Deacon (2013) and Schomerus et al. (2012), there is a lack of tangible progress. Additionally, Kvaale, Haslam & Gottdiener (2013) found that biogenetic explanations for psychological illnesses contribute to negative perceptions and do not effectively reduce stigma. This has significant implications in a society where the understanding of mental illness by the general public and nursing students is primarily influenced by a biogenetic, medicalized perspective (Kvaale et al., 2013; Stickley & Timmons, 2007).

In contrast, stigma may be reduced by psychosocial rehabilitation programmes. As previously discussed, these programmes aim to empower the patient. Research shows that empowerment and self-stigma are on opposite ends of a spectrum (Rüsch, Angermeyer & Corrigan, 2005). By improving the patient's self-esteem, understanding, societal roles, and basic self-care abilities (King et al., 2007), psychosocial rehabilitation programmes can lessen the negative impact of stigma. In a study focused on patients with schizophrenia (Koukia & Madianos, 2005), caregivers and relatives reported lower levels of objective and subjective burden when the patient participated in a psychosocial rehabilitation programme.

Thomas et al. (2012) distinguish between specific factors (such as pharmacological interventions for neurotransmitter imbalances) and non-specific factors (such as contexts, values, meanings, and relationships) in their examination of the credibility of evidence-based medicine in psychiatric practice. They find that non-specific factors are significantly more influential in facilitating positive outcomes, thus endorsing a psychosocial perspective.

In recent years, there has been a shift towards the recovery model in public opinion and policy. This is supported by the literature, which echoes Engel's proposition of a 'new medical model' based on a biopsychosocial approach. The Australian Government Department of Health has also recognized the positive outcomes of a recovery-based model and released the National framework for recovery-oriented mental health services in 2013. Despite ideological differences, psychosocial rehabilitation and the biomedical model can coexist, as suggested by literature examining the modern delivery of mental health care (Barber, 2012; Mountain & Shah, 2008; Shah & Mountain, 2007).

Conclusion

Recently, there have been significant changes in the way mental illness is perceived and the availability of mental health services. The focus has shifted towards community-based care, psychosocial rehabilitation programs, and empowering patients through self-determination. This shift has been accompanied by increased research and positive outcomes for individuals with mental health issues.

However, despite these advancements, modern mental health care still largely follows the biomedical model. While contemporary interpretations of this model recognize the importance of social and psychological factors, they tend to prioritize biological factors. This is problematic because no specific biological causes of mental disorders have been identified (Deacon, 2013).

Barber (2012) argues that a contemporary model is needed in modern mental health services, suggesting that recovery should be considered as the 'new medical model for psychiatry.' Psychosocial rehabilitation, which emphasizes the role of nurses, is linked to improved objective and subjective patient outcomes. According to Engel (1977), the dogmatism of biomedicine unintentionally leads to patients feeling frustrated with their genuine health needs not being adequately addressed. Truly integrating a biopsychosocial approach into modern mental health care would establish a framework for consistent positive outcomes and unlimited innovation.

REFERENCES

The article titled "Recovery as the new medical model for psychiatry" was written by Barber, M. in 2012 and published in Psychiatric Services. It explores the concept of recovery in relation to the field of psychiatry, emphasizing its significance as the new medical model. The article is available in volume 63, issue 3, pages 277-279.

According to Caldwell, Sclafani, Swarbrick, and Piren (2010), the recovery model of care is important in psychiatric nursing practice. In their study published in the Journal of Psychosocial Nursing, they explore the significance of this model and its implications for patient care.

In a study conducted by Callard, Bracken, David, and Sartorius (2013), it was found that psychiatric diagnosis may have a negative impact on patients by labeling them rather than helping them. The study was published in The British Medical Journal, volume 347, with the doi number 10.1136/bmj.f4312.

The cited article, "Models of care delivery in mental health nursing: a mixed method study," was authored by Carlyle, D., Crowe, M., and Deering, D. and published in the Journal of Psychiatric and Mental Health Nursing in 2012 (pp. 221-230).

Chowdur, R., Dharitri, R., Kalyanasundaram, S., and Suryanarayana, R. (2011) conducted a study on the effectiveness of a psychosocial rehabilitation program called the RFS experience. This study was published in The Indian Journal of Psychiatry and can be found in volume 53(1), pages 45-48.

The article "Psychosocial Rehabilitation: Toward a Definition" by Cnaan, R., Blankertz, L., Messinger, K., & Gardner, J. (1988) explores the concept of psychosocial rehabilitation. The article was published in the Psychosocial Rehabilitation Journal and can be found on pages 61-77 of volume 11, issue 4.

Deacon, B. (2013). The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review 33, 846-861.

According to the Australian Health Minister's Advisory Council (2013), the Department of Health in Canberra, Australia has developed a national framework for recovery-oriented mental health services.

Engel, G. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196, 129-136.

Harding, C. (2005). Changes in schizophrenia over time: contradictory findings, recurring trends, and factors influencing outcomes. In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery From Severe Mental Illnesses: Research Evidence and Implications for Practice (pp. 19-41). Boston: Centre for Psychiatric Rehabilitation.

The text provides information about a book titled "Handbook of psychosocial rehabilitation" authored by King, R., Lloyd, C., & Meehan, T. in 2007. The book is published by Blackwell Publishing and is located in Carlton, VIC.

Koukia, E., & Madianos, M.G. (2005). Is the prevention of family burden through psychosocial rehabilitation of schizophrenic patients a comparative study? In the Journal of Psychiatric and Mental Health Nursing, volume 12, pages 415-422.

Kvaale, E., Haslam, N., & Gottdiener, W. conducted a meta-analytic review titled "The ‘side effects’ of medicalisation: a meta-analytic review of how biogenetic explanations affect stigma" in Clinical Psychology Review (Vol. 33, pp. 782-794).

The article titled "An exploration of mental health nursing models of care in a Queensland psychiatric hospital" by McAllister, M. and Moyle, W. (2008) was published in the International Journal of Mental Health Nursing. The article discusses different models of care used in a psychiatric hospital in Queensland. The paper can be found on pages 18-26 of the journal.

Mountain, D., and Shah, P. (2008). Recovery and the medical model. Advances in Psychiatric Treatment, 14, 241-244.

The book "Nursing models for practice" was written by Pearson, A., Vaughan, B., and FitzGerald, M. It was published by Elsevier in Sydney, NSW in 2005.

In their article titled "Mental illness stigma: concepts, consequences, and initiatives to reduce stigma" published in the European Psychiatry journal in 2005, Rüsch, N., Angermeyer, M., and Corrigan, P. discuss the various aspects of mental illness stigma and explore the initiatives aimed at reducing it.

Schomerus, G., Schwahn, C., Holzinger, A., Corrigan, P., Grabe, H., & Carta, M. (2012). Evolution about public attitudes of mental illness: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 125, 440-452.

Shah, P., & Mountain, D. (2007). The medical model, known as the British Journal of Psychiatry, has been declared dead and is now being revived as a new approach.

Stickley, T., and Timmons, S. (2007). The article titled "Considering alternatives: student nurses slipping directly from lay beliefs to the medical model of mental illness" was published in Nurse Education Today, volume 27, pages 155-161.

Thomas, P., Bracken, P., and Timimi, S. (2012). The anomalies of evidence-based medicine in psychiatry: time to reconsider the foundation of mental health practice. Mental Health Review Journal.

Wade, D., and Halligan, P. (2004). Do biomedical models of illness result in effective healthcare systems? The British Medical Journal, 329, 1398-1401.