Competing views of the human body as either a biological phenomena or a complex microcosm borne of its environment, have provided the basis for the development of two different models of care: the biomedical model, and the recovery-based psychosocial model. The model of care adopted by care providers heavily influences the nature of the treatment given, and the trajectory of a patient’s journey through illness, to wellness. Historically, the biomedical model of care has been the foundation of Western medicine, and has remained largely unchallenged as the dominant model of care used in the delivery of psychiatric treatment.
It is practiced with a focus on disease, pathology, and ‘cure’.
The emergence of the biopsychosocial model (Engel, 1977) and psychosocial rehabilitation has provided the mental health arena with an effective alternative to the biomedical model. With an approach that is person-centred and recovery focused, it aligns with contemporary attitudes about mental disorders having their origins and impacts in a social context. This paper will critically analyse and compare the benefits and limitations of both models of care, through an exploration of three key areas: (i) empowerment/disempowerment of the patient, (ii) implications for nursing practice, and (iii) outcomes.
In psychiatry, the biomedical model emphasises a pharmacological approach to treatment, and supposes that mental disorders are brain diseases caused solely, or by a combination of chemical imbalances, genetic anomalies, defects in brain structure, or neurotransmitter dysregulation (Deacon, 2013). This supposition makes up one side of a Descartian divide that exists between biological psychiatry and a biopsychosocial approach to mental health care.
Engel (1977) viewed the biomedical model as ‘reductionist’, and posited that it neglected the social, psychological and behavioural dimensions of illness.
He proposed a biopsychosocial model that takes into account ‘the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness’ (p. 131). It is within this biopsychosocial framework, that recovery-focused psychosocial rehabilitation takes place (Cnaan, Blankertz, Messinger & Gardner, 1988; King, Lloyd & Meehan, 2007). Less objective than the biomedical model, psychosocial rehabilitation focuses on the subjective experience of recovery and wellness, that is, the presence of signs and symptoms may not necessarily align with the individual’s sense of self and wellness.
(i) Empowerment/disempowerment of the patient
A persistent criticism of the biomedical model is the assertion that the patient is disempowered. Firstly, the nature of the doctor-patient relationship suggests that the patient is a passive recipient of treatment; the patient is reduced to a diagnosis, and offered diagnosis-specific treatment options. The role of personal choice exists, however in a limited capacity. Secondly, the ideology underpinning the biomedical model assumes disease to be a deviation from the biological norm, with illness understood in terms of causation and remediation (Deacon, 2013; Shah & Mountain, 2007; Engel, 1977). This perspective assumes the existence of some underlying pathological cause for symptoms and behaviour, and focuses on objective indicators of recovery (King et al., 2007). The implications of this perspective are that the patient cannot, from his own resources, do anything to ameliorate his illness, and to affect any change in his behaviour, he must adhere to diagnosis-specific treatment set out by the psychiatrist. It is argued that the ways in which a patient can be disempowered by a psychiatric diagnosis (stigma, forced hospitalisation, long-term pharmacotherapy etc.) far outweigh any benefits they might receive (Callard, Bracken, David & Sartorius, 2013).
Comparatively, recovery within the framework of psychosocial rehabilitation is widely considered to be empowering for consumers of mental health services (Shah & Mountain, 2007; Callard et al., 2013). Two key principles of psychosocial rehabilitation are an emphasis on a social rather than medical model of care, and on the patient’s strengths rather than pathologies (King et al., 2007). Similar to the doctor-patient relationship of the biomedical model, there exists a relationship between patients, caregivers and clinicians in the psychosocial framework.
The emphasis however is on the formation of a therapeutic alliance (King et al., 2007) in which recovery is owned by the patient, with professionals and services facilitating this ownership (Mountain & Shah, 2008). The aim of psychosocial rehabilitation is for the patient to have self-determination over their illness and health, and a fulfilled sense of self despite the possible continuation of symptoms (Barber, 2012). This is in stark contrast to the biomedical model in which illness is managed by the practitioner, and health is hallmarked by the absence of symptoms and disease (Wade & Halligan, 2004).
The psychosocial perspective must also be considered in terms of its potential limitations. By placing an emphasis on self-determination and self-management of mental illness and wellbeing, there runs a parallel risk of instilling a sense of responsibility or blame within the patient when less than desirable health outcomes occur. This is of particular relevance in mental health settings, where poor health outcomes are unfortunately, likely (Deacon, 2013). In the biomedical model, the psychiatrist would offer some small consolation to the patient in the form of shouldering the bulk of the responsibility.
With regard to empowerment of the patient, this notion of ‘care’ versus ‘cure’ suggests that the biomedical model of care and psychosocial rehabilitation are two competing models of care that are divorced from one another. They are not, however, mutually exclusive, and it is worth noting that contemporary definitions of the biomedical model at least attempt to consider the incorporation of recovery-based treatment approaches (Barber, 2012; Mountain & Shah, 2008; Wade & Halligan, 2004). It has been suggested that modern day doctor-patient relationships are far more aligned with the nature of the psychosocial therapeutic alliance, founded on engagement and the recognition of skills and knowledge of each partner (Mountain & Shah, 2008). Specifically in a mental health setting, it might be argued that the biomedical model parts ways with psychosocial rehabilitation by use of compulsion (Mountain & Shah, 2008).
The intent behind much of today’s mental health legislation is guided by the ideologies of the biomedical model. This results in patients with a psychiatric diagnosis being frequently disempowered, by having their right to self-determination overridden by legal powers of compulsion (Thomas, Bracken & Timimi, 2012). Despite a shift towards self-determination by the biomedical model, mental health patients may be forced to accept treatment against their wishes. In opposition to this, the psychosocial framework favours a community-based, ‘case-managed’ style of care (King et al., 2007), which seeks to empower the patient and maintain independence.
(i) Implications for nursing practice
The medical model is a useful framework to assist the psychiatrist in the identification of disorders and diseases. However, scientists have identified neither a biological cause nor a reliable biomarker for any mental disorder (Deacon, 2013), and arguably, most mental disorders have their origin and impact in a social context (McAllister & Moyle, 2008). Therefore, the validity of the biomedical model as a nursing model of care in mental health settings must be questioned.
The all-encompassing nature of the care delivery required by a psychosocial framework may, at times, appear to be at odds with more ‘traditional’ concepts of nursing. It is understood that the biomedical model is the model on which many nurses base their practice. It is also the model that has long dominated the field of psychiatry (Stickley & Timmons, 2007), despite a plethora of literature espousing the importance of the interpersonal domain and psychosocial factors. Findings from a study by Carlyle, Crowe & Deering (2012) showed that mental health nurses working in an inpatient setting described the role of mental health services, the role of the nurse and nursing interventions in terms of supporting a medical model of care. This was despite recognition amongst the nurses that they used a psychodynamic framework for understanding the aetiology of mental distress, as being a result of interpersonal factors.
The problems with the use of the biomedical model in mental health nursing are varied. The overriding goal of the biomedical model is cure, and therefore nurses that base their practice on it must also aim for this outcome. This is obviously troublesome for a speciality that treats disorders that may not have a definable cause, and typically have poor outcomes (Deacon, 2013). Regarding ‘care’ versus ‘cure’, the challenge for nurses working in mental health settings where their practice is underpinned by the medical model, is the inability to achieve the outcome of care that they believe to be appropriate, that is, a cure (Pearson, Vaughan & FitzGerald, 2005).
In terms of the provision of nursing care, the biomedical model’s focus on disease and the objective categorisation of people by disease can serve to depersonalise patients and so too, the nursing care provided to them (Pearson et al., 2005). It may well be argued that the biomedical model devalues the role of the nurse, because the humanistic side to care is diminished in favour of a medical diagnosis and cure. Overall, the ideals of mental health nursing practice are constrained by the biomedical model (McAllister & Moyle, 2008), however, nurses feel comfortable using this model to explain their practice, in the absence of a defined alternative.
Psychosocial rehabilitation as an alternative to the biomedical model not only has positive implications for consumers of mental health services but also to the nurses who provide their care (Stickley & Timmons, 2007). Indeed, a wealth of literature supports a shift from the medical model to a recovery-based, psychosocial approach (Engel, 1977; Barber, 2012; Caldwell, Sclafani, Swarbrick & Piren, 2010; Mountain & Shah, 2008). In contrast to the biomedical model, the nurse-patient therapeutic alliance is at the core of the psychosocial framework (King et al., 2007). In this way, the role of the nurse moves away from being task-focused, to actively developing, coordinating and implementing strategies to facilitate the recovery process (Caldwell et al., 2010). Additionally, this model of care strongly aligns with nursing perceptions of their role as care providers, their beliefs regarding the aetiology of mental disorders, and their attitudes towards best practice (McAllister & Moyle, 2008; Carlyle et al., 2012).
Generally, the biomedical model has been associated with vast improvements in medical care throughout the 20th century. Despite its persistent dominance of both policy and practice, the biomedical model in regards to the delivery of mental health care is characterised by a lack of clinical innovation and poor outcomes (Deacon, 2013). It does, however, have its redeeming qualities. The primary strength of the biomedical model is its core knowledge base derived from objective scientific experiment, its intuitive appeal, and relevance to many disease-based illnesses (Pearson et al., 2005; Wade & Halligan, 2004). Evidence-based medicine allows the psychiatrist to access objective evidence about the safety and effectiveness of their interventions (Thomas et al., 2012). Shah & Mountain (2007) argue that the model’s rigorous methods used to gather evidence that have resulted in numerous effective psychopharmacological treatments, cannot be translated in helping to identify which specific elements of psychosocial treatments are effective.
This assertion is evidenced by a study documenting the efficacy of a psychosocial rehabilitation programme (Chowdur, Dhariti, Kalyanasundaram, & Suryanarayana, 2011) in patients with severe and persisting mental illness. The study showed significant improvement for all participants across a range of parameters used to measure levels of functioning. However, the results did not reveal the specific effects of various components of the rehabilitation programme, making it difficult to isolate each component and to study its effect. Regardless, the overall benefits of psychosocial rehabilitation should not be ignored simply due to study limitations.
Despite the biomedical model’s rigorous study methods and evidence-based core, tangible signs of progress are few and far between. Indeed, the biomedical approach has failed to elucidate the very biological basis of mental disorder, and also failed to reduce stigma (Deacon, 2013; Schomerus et al., 2012). Kvaale, Haslam & Gottdiener (2013) determined that biogenetic explanations for psychological illnesses increase ‘prognostic pessimism’ and perceptions of dangerousness, and do little to reduce stigma. This conclusion has obvious implications in a society where the layperson’s, and in fact, nursing student’s understanding of mental illness is a biogenetic, ‘medicalised’ one (Kvaale et al., 2013; Stickley & Timmons, 2007).
In contrast, psychosocial rehabilitation programmes may have the effect of reducing stigma. As previously discussed, psychosocial rehabilitation is underpinned by an ideology that seeks to empower the patient. Research has shown that empowerment and self-stigma are opposite poles on a continuum (Rüsch, Angermeyer & Corrigan, 2005). By enhancing the patient’s sense of self, insight, societal roles, and basic self-care functions (King et al., 2007), psychosocial rehabilitation programmes have the ability to reduce the negative effects of stigma. In a study particular to patients with schizophrenia (Koukia & Madianos, 2005), caregivers and relatives reported lower levels of objective and subjective burden when the patient was engaged in a psychosocial rehabilitation programme.
In their exploration into the validity of evidence-based medicine in psychiatry, Thomas et al. (2012) differentiate between specific factors (e.g. pharmacological interventions targeting specific neurotransmitter imbalances), and non-specific factors (e.g. contexts, values, meanings and relationships). They determined that non-specific factors are far more important in relation to positive outcomes, which would support a psychosocial approach.
In recent years, public opinion and policy has become more aligned with the recovery model, evidenced by the wealth of literature echoing Engel’s (1977) proposition of a ‘new medical model’ founded on a biopsychosocial approach. Recently, the Australian Government Department of Health acknowledged the positive outcomes associated with a recovery-based model, and released the National framework for recovery-oriented mental health services (2013). Despite their ideological differences, psychosocial rehabilitation need not be viewed as the antithesis to the biomedical model, with literature suggesting a degree of compatibility between the two that is becoming more apparent in the modern delivery of mental health care (Barber, 2012; Mountain & Shah, 2008; Shah & Mountain, 2007).
Recent years have seen significant changes in the perceptions of mental illness, and the provision of mental health services that are available. The move towards community-based care, psychosocial rehabilitation programmes, and empowerment of the patient through self-determination has been accompanied by a growth in research, and positive outcomes for mental health consumers. Despite this progress, modern mental health care is still largely dominated by the biomedical model. Whilst contemporary interpretations of the psychiatric biomedical model recognise the value of social and psychological factors, they appear to do so in a way that relegates those factors to an order below that of biological factors. This occurs in the absence of any definable biological causes for mental disorders (Deacon, 2013).
A contemporary model is required in modern mental health services. Indeed, Barber (2012) suggests that recovery should be thought of as the ‘new medical model for psychiatry. Psychosocial rehabilitation is associated with improved objective and subjective patient outcomes, and emphasises the role of the nurse. As observed by Engel (1977), the dogmatism of biomedicine inadvertently results in the frustration of patients who believe their genuine health needs are being inadequately met. True incorporation of a biopsychosocial approach into modern mental health care, would create a framework for consistent positive outcomes, and limitless innovation.
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