Consequences of the Medical Model

Talk is Not Enough: How Psychotherapy Really Works
by Willard Gaylin, M.D.

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What had formerly been seen as unhappiness, or a crisis in confidence, or a moral failing was now defined as a clinical condition. Some might say: "What's the difference? Only the name of the game has been changed."

Nothing could be further from the truth. With a change of definition comes a change in rules and attitudes. When you go to a psychotherapist for your distress rather than to your minister, you are not simply speaking to a different person about the same problems. You are speaking to a different professional with different attitudes about your problems. As a result, your problems will be defined in different ways.

To be "sick" is different from being "bad" or even "unhappy." Compare therapy with the Catholic confessional - with which there is some similarity. Confession in either case can lead to some comfort or relief of distress. But what follows differs dramatically, depending on whether the behavior confided is defined as a sin or a symptom. The penitent goes to his priest confessing something he knows to be "sinful." The priest listens and - in a religion of forgiveness like Christianity - offers penance that absolves the penitent from the consequences of his immoral behavior, or sin. It is clear to both penitent and priest that what the individual has done was wrong, evil, sinful, immoral, name it what you will. The purpose of the confessional is to both condemn the sin and forgive the sinner.

Something much more complex happens in a medical model. The very same behavior is no longer defined as sinful, nor stigmatized. We do not condemn the symptom of a disease. No moral judgments are made about a festering sore or a leaky heart valve. A doctor does not look at your impetigo or your bloody sputum with disgust and condemnation. They are "not your fault." You are the suffering victim of your own symptoms. The doctor's role is to cure the symptoms that are disturbing your life. These symptoms are viewed as independent of your autonomy and therefore are not your responsibility.

To the psychotherapist, as well as to the sophisticated layman, the model of symptoms and disease in mental illness is perceived in the same manner as in physical illness. The drug addict - and all of the behavior that is interpreted as being contingent upon his addiction - is observed neutrally by the psychotherapist, without condemnation, without introduction of ideas of retribution or penance. Drug addicts are to be treated. Similarly, there will be no moral judgments made about the phobic, the obsessive, the hysteric, the kleptomaniac (formerly, "thief"), or the sexual voyeur (formerly, "Peeping Tom").

Being cast in the sick role places one in a different scenario from that of the sinner or criminal. The patient is not responsible for his symptom. It is visited upon him from a hostile environment or from his developmental past. The patient is neither sinner nor criminal, but a victim. He is not to be forgiven, he is to be pitied. He is not to receive penance, but treatment. He is not to receive condemnation and scorn, but succor and sympathy. Whatever we are prepared to define as a symptom of a disease, whether it be exhibitionism, alcoholism, or brutality, will be protected from moral judgment or criminal culpability under the medical model. Theoretically you are no more blameworthy for the bad temper that caused you to beat your wife than you would be for an epileptic seizure. This already suggests some of the problems that follow when attempting to apply the medical model (suitable to psychotherapy) to the broader world of social living.

The ramifications of the medical model are profound, influencing such diverse areas as the schools, the courts, and the workplace. Moral and legal culpability for many actions for which we would formerly have been held accountable are mitigated when such behavior is seen as the symptom of a disease rather than a willful choice. For our purposes here, it is only important to realize that the therapist, in his dealing with the same piece of behavior that the court or the priest had dealt with previously, will have a different frame of mind, create a different set of conditions, and institute different methods of change.

About the Author

Willard Gaylin, M.D., is the author of fifteen books, including Feelings, The Killing of Bonnie Garland, and The Rage Within. He is Clinical Professor of Psychiatry at Columbia College of Physicians and Surgeons and cofounder of the Hastings Center, the preeminent institute for the study of ethical issues in the life sciences. For more than thirty years he has been a leading theoretician, educator, and practitioner in the field of psychotherapy and psychoanalysis.