By Ken Duckworth, M.D.
The best way to maximize progress on a challenging journey is to use every resource at your disposal. On a journey, it is often best to maximize scientific (e.g., compass, maps, equipment) resources, as well as learn from prior experience by using hope and intuition. Similarly, in the world of living with mental illness, two models—the medical model and the recovery model—are each great tools to promote progress.
I have come to see that these models can make a big difference for people, particularly when they are integrated. I use a “both/and,” not an “either/or,” approach with the young adults I serve as a psychiatrist at the Prevention and Recovery from Early Psychosis Clinic (PREP) at Harvard University. Together, we use all the tools available for the journey of recovery: science, diagnosis, shared medical decision-making, hope, strengths, education, work and family.
The recovery model is relatively new in the field of mental health and clearly speaks to the needs of many people living with mental illness. It emphasizes many things, but hope, empowerment, peer support and self-management stand out to me as key principles of the model. The medical model has a long tradition and is rooted in evidence and science. At its best, the medical model can be implemented with humanity and compassion. I hope to make a case for both of these models and ultimately show why they are complementary.
Recovery means different things to different people, but some similar principles are found across most models, and its concept has its roots in the substance-abuse community. The Substance Abuse and Mental Health Services Administration (SAMSHA) engaged in a process with many stakeholders to come up with the following definition for recovery from mental illness and substance use disorders: A process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.
Through the Recovery Support Strategic Initiative, SAMHSA has outlined four major dimensions that support a life in recovery:
The recovery model speaks to people’s goals and addresses the ways in which they want to live. It focuses on the goal of having a good life that is not deficit- and symptom-focused. The recovery model involves many aspects of life that are common to all people, thereby promoting shared concerns. It focuses on the individual’s experience as a source of expertise. It also creates positive expectations for people engaged in a recovery process, and supports a strong peer culture. Finally, the recovery model instills hope in a field that has long lacked this kind of vision.
A vulnerability of the model is that the subjective experience of recovery is inherently hard to measure. In a world with shrinking resources, things that aren’t measured are often not adequately attended to or funded. There are a few measures of recovery that are in process, but there is no consensus on using them in the field or a strong way to validate the quality of these measures. Another criticism of the model is that some people with psychosis do not see themselves as ill (the neurological condition known as anosognosia), have not responded to treatment and have overwhelming symptoms. These individuals and their families may feel that the higher expectations fostered by the recovery model leave them behind.
The medical model relies on science—such as a correct biological diagnosis and research. Diagnosis is rooted in pathology—i.e., what is wrong—in order to develop ways to help either cure or reduce symptoms. The medical model relies on scientific proof of a pathological process or treatment interventions that can be replicated in other studies.
The medical model involves the pursuit of scientific truth and has objective facts as its ideal. The model has been robustly successful in acute conditions such as infectious disease and has made great strides in helping people, such as guiding the medical community toward which chemotherapy best treats which cancer or which antibiotic works best for which bacteria. Through this model, some conditions, such as HIV infection, have been turned from being lethal conditions to being chronic-but-manageable illnesses. Medical model care, at its best, marries science with compassion for the individual in treatment. Excellent doctors employ science while also using Dr. Francis Peabody‘s philosophy: “... for the secret of the care of the patient is in caring for the patient.”
In psychiatry, conditions don’t generally lend themselves to acute intervention models. In regards to illnesses that are more chronic, the medical model has been criticized for being too deficit-oriented and physician-defined. The medical model can also ignore a person’s strengths and thereby turn people off by being too pathology-based. Psychiatry faces the additional challenge of dealing with the incredibly complex brain, so the underlying biology that leads to clear treatments based on neurobiology is elusive—at least for now.
Can the first-person vision for hopefulness and reliance on experience be integrated with scientific knowledge to inform better care and outcomes? Yes. I believe that integrating these models is the best way to promote better care and outcomes for both individuals and systems. As a field, we are moving toward this kind of integration, but it—like many things in life—is a process. Here are some examples of how the two models can work together.
The Wellness Recovery Action Plan (WRAP), developed by Mary Ellen Copeland, helps people self-manage their experiences and promotes illness-management strategies. This model was created by Copeland to attend to her own challenges and has intuitive appeal. Research studies now validate its effectiveness. This means that the program isn’t only a subjective positive for the individuals who use it; it is worthy of replication, dissemination and funding.
Similar findings have concluded that an intervention known as Illness Management and Recovery (IMR), which was developed at Dartmouth College, also has scientific validity. The idea that recovery-oriented strategies pass research muster adds another important dimension to their success.
Similarly, NAMI’s Family-to-Family program, developed by Dr. Joyce Burland, is the classic, home-grown NAMI signature program that many NAMI readers and members have taken or taught. It was declared an evidenced-based practice in 2013. The medical model of scientific inquiry led Dr. Lisa Dixon, a service researcher, to demonstrate that NAMI Family-to-Family worked better than a placebo (people on the waiting list did not show the same results). The medical model took a creative homegrown idea and validated it with scientific inquiry.
Cognitive Enhancement Therapy (CET) is a model of “brain training” that is based on the idea that “neurons that fire together wire together.” It is a way to encourage recovery by promoting an active approach to cognition and upholding the construct that the brain is plastic and not fixed. CET is a good example of a recovery approach that grew out of the medical model, as it has its roots in stroke rehabilitation. It has now been studied in individuals in the early stage of psychosis and has been found to make a positive difference in cognition for those individuals. Studies are now underway to examine how it can be used for people living with major mental illnesses who have had cognitive problems for longer periods of time.
Diagnosis is one of the cornerstones of the medical model. Yet diagnosis can also be a key to organizing a recovery plan. For example, if a person lives with bipolar disorder, then taking antidepressants is unlikely to be of much help in the depressive phase (see the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study), and they may actually make things worse by activating mania. A diagnosis of bipolar disorder also increases the need for self-care: getting regular sleep, managing stress, exercising and creating supportive relationships. These are key recovery self-care principles that research has demonstrated to be effective for the management of bipolar disorder.
Even when there isn’t such a clear course charted from an accurate diagnosis, I have been impressed by the fact that the diagnosis itself can still provide relief and hope. I was recently thanked for telling a person that I thought her major issue was in the self-regulation of emotions that is commonly found in borderline personality disorder. She responded with relief, exclaiming, “Now I can do something about it!” When I was first training as a psychiatric resident, the term “borderline” was often used derisively. Today, led by the work of Dr. Marsha Linehan (whose own recovery with this condition was featured in the New York Times), borderline personality disorder is viewed as a challenge that has scientifically validated strategies.
The recovery strategies of several interventions— dialectical behavioral therapy (DBT) and mentalization have been well-studied—focus on developing skills for how to handle difficulties in managing emotions. The work of DBT is recovery-based and has been shown in research to reduce the risk of suicide. This is another great example of integration: A recovery intervention developed by a person who thrived while living with the condition has the scientific validity to promote the prevention of suicide.
Symptoms sometimes confuse people when we talk about recovery. Can a person be in recovery when they are still hearing voices? Some traditional medical practitioners might say no—that symptom control is what defines recovery. I think a more modern view says that recovery with an illness as opposed to only from an illness is possible. We don’t have cures in our field, so living with auditory hallucinations is likely to be part of life for those affected by them. I encourage people to maximize their biological return to minimize their symptoms, and to also find goals that they want to focus on, like love and work. Engaging in life fully is a way to embrace recovery, with or without symptoms.
Shared decision-making is another great example of how these models can be well integrated. For example, at my clinic, considering a change in medicine that is helping but is generating medical risk is a common dilemma. By looking at the science (and the limits of what we know) and incorporating what the person knows about their stresses, supports and capacity for risk, only then can a sensible collaborative course be charted. Recovery meets medical model again in the office. The key is to learn from all decisions scientifically and experientially.
Learning is one essential aspect of both the recovery and medical models. The recovery model emphasizes experiential learning and how that learning can be used to help self-manage and to offer support for a person on his or her journey. The medical model looks at levels of knowledge to see what can be reliably identified, validated and ultimately treated. Consequently, learning is a core thread that runs through both models. As long as we are all learning and using all the tools at our disposal, we are moving forward in our journeys.
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