in Educational material, Thinking about psychiatry

Models of mental illness

(Picture credit – taken with a tilt shift lens – looks like a model…)

It’s widely accepted that individuals can be disturbed or troubled of mind.  What is controversial is how we should understand this.

Asides psychiatrists, many professional disciplines work and research in the field of mental disorder.  Each discipline approaches the subject from their own viewpoint, using their own conceptual model to explain what they find before them.

Alas there is no single model that has complete explanatory power.  To fully understand an individual’s difficulties it is often necessary to borrow from several.  This would be the favoured approach from an eclectic practitioner.  In practice it’s easy to favour a pet model which most closely fits one’s world view and defend this against those supported by others.

The on-going debate about the merits of drug treatments versus talking therapy can be viewed as a clash of models: biological versus psychodynamic/cognitive.


The disease or biological model

This model holds that any dysfunction that effects mental functioning can be regarded as ‘disease’ in a similar way to dysfunction that affects other parts of the body.

In the disease model, a disorder affecting mental functioning is assumed to be a consequence of physical and chemical changes which take place primarily in the brain.  Just like any other disease a mental disease can be recognised by specific and consistent signs, symptoms and test results.  These distinguish it from other diseases.

Psychiatrists who adhere to the disease model are often referred to as ‘biological psychiatrists’ (as in ‘he’s very biological’).
With a biological approach comes a preference for physical treatment methods, primarily drugs, but also ECT.

This model best applies to schizophrenia.


The psychodynamic model

The central tenet of the psychodynamic model is that a patient’s feelings have led to problematic thinking and behaviour.  These feelings may be unknown to the patient and have formed during critical times in their life, due to interpersonal relationships.

These unknown (or unconscious) feelings are uncovered during therapy.  Therapy can take place over a large number of sessions and over a time period of a year and beyond.

During therapy a relationship builds up between therapist and patient.  The emotions that the patient attaches to the therapist are collectively known as ‘transference’, and those the therapist attaches to the patient collectively as ‘counter transference’.  By understanding these feelings a patient may gain an understanding that they can take with them to future relationships.

This model is applied broadly, but has limited applicability to the most severe mental disorders.


The behavioural model

The behavioural model understands mental dysfunction in terms theory emerging from experimental psychology.

Symptoms, as understood by the behavioural model, are a patient’s behaviour.  This behaviour has come about by a process of learning, or conditioning.  Most learning is useful as it helps us to adapt to our environment, for example by learning new skills.  However some learning is maladaptive and behaviour therapy aims to reverse this learning (counter conditioning).

This model best applies to phobias.


The cognitive model

The cognitive model understands mental disorder as being a result of errors or biases in thinking.  Our view of the world is determined by our thinking, and dysfunctional thinking can lead to mental disorder.  Therefore to correct mental disorder, what is necessary is a change in thinking.

This model will be familiar to anyone who has trained or undergone cognitive behavioural therapy (CBT).  CBT aims to identify and correct ‘errors’ in thinking.  In this way, unlike psychodynamic therapy, it takes little interest in a patient’s past.

This model is widely used, but classically applies to depression and anxiety.


The social model.

The social model regards social forces as the most important determinants of mental disorder.  The social model takes a broader view of psychiatric disorder than any other model.  It regards a patient’s environment and their behaviour as being intrinsically linked.

In some ways it is like the psychodynamic model, which also sees patients as molded by external events.  However whereas the psychodynamic model sees mental disorder as highly personalized and its determinants not immediately recognizable, the social model sees mental disorder as based on general theories of groups and caused by observable environmental factors.



For someone who develops persistent depression following the death of a close relative :

“This can be perceived in several ways by psychiatrists.  One sees the depression as a pathological event that is directly due to the biochemical changes occurring in the brain of someone who is predisposed to pathological depression through an accident of illness.  Another sees the depression as a reactivation of unresolved childhood conflicts over an early loss.  Another regards the depression as part of the normal mourning process that has got out of control because the person’s thoughts become fixed in a negative set which sees everything in the most pessimistic light.  Yet others conclude that the mourning response has been exaggerated primarily by society or see it as an abnormal form of learning which is no longer appropriate for the situation but is receiving encouragement from some quarter (positive reinforcement)”

From Models for mental disorder

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  1. How about systemic/family therapy formulations? They’re common in places with strong family ties and relevant training available…

  2. Have you ever considered that the conventional idea of mental disease might be up-side down? That its development out of pathology and the medical model has skewed its perception? I’m interested to know what you think about a more synthetic model which might view “symptoms” as purposive rather than causal.

  3. “…using their own conceptual model to explain what they find before them”..and therein lies the fatal flaw with all the disciplines but especially psychiatry – how about letting the individual decide what their explanatory framework is and mental health professionals work within that and this may not mean agreement.
    There are no biological ‘markers’ for differences in perception which can be tested for like diabetes and changes to the brain are typically observed in the scans of medicated brains which cause these chemical and structural changes. Why would certain types of therapy not be suitable for what is viewed as psychosis? Where are the trials evaluating this [other than CBT]?
    Where are the trials evaluating approaches developed by Loren Mosher [Soteria] and approaches developed by the hearing voices movement which focuses on understanding the meanings and functions of people’s differences in perception within the context of their life experiences? The first line response to differences in perception in psychiatry is medication and for over 50 years the rate of benefit has hardly shifted, so why doesn’t the profession be brave and look at incorporating all sorts of influences from philosophy to the spiritual to service user defined approaches. A truly holistic approach would be open to anything and anything the individual wants to look at. The biggest disservice we do to people is to define their distress for them.

  4. Forget what is unimportant, and live in the today. No one needs to have a strong exertion over you, that is one way to get over depression.

  5. I agree with the other Louise – mental health problems, aka emotional distress, have individual solutions. I know people who would not dream of stopping their medications – on the other hand, I don’t believe I have ever benefitted from being drugged. I think any psychiatrist needs to start by talking to the individual and trying to understand them – it may help to know that even in the midst of psychosis there are lucid episodes where a patient can be reached (this was certainly my experience and that of many others I have met).

  6. The ‘recovery model’ with NHS Trust ‘recovery colleges’ are no better. It’s just the medical model wrapped around a bit of Budlite mindfulness, life coaching, with insistence on using community facilities. Maybe people prefer the company of others with first hand experience and don’t want to use the local library, gym, adult education college for good reasons. These trumped up courses never address iatrogenic damage and developing one’s own understanding. Service commissioners see recovery as discharge or employment and so-called critical thinkers see recovery as no meds, no state support or else you’re a lazy idiot. There’s only room for ‘recovery stories’ with enforced hope and smiling. Anyone who disagrees is shown the door.