Models of Treatment for Mental Disorder

By: Peter Tyrer and Kenneth R. Silk

This subject is relevant when it comes to choice of treatment for any disorder. The selection of treatment will depend to some extent on the model each practitioner uses for mental disorders. These have been summarized as the disease, psychodynamic, cognitive-behavioural and social models (Tyrer & Steinberg, 2005). Each of the models on its own is unsatisfactory but together they can be very useful. The disease model is the equivalent of the well-established medical model of common parlance and is well-suited to organic disorders as it is associated with demonstrable (physical) organic pathology, either gross or accessible by microscopic means. Once a disease is clearly present it allows four elements to be identified relatively clearly:

(1) The description of symptoms and main features of the disorder (the clinical syndrome matching the underlying pathology).
(2) Identification of the specific pathology (i.e. the structural or biological changes created by the illness).
(3) Study of the course (natural history) of the syndrome.
(4) Determination of its cause or causes.

Although some disorders (e.g. Korsakoff’s psychosis, Huntington’s chorea) can satisfy all these requirements, most conditions encountered in psychiatry do not, and many do not get beyond the first element. The psychodynamic model does not even accept this element and maintains that the presentation of the complaint is a coded message that requires much further analysis (psychoanalysis) before a real understanding of the problem (or conflict) can be understood. The cognitive behavioural model blurs the distinctions between the disorders and examines the extent to which cognitive misinterpretations and distortions are present in the condition, so that, for example, in generalized anxiety disorder and obsessive– compulsive disorder the error may be in thinking, whereas in personality disorder the misinterpretation may be at the level of fundamental beliefs or schemas (Davidson, 2000; Tyrer & Davidson, 2000; Young et al., 2003). The social model abhors all diagnosis as stigmatic labelling, and that any advantages that they enjoy in terms of professional communication are more than offset by the depersonalization of diagnosis.

In practice most psychiatrists like to claim they are eclectic (i.e. they choose whichever model most fits the problem), but in the absence of clear guidelines this just looks like opportunism. However, by following diagnostic procedures and selecting treatment by diagnosis they are often accused by other practitioners and patients of following the ‘medical model’, a rather broader definition of the disease model described above. The proponents of alternative models are often dismissed or ignored but should not be. The simple fact is that a treatment that is not perceived by either therapist or patient to be in the right ‘frame of management’ will rarely be effective in practice because it will not be followed. This is very important when considering the evidence base of different treatments. If a psychological treatment is marginally inferior to a drug treatment, but the patient and day-to-day therapists concerned are violently opposed to drug treatment, then it is desirable, one might say essential, for the psychological therapy to be chosen. It may not be the best treatment in an ideal world but pragmatic decisions are the best for such situations. treatments that are likely from present evidence to be very similar in efficacy that so many treatments deriving from different models are seldom compared in randomized controlled trials. Under such circumstances the treatment that best fits the patient’s perception of the correct treatment is probably the one that should be chosen.

References

Peter Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in Psychiatry, 2008, Cambridge University Press

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