by Chuck Ruby, PhD

On April 28, 2024, psychiatrist Awais Aftab ridiculed efforts to challenge the medical model in his blog post, "People Are Stumbling From One Misguided Narrative About the Medical Model to Another." In it, he discounted critical psychology/psychiatry criticisms about the orthodox mental health industry's insistence on turning personal distress and behaviors into illnesses rooted in individual dysfunction. The title of his post suggests those criticisms are clumsy and ignorant views of a "diverse and dynamic" matter.

He starts by explaining his displeasure with the term "medical model"; not necessarily the "medical" part of the term, but the "model" part. He complains that it "takes something diverse and dynamic—the theory and practice of medicine—and turns it into something circumscribed, fixed, and static...." He seems to be saying that we shouldn't establish models with which to understand phenomena. If this is so, he is supporting an unbridled mental health industry that has no bounds in its ever-increasing interest in overseeing the many problems we experience throughout life. This necessarily leads to a similarly boundless and unspecified construct of mental illness - it is what we say it is.

We can debate the legitimacy of models, and (in contrast to what Dr. Aftab seems to suggest) we can adjust them as we go so they fit the data and do not become "fixed and static." However, we must have models just as we must have definitions. If we didn't use them to "circumscribe" ideas, utter chaos would ensue when discussing the issues involved and any profession that renounced clear models and definitions would not be "circumscribed," allowing it to claim dominion over increasing swaths of human life.

This isn't just an academic matter. Such a boundless model being applied to the problems of human values, meaning, choice, distress, and action has grave consequences. If the alleged illness is of mental functioning, then the diagnosed person's grasp of reality and decision-making would be compromised. This invites the diagnosing clinical professionals to step in as arbiters of human freedom. I wouldn't have as much a problem with this model if those professionals honored their ethical obligation to provide full information to the person so affected, and then obtain that person's full consent prior to doing anything. But that is not the way it works in practice. There is only a token nod to informed consent. The claim that mentality is ill or dysfunctional is the foundation of the widespread coercion, lack of due process, authoritarianism, and human rights violations so common throughout the history of the mental health industry to this very day.

Dr. Aftab has a particular problem with the American Psychological Association's (APA) definition of the medical model (So do I, but for different reasons - see below). First, in contrast to the APA's definition that the medical model is "the concept that mental and emotional problems are analogous to biological problems," he thinks it “would be more accurate to say that the medical model considers mental and emotional problems to be analogous to problems encountered in general medicine."

But what problems are encountered in general medicine? Does this mean that any complaint brought by a patient to a GP is a matter for medicine? Keep in mind that people have long been trained by the mental health and drug industries to see mental disorder behind every distressing thing. Therefore, they are very likely to approach their GP with all sorts of problems merely because they hurt. This seems self-serving for the mental health industry since it means all feelings of unease, even those without a basis in individual dysfunction, are to be assessed and treated via the medical model, thus making medicine the expert in those problems. So, even though Dr. Aftab doesn't like the term "medical model," he uses it here, but defines it in a way that doesn't "circumscribe" the matters to which it applies.

His second concern with the APA's definition is its view that the medical model involves detectable and specific physiological causes. He says this "restricts the range of possible options... when in reality, medicine deals with a very wide range of problems." (italics in the original). As with his first concern with the APA's definition, as well as his hesitation with circumscribing medicine with a model, this one reveals his interest in removing walls that would form the boundary between medical problems and non-medical problems.

I'm not sure if Dr. Aftab's criticism of the APA's definition of the medical model assumes that those within the critical psychology/psychiatry movement agree with the APA. I know many who don't, and I am among them. The APA has become just as medicalized and paternalistic as the other APA (American Psychiatric Association). To us, the important issue with the medical model, as conventionally used, isn't that it points to biological problems or specific and detectable physiological causes.

Instead, our critique is against the unfounded claim that all experiential and behavioral problems in life are pathological and the result of internal dysfunction to be assessed (judged) and treated (corrected). This claim persists despite the fact that the alleged pathology and dysfunction in the individual has eluded scientific inquiry for more than two centuries. How many more centuries must pass without such evidence of pathological origins before the mental health industry gives up?

But wait, they are forced to give up when pathology is found. That is because in these instances, the illness becomes a target for neurology, endocrinology, nutritional science, or the other medical specialties regarding that real pathology. Ironically, as long as no evidence exists, conventional psychiatry, clinical psychology, and the other clinical professions can survive.

Furthermore, critical psychology/psychiatry does not deny the complexity of those problems that get diagnosed as mental disorder, just as we wouldn't deny the complexity of physiological pathology. And, as far as I know, we have never suggested that the physiology doesn’t affect psychology, or vice versa. But this reality doesn’t justify conflating the two and pulling them within the bailiwick of the mental health industry any more than it justifies giving the clinical professions dominion over politics and economics just because they are also determinants of human problems.

In his essay, Dr. Aftab uses the example of a recent story published in the Guardian about survivor Rose Cartwright to point out how people misunderstand the medical model (and, thus, criticisms of it are said to be "misguided"). Specifically, he claims that the model is popularly, yet falsely, thought to be an essentialist approach to mental disorder. This is the belief that each mental disorder category has an underlying essence, rooted in biological or psychological features. Each category has a unique essence common to all who are diagnosed with it.

But I know of no critical psychologist or psychiatrist who thinks this. In fact, we hold the opposite and reject the essentialist view. The different diagnostic categories seriously overlap, making it difficult if not impossible to use the specific DSM criteria to distinguish one from another. This is why the DSM's categories are admittedly unreliable and invalid.

Ms. Cartwright's revelation was not about essentialism. Instead, it was about finding out that OCD, and by extension all other mental disorders, weren't brain dysfunctions. According to her: “This is what I think is wrong with the medical model: a failure to understand mental health in context. An assumption that a disorder is a [pathological] ‘thing’ that an individual has, that can be measured, independent of subjective experience.”

It is commonplace within the conventional mental health industry, and characteristic of the medical model, to claim internal dysfunction responsible for a host of problems and research efforts have been underway to support this claim. However, as mentioned earlier, those efforts have consistently failed. At best, they have shown differences in physiology and psychology, not dysfunction or pathology. It is absurd to claim something is a medical matter based only on differences.

Demonstrating that the brains or genes of people who have been diagnosed with a mental disorder are different in function than those not diagnosed is not a demonstration of a dysfunction. Likewise, demonstrating a difference in psychological functioning between those with diagnoses and those without is not a demonstration of a dysfunction. To do so in either case would be to claim dysfunction in people for a plethora of otherwise normal things such as playing the piano, holding conservative political views, and regularly exercising. But despite this failure of psychiatric research, the “theories” have survived. In no other area of medical science has this happened and there are many examples when theories were discarded because they lacked evidence (e.g., animal magnetism, miasma theory, humorism).

Those of us in the critical psychology and psychiatry movement suggest that for anything to be legitimately handled with a medical model, it must at least have good theoretical grounding in an internal pathological process (the DSM euphemistically calls this “a dysfunction in the individual”) that is responsible for the illness, and that such theory survives ongoing research attempts to disprove it. Without this, the mental health industry opens the door to Orwellian control. Medical authorities step in where religious authorities once reigned, and where legal authorities fear to tread.

The conventional medical model makes a priori moral judgments about what actions and experiences are unwanted, inconvenient, or uncomfortable, and then it dubs them illnesses. Then it sits back and ignores the long line of research results that fail to support the notion of an internal dysfunction, perpetually claiming evidence is just around the corner.

Chuck Ruby, PhD, is a psychologist who has been in private practice for the past 25 years, after a 20-year career with the U.S. Air Force. You can read more about him at his personal website. He is the author of Smoke and Mirrors: How You Are Being Fooled About Mental Illness - An Insider's Warning to Consumers. Dr. Ruby is the past Chairperson of the Board for ISEPP and has been the Executive Director since 2015.