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A General Systems Approach to Psychiatry and the Medical Model
A General Systems Approach to Psychiatry and the Medical Model SAMUEL
R.
WARSON,
• Psychiatry, which has become authoritative on the subject of "identity crises" seems to be undergoing one of its own. Where do we belong and what model should we use in approaching the problems that confront us?' There are undoubtedly many reasons for the soul searching that goes on but the most important in my experience was confusion about the model that is our birthright, the medical model. To clarify the confusion I embarked on what I thought would be a simple task of tracing the model and what it has had to offer to the understanding and solution of the problems that concern psychiatry. I found that investigating the medical model was like opening the proverbial can of worms! To begin with, what is the "medical model"? Because physicians are programmed to use this model automatically there is very little reflection about it. And indeed the model is so overshadowed by how the physician uses it that there may seem to be as many models as there are physicians. However, there is a consistency of approach by physicians to problems of health that betrays the presence of an underlying model which descriptively can be called the "medical model". Attempts to describe the model itself usually fell short of general application or were more applicable to derivatives, such as disease or treatment models, and eventually I found a systems approach to be most useful in clarifying and defining the medical model. When approached systemactically the medical model can be defined in terms of the structure and function of the global system it represents and how it operates. Structurally the medical model is a representation of the knowledge Dr. Warson is Clinical Professor of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida. May-June 1972
M.D.
and technology that is derived from many sources and changes as new knowledge becomes available. Operationally the medical model can be defined as a representation of the system and method used by the physician in his approach to problems of health. Historically, the model of the medical model we use today was Hippocrates, whom Aristotle, himself a physician, called "the great physician". Except for changes in knowledge and technology and an expansion of the system through growth and differentiation the basic model has not cIfanged since the time of Hippocrates. The genius of Hippocrates was the bringing together of the system and method, both of which existed prior to his time. The system was that of the natural philosophers who approached matter as an organized complexity made up of interacting and interrelated structural-functional units and component systems. The method was that of the natural scientist; observing, grouping and processing data in an orderly and systematic manner, (i.e. the scientific method). The system and method obviously feed and complement one another but do not form a closed circle because the system is open in terms of new knowledge from many sources and the method is open ended in terms of what data is collected. Different orders of data referable to any system are recognizable in the medical model: those data concerned with structural elements, those with how these function and those with the interaction and interrelationship of components and how these are organized in terms of the whole. (It is interesting to note these orders are reflected in the classical division of medical education into the anatomical, the physiological and the clinical sciences). Prior to the development of the Hippocratic model, medicine was apparently bog197
PSYCHOSOMATICS
ged down in unsystematic data collecting. This led, for example, to equating symptoms with diseases ad infinitum. By introducing a systems approach Hippocrates broke out of this bind and offered a model for the solving of health problems that operationally went beyond the existing limitations of data. "It is sophistry", he said, "to think that we have to know what man is before we can understand his illnesses. It is possible to know how the body functions and reacts generally and specifically in its organ systems."2 About 500 years later Galen,3 in spite of his great interest in anatomy and dictum that structure determines function, used a systems approach clinically. He talked of organ systems as having "faculties" or functions and "sympathetic" relationships with one another. However, his emphasi~ on the primacy of structure has persisted, as evidenced by the primary position of anatomy in the programmine; of the education of a physician and the concern of the clinician, including the psychiatrist, when functional disturbances can't be correlated with structural changes. A review of the case histories of Hippocrates reveals that his observational method included data on the thinking, feeling and actions of his patients (the data of primary concern to the psychiartist) and that these were processed in diagnostic and treatment considerations. For example, he noted that patients with anxiety reflected in dreams could go on to develop severe illnesse~; and that seriously ill patients tended to give up and die if not supported by the physician. What Hippocrates lacked was a component system to which he could refer this psychological data. Philosophy, which had been of such great help on the nature of matter, bogged down on the nature of the mind , apparently because of a problem in relating rational and irrational behavior. Plato and Aristotle got around this by using a somewhat supernatural approach to the irrational, and Descartes by separating the mind from the body. Later, Kant concluded that the mind could only be approached through metaphysics, which would remove psychiatry from medicine, as many think it should be today. 198
Having no system for psychological data in his model, Hippocrates referred observations on thinking, feeling and acting to a closely related system, the central nervous system, in spite of the difference in the nature and order of the data. Alcmaeon, "the father of psychology", had previously related consciousness to the activity of the brain, and by default the brain became the "organ of the mind". This led to psychiatry and neurology in their development as medical specialties becoming linked to the same system in spite of the lack of evidence of structural correlations. In turn this led to confusion within as well as outside of medical circles about the differences between psychiatry and neurology as evidenced by attempts to keep them together (in such anachronisms as the "American Board of Psychiatry and Neurology") and by the commonly encountered confusion of neurological and psychological data, as in "nerves" and "nervousness". It took a neurologist, Freud, to break out of this bind, which he did by making rational and irrational behavior part of the same system through his "discovery of the unconscious". This system is the "personality system" or how we function as a person. Like other systems it has an organ, the "mind", with an organizational and management function. The personality system interacts with and relates to (or communicates with in a transactional manner) other systems in the internal and external environments of the person to maintain homeostasis and organize man's goal striving; activities. Although Freud's contribution to the development of personality theory is generally acknowledged, the effect of this on the medical model has not received much recognition in medicine. Through his structuring of the personality system and how it works as well as his recognition of the role of psychodynamics, Freud added a new dimension to the medical model making it much more comprehensive for psychosomatic and other multisystem disturbances as well as for the understanding of problems primarily related to the personality system. From a systems point of view the medical Volume XIII
GENERAL SYSTEMS APPROACH-WARSON
model can be defined as a comprehensive multisystem approach to health problems in the organized complexity we call a human being. Although psychiatry like other medical specialties concerns itself primarily with one of the systems involved, ''the personality system", the education, training and experience of the psychiatrist make it possible for him to recognize and deal with interactions and transactions between the personality and other systems. Using a systems approach there is no confusion about the identity of psychiatry if the medical model is not confused with other models. This is particularly true of the disease model which resulted from a major breakthrough in medicine that has been much less useful in psychiatry than in other branches of medicine. How useful the medical model itself has been in the generation of knowledge about human behavior and the development of new treatment approaches is evident from the contributions of physicians who were not trained as psychiatrists (such as Freud and Pavlov). And the contributions of psychiatrists such as Szasz and Laing when viewed from a systems approach really extend the use of the medical model rather than replace it with psycho-social models.
Many psychiatrists in their preoccupation with the personality system have seemed to separate psychiatry from the medical model. (Freud at one time actually thought this would be a good idea!) However it would be difficult to imagine what their contributions would have been like without a background of training and experience in the use of the medical model. That this use has led to blind alleys at times, such as the confusion between neurological and psychiatric systems, does not warrant "throwing out the baby with the bath water". The medical model is open enough to sooner or later systematically incorporate what is worthwhile from any source and orderly enough to use such contributions effectively. It has stood the test of time and has been a good safeguard against the development of closed systems of health care and unbridled use of speculation that we encounter so frequently in the field of mental health. REFERENCES 1. Mannucci. M.: What Model for Psychiatry. Attitude Vol. 1. No.5, 1970. 2. Chadwick, J. and Mann, W.N.: The Medical Works of Hyppocrates. Oxford, Blackwell, 1950.
3. Castiglioni, A.: A History York, Knopf, 1947.
01
Medicine. New
Modern psychopharmacology has brought psychiatry closer to the mainstream of medicine where properly it belongs Much of recent psychopharmacology has consisted of an empirical shooting at target symptoms. . . . We can expect our aim to become more precise as we specify which drug is best for whom under what conditions. At the same time, the search for new target symptoms will go on. . .more exquisite targets consistent with dynamic concepts such as denial, projection, reality sense, and narcissism; finally, drugs to enhance human qualities, such as altruism, brotherly love. and scientific creativity. Milton Greenblatt. M.D. The Future of Psychiatry, Edited by Hoch and ZUbin, Grune and Stratton, N.Y. 1962.
May-June 1972
199
R.
WARSON,
• Psychiatry, which has become authoritative on the subject of "identity crises" seems to be undergoing one of its own. Where do we belong and what model should we use in approaching the problems that confront us?' There are undoubtedly many reasons for the soul searching that goes on but the most important in my experience was confusion about the model that is our birthright, the medical model. To clarify the confusion I embarked on what I thought would be a simple task of tracing the model and what it has had to offer to the understanding and solution of the problems that concern psychiatry. I found that investigating the medical model was like opening the proverbial can of worms! To begin with, what is the "medical model"? Because physicians are programmed to use this model automatically there is very little reflection about it. And indeed the model is so overshadowed by how the physician uses it that there may seem to be as many models as there are physicians. However, there is a consistency of approach by physicians to problems of health that betrays the presence of an underlying model which descriptively can be called the "medical model". Attempts to describe the model itself usually fell short of general application or were more applicable to derivatives, such as disease or treatment models, and eventually I found a systems approach to be most useful in clarifying and defining the medical model. When approached systemactically the medical model can be defined in terms of the structure and function of the global system it represents and how it operates. Structurally the medical model is a representation of the knowledge Dr. Warson is Clinical Professor of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida. May-June 1972
M.D.
and technology that is derived from many sources and changes as new knowledge becomes available. Operationally the medical model can be defined as a representation of the system and method used by the physician in his approach to problems of health. Historically, the model of the medical model we use today was Hippocrates, whom Aristotle, himself a physician, called "the great physician". Except for changes in knowledge and technology and an expansion of the system through growth and differentiation the basic model has not cIfanged since the time of Hippocrates. The genius of Hippocrates was the bringing together of the system and method, both of which existed prior to his time. The system was that of the natural philosophers who approached matter as an organized complexity made up of interacting and interrelated structural-functional units and component systems. The method was that of the natural scientist; observing, grouping and processing data in an orderly and systematic manner, (i.e. the scientific method). The system and method obviously feed and complement one another but do not form a closed circle because the system is open in terms of new knowledge from many sources and the method is open ended in terms of what data is collected. Different orders of data referable to any system are recognizable in the medical model: those data concerned with structural elements, those with how these function and those with the interaction and interrelationship of components and how these are organized in terms of the whole. (It is interesting to note these orders are reflected in the classical division of medical education into the anatomical, the physiological and the clinical sciences). Prior to the development of the Hippocratic model, medicine was apparently bog197
PSYCHOSOMATICS
ged down in unsystematic data collecting. This led, for example, to equating symptoms with diseases ad infinitum. By introducing a systems approach Hippocrates broke out of this bind and offered a model for the solving of health problems that operationally went beyond the existing limitations of data. "It is sophistry", he said, "to think that we have to know what man is before we can understand his illnesses. It is possible to know how the body functions and reacts generally and specifically in its organ systems."2 About 500 years later Galen,3 in spite of his great interest in anatomy and dictum that structure determines function, used a systems approach clinically. He talked of organ systems as having "faculties" or functions and "sympathetic" relationships with one another. However, his emphasi~ on the primacy of structure has persisted, as evidenced by the primary position of anatomy in the programmine; of the education of a physician and the concern of the clinician, including the psychiatrist, when functional disturbances can't be correlated with structural changes. A review of the case histories of Hippocrates reveals that his observational method included data on the thinking, feeling and actions of his patients (the data of primary concern to the psychiartist) and that these were processed in diagnostic and treatment considerations. For example, he noted that patients with anxiety reflected in dreams could go on to develop severe illnesse~; and that seriously ill patients tended to give up and die if not supported by the physician. What Hippocrates lacked was a component system to which he could refer this psychological data. Philosophy, which had been of such great help on the nature of matter, bogged down on the nature of the mind , apparently because of a problem in relating rational and irrational behavior. Plato and Aristotle got around this by using a somewhat supernatural approach to the irrational, and Descartes by separating the mind from the body. Later, Kant concluded that the mind could only be approached through metaphysics, which would remove psychiatry from medicine, as many think it should be today. 198
Having no system for psychological data in his model, Hippocrates referred observations on thinking, feeling and acting to a closely related system, the central nervous system, in spite of the difference in the nature and order of the data. Alcmaeon, "the father of psychology", had previously related consciousness to the activity of the brain, and by default the brain became the "organ of the mind". This led to psychiatry and neurology in their development as medical specialties becoming linked to the same system in spite of the lack of evidence of structural correlations. In turn this led to confusion within as well as outside of medical circles about the differences between psychiatry and neurology as evidenced by attempts to keep them together (in such anachronisms as the "American Board of Psychiatry and Neurology") and by the commonly encountered confusion of neurological and psychological data, as in "nerves" and "nervousness". It took a neurologist, Freud, to break out of this bind, which he did by making rational and irrational behavior part of the same system through his "discovery of the unconscious". This system is the "personality system" or how we function as a person. Like other systems it has an organ, the "mind", with an organizational and management function. The personality system interacts with and relates to (or communicates with in a transactional manner) other systems in the internal and external environments of the person to maintain homeostasis and organize man's goal striving; activities. Although Freud's contribution to the development of personality theory is generally acknowledged, the effect of this on the medical model has not received much recognition in medicine. Through his structuring of the personality system and how it works as well as his recognition of the role of psychodynamics, Freud added a new dimension to the medical model making it much more comprehensive for psychosomatic and other multisystem disturbances as well as for the understanding of problems primarily related to the personality system. From a systems point of view the medical Volume XIII
GENERAL SYSTEMS APPROACH-WARSON
model can be defined as a comprehensive multisystem approach to health problems in the organized complexity we call a human being. Although psychiatry like other medical specialties concerns itself primarily with one of the systems involved, ''the personality system", the education, training and experience of the psychiatrist make it possible for him to recognize and deal with interactions and transactions between the personality and other systems. Using a systems approach there is no confusion about the identity of psychiatry if the medical model is not confused with other models. This is particularly true of the disease model which resulted from a major breakthrough in medicine that has been much less useful in psychiatry than in other branches of medicine. How useful the medical model itself has been in the generation of knowledge about human behavior and the development of new treatment approaches is evident from the contributions of physicians who were not trained as psychiatrists (such as Freud and Pavlov). And the contributions of psychiatrists such as Szasz and Laing when viewed from a systems approach really extend the use of the medical model rather than replace it with psycho-social models.
Many psychiatrists in their preoccupation with the personality system have seemed to separate psychiatry from the medical model. (Freud at one time actually thought this would be a good idea!) However it would be difficult to imagine what their contributions would have been like without a background of training and experience in the use of the medical model. That this use has led to blind alleys at times, such as the confusion between neurological and psychiatric systems, does not warrant "throwing out the baby with the bath water". The medical model is open enough to sooner or later systematically incorporate what is worthwhile from any source and orderly enough to use such contributions effectively. It has stood the test of time and has been a good safeguard against the development of closed systems of health care and unbridled use of speculation that we encounter so frequently in the field of mental health. REFERENCES 1. Mannucci. M.: What Model for Psychiatry. Attitude Vol. 1. No.5, 1970. 2. Chadwick, J. and Mann, W.N.: The Medical Works of Hyppocrates. Oxford, Blackwell, 1950.
3. Castiglioni, A.: A History York, Knopf, 1947.
01
Medicine. New
Modern psychopharmacology has brought psychiatry closer to the mainstream of medicine where properly it belongs Much of recent psychopharmacology has consisted of an empirical shooting at target symptoms. . . . We can expect our aim to become more precise as we specify which drug is best for whom under what conditions. At the same time, the search for new target symptoms will go on. . .more exquisite targets consistent with dynamic concepts such as denial, projection, reality sense, and narcissism; finally, drugs to enhance human qualities, such as altruism, brotherly love. and scientific creativity. Milton Greenblatt. M.D. The Future of Psychiatry, Edited by Hoch and ZUbin, Grune and Stratton, N.Y. 1962.
May-June 1972
199