Using a Medical Model With Psychotic Patients

To the Editor: In the March 2006 issue of the Journal, Douglas Turkington, M.D., and colleagues (1) provided a useful review of the state of the field regarding cognitive behavior therapy in treating schizophrenia. While we eagerly await further study and greater availability of this treatment modality for patients with schizophrenia, we were dismayed by the authors’ characterization of a medical approach.

The authors presume a “biomedical” medical model in which one is “more likely to ignore” (p. 367) aspects of the patient’s experience, “forbids any exploration of a personal meaning (formulation) of psychotic experiences” (p. 370), and goes about in an effort to “persuade or force the patient to agree that he or she has symptoms of a mental illness” (p. 368). Certainly, diagnoses (at various stages of validity within and between different medical specialties) are at the core of medical practice and decision making (2) . They are even critical to cognitive behavior therapy, which is usually initiated after a diagnosis is reached; thus cognitive behavior therapy for schizophrenia . Most who work with psychotic patients know, however, that treatment, regardless of modality, can often proceed without the patient sharing the physician’s explanatory model.

In fact, we were impressed more by the ground shared by medical and cognitive behavior approaches to schizophrenia than by any alleged contrast. Many of the therapeutic techniques (e.g. alternative explanations) described by the authors are extensions of less structured means of interviewing and fostering a doctor/patient relationship with the psychotic patient. The idea that a cognitive behavior therapy formulation “ensures that neither the patient nor the patient’s caregiver is led to feel that he or she is to blame for the symptoms or the illness,” is redolent of the Parsonian “sick role” seen by some (and criticized by others) as being at the heart of the medical approach (3) .

A medical model at its best can be a mode of thought and conduct, whereby a physician flexibly assesses and engages potential patients in an ongoing way, determines if and what disease is present, and then devises treatments based on diagnoses and patients’ individual needs (4) . Cognitive behavior therapy and other specific therapies in psychiatry, including “biomedically”-oriented therapies, are interventions. Patients are assigned to interventions based on prior assessment for suitability for a particular intervention. In such a system, cognitive behavior therapy is neither subordinate nor an alternative to a medical model. It is a specialized skill. However, people do not come to us pre-specialized, and it is ironic that psychiatry often comes to them that way.