Stigma and the Medical Model
Dr. Michael Haslam
This delineation was somewhat subversive in that it enabled other professionals, the first in line being the clinical psychologist, to move out of their role as the equivalent of, shall we say, the hematologist or radiologist in the general hospital and become therapists. This was soon to be copied by social workers, nurses and a variety of individuals who perceived counselling as, in some way, superior to psychotherapy and psychoanalysis which had been practiced, of course, by doctors for many decades.
In reality, the medical model was an holistic approach taking into account the social factors, the past history and the family history of an individual and looking both at the environment and into the various causes of disease, from genetic to infection, in deciding a diagnosis. Diagnosis was perceived as crucial before a logical treatment could be devised and implemented. Treatment was also eclectic ranging from the psychotherapeutic approach, behaviour therapy and therapeutic skills. It was little wonder that other therapists from the newer professions wished to distance themselves from the physical treatments and from medication since they were, not being doctors in medicine themselves, unable to prescribe or to carry out physical examinations without which diagnosis was likely to be compromised.
Nevertheless this trend of labelling has continued, pursued by such organisations as MIND and has given the profession in general medicine and, in particular psychiatry, a bad name.
Psychiatry had a particular problem in that it was concerned with two large groups of individuals, those with a serious brain disease, such as schizophrenia or the melancholic or manic depressive illnesses on the one hand, and dementia's on the other, and secondly a large range of behavioural and personality disturbances ranging from obsessional states, anxiety states and phobias, through to the more serious personality problems which overlapped with the criminal. Both these groups had been perceived as requiring the care of a psychiatrist in the past, but the latter soon started to be taken over by the new therapy and the multi-disciplinary team, loved by everybody on the whole except the doctors and the patients.
Psychiatry has always had to deal with prejudice from the general public and indeed often from colleagues. There is a stigma attached to psychiatric illness and many pejorative words are used to describe sufferers and the places in which they receive treatment. One great advantage of the medical model lay in the return of psychiatry to the general hospital environment with development of sensible and effective treatment programmes involving medication or other physical therapies, this taking off largely in the 1950s and 60s of the last century .This allowed a progressive movement of new patients into general hospital psychiatric units rather than into the old county asylum, which had been a great advance in Victorian times but was now seen as less appropriate.
Whether inpatient treatment was better carried out in a District General Hospital environment was not entirely clear, since in the past the calm, the beautiful grounds, and the gracious environment in which psychiatric hospitals had been formed was not seen in the cramped space of the District General Hospital and patients with other conditions than psychiatric looked somewhat askance at having such a unit, as it were, close by.
Prejudice however and stigma is the result of the manifestations of the disease, not from where the disease is to be treated or its management. You can call a spade a spade, or call it a shovel, it still serves the same purpose. Schizophrenia manifests itself often by somewhat bizarre behaviour and thinking and it is this, which causes the stigma rather than the county asylum. Wherever therefore such a patient is treated will sooner or later be stigmatized unless the population is educated out of stigma altogether. In which case, it does not matter where the patient is treated. The advantage of the district unit, however, lay in the fact that the patient, when entering such a unit, was not demonstrating to his friends and relations that he was going to the "funny farm"! The same applied to the outpatient appointment.
In the 80s further development began to take place with the complete closure of many inpatient units and the idea that patients with such conditions could be treated in the "community". This was to be a loving caring place outside the walls where all would be well. Of course the manifestations of psychotic illnesses were even more obvious when patients were treated in their homes or in the community, than if they entered hospital, so the stigma was simply moved into the community with them. "Not in my backyard" was the response, when people tried to set up small community units dotted around towns, and the facilities which had been able to be provided in the larger hospital units, in the way of recreation and social activities, could no longer economically be provided. One has now seen a return to individuals being treated in what, 150 years ago, would have been called small private mad houses, and instead of attending the general outpatient unit in the busy local district hospital, individuals, certainly in York, are moved to a small terraced house in a back street down the road from the hospital where presumably it is seen as more normal but, more to the point, out of view. The stigma therefore begins to be felt in the small terraced house down the road.
For the outpatient this may or may not be a good thing but for somebody who is suffering from a disease process affecting thinking emotion or behaviour the important thing is to get proper care.
How can the medical model be applied, and indeed should it be applied, to the management of individuals with a gender that does not entirely match their physical attributes? Is it indeed appropriate for the doctor to be seeing the individual who likes to dress in the clothes normally perceived to belong to those with different physical attributes or to the person who sees themselves as belonging to the other gender from that which their physicality would suggest, i.e. the transsexual who may or may not have a female brain locked in a male body or vice a versa.
Should medicine or the law concern itself with such problems in society? Should medicine or the law concern itself with fetishistic behaviour, with homosexuality, with individuals with red hair or with golfers ?
The psychiatrist or the counsellor may have a role in dealing with all these individuals but only because they are unable to function easily in a rejecting society and are therefore a minority group with the stresses that that may incur. Certainly intersex would seem to be an appropriate role for the medical model since there clearly has been a developmental abnormality in these cases. The same might be true, subject to further research, of many cases of transsexualism, if indeed there is a fetal hormonal reason for the development of a gender, which is inappropriate to the apparent physical sex. Perhaps the same might apply to homosexuality, but one questions the ethics of attempting to change the orientation of such individuals who are doing society no harm and who if society were not rejecting might in many cases be perfectly content with their condition. Those who are not content with their condition might seek counselling therapy or indeed a physical operative change if this were possible, but in such cases this should be the decision of the individual after appropriate thought and not an imposition by an intolerant majority.
There are many borderline states where medical intervention may be appropriate and many where it would seem not to be the case. One must think of varieties of plastic surgery for such things as the restoration of scalp hair, the straightening of a nose, or the enlargement of a breast. If a treatment became available to change skin colour would it be ethical to turn white men black and black men white? Should it be left to the individual to decide what colour they wish to be? Where should the resources come from to assist such individuals if they do want to make changes, which much of society might perceive as unnecessary or even undesirable?
Perhaps it is for society to decide on where the line should be drawn in such borderline cases. Unfortunately however society is ill informed and cannot be left to make such decisions unless it is to be fully educated in the process. Society has a long way to go before it reaches that stage. In the meantime the individual with a problem over their gender must work within the system, imperfect as it is, that presently exists. What is required is that the professionals, whoever they may be, who take on the task of helping such people should be themselves free from bias and there to help the patient rather than to retain some preconceived notion of what should be done.
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