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Models of Mental Disorder
Summary
Tommy Svensson and Lennart Nordenfelt (2012)
Introduction
Team-based psychiatric care of non-institutionalised patients requires that staff with different
professional and occupational backgrounds shall be able to co-operate and make well-founded
joint decisions concerning the particular patient. Furthermore it is important that patients
themselves and their next of kin should to the greatest extent possible be involved in — and
have a say in — the decision-making. A prerequisite for well-functioning co-operation is that
the basic models of mental disorder which guide the thoughts and actions of the particular
team-members shall be in accord. Such models can involve on the one hand notions
concerning the essential nature of mental disorder, its aetiology and appropriate treatment, on
the other hand broader notions concerning such matters as the patient’s and society’s rights
and obligations in respect of care. Though in certain cases the models and the underlying
notions may be explicit and well-articulated, in many cases they would seem to be simply
taken for granted, implicit and perhaps not reflected upon. It is reasonable to assume that a
consensus among the members of the psychiatric team with regard to the appropriate model
(whether this model be articulated or not) will greatly facilitate co-operation and joint
decision-making, and thereby enhance the quality of the care. In contrast, lack of consensus
(especially if implicit and not reflected upon) can be supposed to give rise to difficulties and a
lower quality of care. Comparatively little is known about the state of affairs in Sweden when
it comes to similarities and differences between the various occupational categories making
up psychiatric teams in respect of the basic models of mental disorder to which they
(explicitly or implicitly) adhere. The project “Models of mental disorder and their role in joint
decision-making” was designed to provide some of the missing knowledge.
Background
In the discussion of mental illness and mental disorder which has been so abundant since the
60s, both within the field of psychiatry and outside it, the opposition between the different
paradigms, perspectives and approaches has sometimes been very much in evidence. In the
early stage of this discussion there were several attempts to concretise and characterise
different basic models of mental illness — models not easily reconcilable with one another.
The perhaps best-known categorisation of models was drawn up by Siegler and Osmond
(1974), who distinguished and described a dozen of them. Since that time, however, there has
been considerably less evidence (either in Sweden or elsewhere) of open opposition between
one model and another. The transformation of the organisation of psychiatric care during the
so-called “de-institutionalisation period” was characterised by an increasingly marked striving
for concord and co-operation both between professions and between psychiatric traditions. A
now common — and perhaps somewhat idealised — representation of how severe mental
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disorder should be understood and treated indicates that both biological, psychological and
social factors are to be accorded importance (see e.g. Crafoord, Jacobsson & Åsberg 1997). It
would seem often to be presupposed that that there is a sort of nuanced bio-psycho-social
model to which allegiance is paid by doctors, psychologists, nurses, occupational therapists,
physiotherapists, mental orderlies, etc. — and perhaps, indeed, by patients and their next of
kin as well. However, very little Swedish research has been undertaken concerning what
allegiance is paid to this model by those engaged in the day-to-day reality of providing
psychiatric care.
A number of international studies indicate that a consensus model such as this can be
problematised on both theoretical (Fulford 1989, 1998) and empirical (Colombo 1997)
grounds. It appears that unobserved differences in the models of mental disorder to which
different actors within the realm of psychiatric care at least implicitly pay allegiance can give
rise to defective communication and thereby seriously impede constructive joint decisionmaking. Furnham and Bower (1992) maintain that there emerge five main paradigms when it
comes to the position adopted with regard to mental illness. Colombo (1997) distinguishes a
medical model, a moral one and a psychosocial one. And Taylor and Taylor (1989) say that
most programmes for working with the mentally disordered in the UK are based on
Colombo’s three models — or rather, on one of the three.
The project “Models of mental disorder and their role in joint decision-making” was
inspired by, and influenced in both conception and design by, a research project which has
been going on since 1998 at the University of Warwick under the direction of Professor Bill
Fulford. The starting-point for the latter project was the increasing awareness during the 90s
that communication and decision-making within team-based psychiatric care were not without
their problems and that certain of these problems might be attributable to divergent —
sometimes, indeed, more or less irreconcilable — basic conceptions of how mental disorders
should be understood and treated. The purpose of the Warwick study is on the one hand to
elucidate what conceptions of the nature, causes and appropriate treatment of mental disorders
are held by the different categories of staff within psychiatric care and by the patients and
their next of kin, on the other hand to elucidate how the similarity or dissimilarity of these
conceptions affects joint decision-making.
The purpose of our project was much the same as that of the Warwick project. A further
aim was that it should be possible to compare our results with the Warwick ones in certain
essential respects.
Purpose and principal questions addressed
The purpose is twofold: first to characterise the basic models of mental disorder such as they
appear among representatives of the different categories of staff making up the psychiatric
team and among patients and next of kin, second to investigate whether differences between
the models adhered to affect the quality of joint decision-making in psychiatric teamwork.
The principal questions addressed are these:
 Are there essential differences between the models of mental disorder adhered to
(whether explicitly or implicitly) by the different occupational groups within
psychiatric teams?
 Are there differences with regard to such models from one clinic to another?
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 What is the relation between the staff’s models and those of patients and next of kin?
 Do similarities in the models make for the smooth functioning of joint decision-making
in psychiatric teamwork, and dissimilarities impede it?
Method and accomplishment
Clinics and respondents
The study concerns staff, patients and next of kin at the psychiatric clinics in the towns of
Motala, Oskarshamn and Värnamo. A random stratified sample was drawn from the members
of the psychiatric teams at these clinics, comprising doctors, nurses, orderlies, psychologists,
social workers and occupational therapists.
Motala
Värnamo
Oskarshamn
Total
Doctors
4
2
1
7
Nurses
4
4
4
12
Orderlies
4
2
4
10
Psychologists
4
4
3
11
Social workers
4
4
2
10
Occupational therapists
4
3
1
8
24
19
15
58
Total
The 8 patients and 9 next of kin who participated in the study were selected by the local
patient and next of kin associations.
Interviews
The method of data collection was semi-structured two-stage face-to-face interviews. The first
stage comprised an inquiry, based on a fictitious case history, concerning basic conceptions of
the causes, prognoses and appropriate treatment of severe mental disorders, whilst in the
second stage the focus was on experiences of critical events in psychiatric teamwork calling
for joint decision-making.
Thus the interview guide was in two parts. The first focused on the respondent’s
conception of the nature of mental illness/disorder — focused, in other words, on the basic
model to which the respondent paid allegiance. A fictitious case history/vignette constituted
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the basis for a number of semi-structured interview questions about conceptions of causes,
consequences and treatment. The case history closely followed the case vignette used in the
Warwick project but was modified so as to better fit the Swedish context. It is based on
descriptions of schizophrenia to be found in DSM IV. This approach is common and welltried in research (not least that which has a social-scientific orientation) on mental-health
issues (see e.g. Star 1952, Phillips 1963, Bord 1971, Howells 1984, Nieradzik & Cochrane
1985, Furnham & Rees 1988). With reference to the case history, questions were asked
concerning the following topics: (1) description of the problem; (2) interpretation of the
(fictitious) person’s behaviour; (3) conception of the value of diagnoses; (4) aetiological
assumptions; (5) methods of treatment; (6) conception of traditional institutional psychiatric
care, of non-institutional psychiatric care and of the relation between the two; (7) prognosis;
(8) rights and obligations of society and of the patient. The responses to these questions were
to form the basis of an analysis in terms of the different (explicit or implicit) models of mental
disorder as described above.
The second part of the interview involved questions concerning the experience of joint
decision-making in team-based psychiatric care. The approach was that of the Critical
Incident Technique. The respondents were asked to tell of any crucial clinical sequences of
events where there was joint decision-making, including whether the outcome was
satisfactory or not. They were encouraged to offer as exact and detailed an account as possible
of what factors facilitated or impeded the decision-making and affected the outcome in a
positive or negative direction.
Results: Comparisons between professions
The overall impression to be gained from the data is that there would seem to be a
considerable degree of agreement among the representatives of the different professions as to
the causes, characteristics and appropriate treatment of mental disorders. Broadly speaking,
there appears to be a well-established bio-psycho-social model underlying the manner in
which issues are considered and described. Only rarely, for example, did any of the
respondents argue in favour of a clear-cut exclusively biological or psychological approach.
Nor did it often occur that a person rejected or disparaged the angle of approach adopted by a
team-member of another profession.
Nevertheless there are fairly distinct differences of emphasis within the framework of the
prevalent bio-psycho-social model. Most of the doctors emerge as embracing a more or less
marked biomedical point of view, though at the same time acknowledging the importance of
other points of view when it comes to assessing a patient’s need for care. This biomedical
stance comes out most clearly in respect of on the one hand the importance assigned to
diagnosis and medication, on the other a consensus of opinion that Erik, the fictitious
protagonist, is ill.
A more diversified picture emerges in the case of both the nurses and the mental orderlies.
Some of them strongly favour a biomedical standpoint, others a more psychosocial one. There
is similar variation in the view of diagnoses, which are seen by some as descriptions of
symptoms but by others principally as a means of professional understanding.
The psychologists are generally cautious in the use of psychiatric diagnoses, though there
are those that see such a diagnosis as an equally valid alternative. Naturally enough, the
psychologists are those who most clearly perceive the utility of conversation as a form of
treatment — it is worthy of note, however, that few of them directly reject medication as an
alternative.
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Common to the social workers and the occupational therapists is that more often than not
there was an unwillingness to offer a diagnosis of Erik simply on the basis of the case history.
They wanted more information about the case and its context. Though some of them did see
medication as an alternative, the general view was that other forms of treatment were called
for and that the first thing to do was to determine what network the patient had. A marked
characteristic of the occupational therapists is the divergent view of what should be given
priority. Attention should not in the first place be directed towards the illness but towards the
patient’s ability to function in daily life in spite of the illness. Thus treatment of the illness
was not the primary concern.
Comparison with the Warwick study
The Warwick study (Colombo et al. 2003) which was briefly referred to in the Background
section was the source of inspiration for — and indeed to a great extent the model for — our
study with regard to design and data collection. One of our aims was that it should to some
extent be possible to compare our results with those of the English study.
In contrast with our study, the Warwick study started from a predefined model typology.
On the basis of literature studies six models of mental disorder were set forth: a “medical”
(“organic”) one, a “social” one, a “cognitive-behavioural” one, a “psychotherapeutic” one, a
“family-orientated” one and a “conspiratorial” one. It was presumed that these models were
clearly distinguishable from one another with regard to the conception of mental disorder
(involving assumptions concerning aetiology, the significance of diagnoses, etc.), with regard
to measures to be taken (treatment strategies, hospitalisation, hospital care in relation to
community-based care, etc.) and with regard to ideology (conception of the rights and
obligations of the patient and of society, etc.). Twenty persons from each of the following
categories involved in psychiatric teamwork were interviewed: psychiatrists, psychiatric
nurses, social workers, patients, next of kin. As in our study, the interviews involved on the
one hand questions in respect of a “case vignette” designed to identify implicit models of
mental disorder, on the other hand questions concerning joint decision-making based on
descriptions of “critical incidents”.
The most important findings from the study are that the models receive markedly different
support from the different professional groups involved and that the patient group endorse two
models and can be divided into two distinct sub-groups in accordance with which of the two
they endorse The pyschiatrists massively endorse the medical model whilst the social workers
endorse the social model. The psychiatric nurses strongly endorse the medical model but also
endorse the psychotherapeutic and social models. One sub-group of patients more or less
unequivocally endorse the medical model, the other sub-group incline to the
psychotherapeutic or the social model.
Colombo et al. maintain in their analysis that the results point to ideological tension
between psychiatrists and social workers, a portent of difficulties in co-operation. Psychiatric
nurses often have to act as “mediators” between the different ways of looking at things,
thereby exposing themselves to criticism from both sides. The authors state that the
psychiatrists, because of their greater power, often exercise a disproportionately large
influence, and that this gives rise to certain difficulties of co-operation in that other groups
feel steamrollered and feel that their competence is not put to proper use. The disparity of
power also affects the relation between psychiatrists and patients in that the patient’s
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autonomy and right to have a say concerning his or her care and treatment are not respected,
whereby patients often feel that they are not being listened to.
The authors conclude that if teamwork is to be successful, it is necessary that greater
consideration be shown for different groups’ implicit models and that the patient’s right to
participate in the decision-making be taken far more seriously.
There are certain important differences between the Warwick study and our own which
make direct comparison difficult. For instance, the teams we studied included two
professional groups (psychologists and occupational therapists) not included in the English
study. Further, our study involved the participation of mental orderlies (Sw. mentalskötare), a
group of care staff with a long historical tradition within Swedish psychiatry and who have
played a central role particularly in institutional care but for whom there does not appear to be
an equivalent in contemporary English community-based psychiatry. Another important
difference is that the social workers included in the Warwick study’s psychiatric teams appear
to have a much more independent status than their Swedish equivalents. The social workers
included in our study are an integral part of the psychiatric clinical organisation, whilst the
English social workers come from “outside” and represent the social services rather than
psychiatry in the teamwork.
If we make an overall comparison of the the results of our study with those of the Warwick
study, certain differences emerge fairly clearly. One important difference is that when it
comes to the nature, causes and appropriate treatment of mental disorder, the team-members
in our study exhibit a far more eclectic and pragmatic position than do their counterparts in
the English study. With regard to the aetiology of mental illnesses, the participants in our
study tend to look for combinations of biological and psychological or social causes. They can
speak, for example, of a particular person’s illness as being probably explicable in terms of a
genetically determined vulnerability in combination with the triggering effect of mental or
social factors. Furthermore many of our respondents (regardless of professional affiliation)
speak of the need of combined treatment strategies, where both medication and psychosocial
measures have an important role to play. This means that the clear distinction between the
support for one model and that for another such as is to be found among different professional
groups in the English study is absent from our study. The difference which Colombo et al.
observed between psychiatrists and social workers with regard to the endorsement of the
medical model or the social one, and which involved a repudiation of the other model, is
barely visible in our study. It can indeed be said quite generally that our respondents’
reasoning about the interpretation and treatment of mental disorders hardly ever had anything
to do with the repudiation of one or another way of looking at things. There emerges from our
interviews a sort of care-ideological “culture of mutual understanding” not to be found in the
Warwick study. The role of mediator, seen as so problematic by the psychiatric nurses in the
latter study, is not described in anything like the same terms by the nurses in our study.
Further, the endorsement of a “conspiratorial”, anti-psychiatric model which Colombo et al.
found in the case of some of their respondents is almost completely absent from our findings.
When it comes to joint decision-making there emerges another interesting difference
between the two studies. In the English study joint decision-making appears as a
comparatively well-defined and familiar phenomenon. The participants discuss its pros and
cons with no apparent questioning of what it implies. In our study, however, there is often
considerable uncertainty about it. The co-operation in psychiatric teams is for the most part
seen as being a question of different professions contributing different knowledge and skills,
whilst the making of important decisions is for the most part seen as occurring side by side
with this co-operation. For this reason the persons involved often find it difficult to offer clear
examples of joint decision-making with good or bad outcome. It seems likely that a closer
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analysis of these differences presupposes a deeper study of the actual processes of decisionmaking in English and in Swedish team-psychiatry. It is fairly apparent, though, that joint
decision-making forms a more clearly articulated part of the ideal image of psychiatric teamwork in English psychiatry than in Swedish, and that practical difficulties having to do with
this decision-making come out more clearly in the English study.
A third area where there are marked differences between the Warwick study and our own
is that of the involvement of patients and next of kin in the teamwork. The former study
appears to presuppose that patients and next of kin shall have a very great deal of influence —
they are described virtually as members of the pyschiatric teams. In our study, by contrast,
there emerges a great deal of uncertainty with regard to such influence. The patients and next
of kin often seemed a little bewildered when it came to the part of the interview that
concerned their participation in some form of decision-makin, and they were unable to give
any examples of decision-making in which they felt they had played a significant part.