The medical model is widely believed to be effective for a multitude of conditions. It is remarkably ineffective in much of substance abuse, addictions and mental health treatment. The primary reasons for this are measurability, objectivity vs. subjectivity and the importance of the client’s honesty and insight in reporting symptoms and experiences that are almost always emotionally negative and complex. Both clients and providers often face the possibility of significant losses (career, relationships, reputation and others) simply by admitting a problem with any or all of these and seeking treatment.
The medical model works well for a person who has broken a leg. Hypothetically that patient could see ten different doctors and almost assuredly receive the same diagnosis, prognosis, and course of treatment. What the medical profession has learned about broken legs tends to be effective for nearly all people who have them. There is minimal or no deviation. This knowledge continues to grow and is continuously researched and revised as new approaches are developed and old approaches refined. In this manner, “evidenced based practice” evolves beneficially in the medical field.
For those who live with Mental Health (MH), Substance Abuse (SA), and Addictions, it is entirely possible that a person could see ten different clinicians and be given ten different diagnoses, many different prognoses and forms of treatment. All three of these conditions have overlaps in symptoms. Further, there is often a chicken and egg scenario regarding which existed first and/or which caused the other. These conditions are vastly more subjective in nature than nearly all other medical conditions.
Example: A person presents to a clinician with depression. They show signs of alcoholism but when asked if their drinking is a problem, they deny drinking frequently or to excess (“I’m not one of those people”). Perhaps they admit to episodically abusing medications prescribed by their primary care physician (“just to get through a stressful time”). In most cases we must rely on verbal reports from the client to establish which of these occurred first and to what severity. We expect that people who are drinking often or to excess may be depressed. We also know that people who live with depression are more likely to abuse alcohol than people who are not. We must also consider the effects of abusing medications and whether mixing them with alcohol may be potentially deadly. Client self determination is paramount in voluntary treatment. The clinician may only treat what the client is willing to have treated. In this context, we may be asked to provide services that are often beneficial but episodically insufficient. All of these challenges make research of MH, SA, and Addiction assessment and treatment highly problematic.
The medical community has incredible technology to provide empirical evidence of conditions a person may live with. MRIs, X-rays, EKGs and hundreds of other tests and scans provide insight into what is occurring and how it can best be remedied. These forms of technology and how they can best be used provide further findings and evidence based medicine continues to evolve.
MH, SA, and Addictions are largely dependent upon clients honestly self reporting. Assuming that a person has not presented with damage to their physical self that is consistent with abuse of substances, we rely primarily on anecdotal evidence and collateral contacts. The stories of substance abusers and addicts are best suited to qualitative research, which is problematic in the pursuit of evidenced based practices.
In general, people receiving medical treatment see clear and compelling reasons to seek and maintain treatment. The person who has a broken leg is in pain, is aware that their body is damaged, and wishes to have their condition remedied. A person being forced to receive medical care against their will is the exception, not the rule.
Relative to most other medical conditions, MH, SA, and Addictions treatment is far more frequently involuntary. Treatment may be forced for a variety of reasons. Defining successful outcomes in involuntary treatment is not meaningfully based on client reporting and continued compliance is by no means assured.
In the medical model, the patient is a passive recipient of services as a trained expert provides care. Following the efforts of medical personnel there will often be rehabilitation processes in which the patient becomes more active and more knowledgeable of their condition and how to best recuperate from it. The motivation to do these things is clear cut – I want to have full functioning of my leg therefore I must comply. Efforts in rehabilitation are often monitored and facilitated by other medical personnel. These efforts will also be researched and provide insight into improving patient outcomes.
In most MH treatment and in all SA and Addictions treatment, passively receiving treatment generally cannot yield positive outcomes. The earnest desire for a better life and the willingness to be accountable and actively engaged in treatment are necessary for optimal outcomes. The only passive function of treatment in MH, SA, and Addictions is being medicated (often to addictive drugs prescribed by those in the medical professions). In most cases it is also necessary for clients to make significant changes in their thinking, coping, and behavior, not for a limited duration, but rather for the rest of their lives.
In the medical model, success is often defined as remission, an overall improved baseline of functioning, or a return to a previous baseline of functioning. In MH, SA, and Addictions returning to previous levels of functioning or ways of living are often ill advised. Additionally, baseline levels of functioning frequently change in the first year of abstinence from drugs and alcohol and are difficult to differentiate empirically. Remission and/or freedom from impaired functioning in these three fields are often only the beginning. Ultimately, the best treatment for most clients in MH, SA, and Addictions encourages clients early and often to solicit natural supports and self help groups. While self help is not at all “evidenced based practice” anecdotal evidence is compellingly clear that 12 step programs facilitate progressively higher quality of life for their members. For countless individuals, the use of 12 step programs eliminates the need for any professional involvement.
Beyond abstinence or freedom from impaired functioning is the concept of “recovery.” Whereas treatment may allow one to have improved functioning, recovery from addiction, substance abuse and mental health conditions (especially recovery from trauma, various forms of abuse and being an Adult Child Of an Alcoholic) allows one to have a newfound life. Here we find the paramount distinction between the measurable and the immeasurable – successful treatment outcomes versus “recovery.” If we define what success is in objectively measurable and agreed upon terms, we marginalize those who do not fit into categorical approaches of evidenced based practice. By allowing individuals to declare for themselves what success is, we cannot create uniform outcomes and practices. By encouraging involvement in self help programs we move toward the most effective interventions and move away from encouraging dependence on professional support.
The most important factors in recovery cannot be meaningfully measured. Accountability, willingness, resilience, fortitude, integrity, determination, and courage can never be calculated. The role and importance of spirituality and religion are not measurable. The importance of assisting clients to attain plateaus in their lives in which professional interventions are unnecessary must always be our “best practice.”