Models for Tretament and Models for Research
As one of my editors put it, "the idea may get around that a genetic and organically minded neo‑Kraepelinian has little time for social and personal factors as they affect the illnesses of his patients." Do I wish to defend myself against this? Altogether, I must have spent a good deal longer in looking after patients entrusted to my care than in researching the conditions from which they were suffering. In treating a patient one has to try to be all‑wise, and it is not unusual to suppose that one is. One must take account of everything that might be helping to make him ill, or that might be used to try to get him better. It is best to keep a certain distance from the patient, with a view to seeing his problems objectively; but even so, one must be warmly engaged on his behalf. One must be prepared, for instance, to spend time and trouble defending his interests vis‑à‑vis employers, community services, and relatives. One can't do this without taking personal and social factors very much into account, both when trying to understand the patient and when trying to help him.
Where genetics comes in is in helping to settle the diagnosis, a vitally necessary task and one in which knowledge of the social and personal background does not often give much help. I do not believe you can do your best for a schizophrenic patient without first deciding that his trouble is schizophrenia. But it makes no difference to treatment if one knows he has a family history positive for this disorder, or knows that he has not.
In the therapeutic situation, the medical model has proved to be the most consistently successful one; I think it is a necessity and that it is irreplaceable. Most of our patients are ill, and we cannot afford to try out other "models" until we can be sure that there is no illness and that the medical approach is inappropriate and best replaced by a wholly different way of looking at the situation.
In requiring a "diagnosis," this strategy makes one try to conceive of this man this patient one is talking to, with all his individual qualities ‑ in relation with predecessors, the other patients one has studied oneself, and the abstractions of the text‑books. It matters very little whether one calls the condition a "disease" or a "syndrome" or a "reaction type"; at least, these are not counters which do a lot of work for me. One matches this patient with the others, in respects which the accumulated experience of generations of psychiatrists has shown to be important. The extent and the ways in which this patient resembles those others provide the main indications for treatment, and the main guides for predicting an outcome.
With new and more powerful methods of classification, our present diagnostic systems may become obsolete, replaced perhaps by statistical taxonomy. But the basic logic and the rationale for prognosis and treatment will be the same. When the individual patient, despite his uniqueness, has been identified with a point in a multidimensional universe, whose many parameters are tracked by many millions of observations, it will still be the relationships between that point and all the others, whether considered in clusters or not, which will tell the working doctor what to do.
When we leave the therapeutic, i.e., medical, situation, we are not compelled to take the medical model along with us. If we are dealing with large groups of patients or with populations, or with administration, welfare, or research, we can use quite different instruments. Trained as a doctor, I am of course stuck with the medical model; I don't think that doctors who have abandoned it have done very well. Necessarily, I took the model with me into the planning of research and the consideration of its results. It proved very useful, rigorous enough and adaptable enough, and I never felt it had let me down. So I believe that it corresponds with the realities we are trying to grasp.
Of course, what was necessary for me has not been a necessity for others who can and do enter research with models of a very different kind. I may or may not be able to understand the way they think; if science is a common language shared by us, I should be able to understand their conclusions, perhaps apply them, perhaps be in the position to check them. But they must forgive him, if the neo‑Kraepelinian sticks to his own pathway.
What I have tried to be as a doctor and what I have tried to do as a journal editor are another matter, but it is true that in research I have had relatively little time for examining the role of social and personal factors in contributing to psychiatric illness. I might have found more time, if the results of environmental research had lent themselves to being checked with more precision, in the type of studies in which I became involved.