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Why the Medical Model is Inadequate for Treating Mental Patients (1972)

Why the Medical Model is Inadequate for Treating Mental Patients (1972)

© 1972, 2013 by Dallas Denny

Source: Denny, Dallas. (1972). Why the medical model is inadequate for treating mental patients. Paper for Middle Tennessee State University.




Background: How I Came to Write This Paper

From December, 1971 through mid 1973 I worked evening shift at Central State Psychiatric Hospital in Nashville, Tennessee. I lived 40 miles away in Murfreesboro, where I spent my days and early afternoons earning my bachelor’s degree. My twin majors were psychology and sociology.

Asylum for the Insane, Nashville

CSPH dated to the early 1800s, and most of the original buildings were not only still standing, but were chock-full of patients. In those days mental hospitals were like roach motels—you could check in, but you couldn’t check out. Many of the patients had been there for decades.

One of the newer units was notorious because it housed a team of behavior modifiers. Staff spoke of the behavior analysis program as if it were Viktor Frankenstein’s laboratory. While in a 13-week class which trained me to be a “medicine aide,” I received a lowered grade for my case study because I told my instructor, in regard to my chronically schizophrenic assignee, “I reinforce her when she is being appropriate by paying attention to what she says. “That’s behavior modification!” my instructor said, in shock. I explained that we all differentially reinforce one another in our daily interactions, but she was having none of it. If I hadn’t backed off and told her I wouldn’t do it any more, I would have failed the course. As it was I was flagged as a troublemaker and placed on graveyard shift, which led to my resignation and a move to a similar state position at Clover Bottom Developmental Center, which was a similarly old institution a few miles away that housed children and adults with mental retardation and other developmental disabilities. I worked there until just before my graduation from MTSU.

At both institutions I saw horrid abuses of inmates. I protected them whenever possible, sometimes at considerable cost to myself. For instance, at Clover Bottom my supervisor once dragged a nine-year-old nonretarded (long story!) boy into a bathroom and pulled the off-the-hinges door closed. His crime? He had been excited because he was about to see his brother, who was also a resident of the facility, at the weekly dance, and couldn’t sit still. As he began banging his head on the concrete floor, making horrible echoing booming sounds, she forbade me to let him out of the room. As soon as she turned to walk away I dragged the door open, put my foot between his head and the floor, and calmed him down. Later, she was going to have my ass until I told her that because he had been unable to open the door she had in effect placed him in seclusion without a physician’s order. Did she want to go there? She backed down, but had her buddies on the campus police pull me over and give me an undeserved ticket.

My studies at MTSU provided a frame for the terrible things I saw about CSPH and Clover Bottom. I was particularly influenced by the works of Irving Goffman, a sociologist who made sense of human behavior in and out of institutions. I was struck by his book Asylums, in which he pointed out that once institutionalized every move an individual makes is read through that stigma. The paper below illustrates that.


Why the Medical Model is Inadequate for Treating Mental Patients

By Dallas Denny


Insanity is a legal term— a label designed to assign to an individual a status of incompetence to manage his own affairs. In Tennessee an insane person is anyone who has been declared so by a judge and two physicians. This practice is questionable in light of past injustices to individuals and because neither judges nor physicians are qualified or trained in the diagnosis and etiology of mental disorders.

A mental patient, on the other hand, is any individual who is a resident or out-patient of a mental institution. It is not implicit or explicit in the definitions of either an insane person of a mental patient that an individual must or even should be crazy.

As Irving Goffman has pointed out, the in-patient of a mental hospital is viewed as “sick.” He is treated under the auspices of the medical model, which makes it extremely difficult for the individual to appear to be “normal.” Every behavior he does or does not engage in is seen in the light of his “illness.” A talkative person thus becomes “manic,” and a quiet one “withdrawn.” The individual who stands up for his rights and does not tolerate perceived injustices is in for special trouble, while the complacent or “good” patient who sits quietly is rarely bothered by staff. This is how the system works. Subtle and not-so-subtle pressures are put upon the individual to conform and be a “good” patient. The purpose of this paper shall be to make the reader aware of the “systems” at work in many large mental institutions.



When a person is mental to our institution (Hospital X), he is given an “admission interview” by a physician. The person is often excited, angry, and disheveled upon presentation to the interviewing physician. He may understandably be hostile to the idea of being insti­tutionalized against his will. Medications, often phenothiazines, often to be administered intramuscularly within the hour, are prescribed as a result of this interview and this interview alone. The new “patient” is taken to the ward, by force if necessary, but by suggestion if possible. He isn’t allowed the civil liberty of a phone call, even to inform friends or relatives of his location. MEDICATION SHOULD BE PRESCRIBED AFTER THE PATIENT IS SETTLED ON THE WARD AND HAS HAD AT LEAST 24 HOURS TO CALM DOWN. HE SHOULD BE ALLOWED ONE PHONE CALL!

Once on the ward, the patient’s belongings, if he had the chance to pack any before being summarily removed from his home environment, are scrutinized and searched, often with inappropriate remarks by the searchers. Personal belongings and grooming aids, with the possible exception of a comb, are confiscated. Clothes are not returned, under the pretext they must be marked. This marking process, at Hospital X, involves sending the clothes two floors below and having the patient’s name stamped on them in indelible ink. Expensive clothes are often lost or ruined while they are being marked. It’s not difficult to see why a person wouldn’t wish to wear a coat marked “Hospital X” After his release, especially when the marking is plainly visible from the outside. Once the clothes are removed for marking, the new patient needn’t expect to see them for several days, at best. Sometimes the clothes in which he was admitted are confiscated while he is sleeping. Upon awakening, the new patient must make do with whatever rags he may find in the ward clothing bin.

As Irving Goffman noted in Asylums, a person’s personal belongings, especially his grooming aids, constitute an important part of his self-image. If deprived of them, his self-concept must suffer. Cosmetics are removed, as are such things as shaving gear and mirrors. There is a rule that the patient can obtain this equipment for hygienic purposes when needed, but, in truth, the wards are so understaffed that this isn’t practical. The patient learns, after waiting all morning for several mornings for his grooming aids and not receiving them, to give up the cause. This is a contributing factor in the poor grooming of mental patients, which is looked upon as proof of their sickness.

Many patients must wear whatever clothing they can scrounge from a laundry bin, because their clothes are still at home, or because their clothes have been misrouted in laundering. Clothes which have been ironed are the exception rather than the rule, it being commonly believed by ward staff mental patients haven’t judgment enough to keep from burning themselves. Such make-do and inadequate clothing only further adds to their dishevelment.

Let’s return to our new patient. During the night his clothes, with the exception of his shoes, were removed. Upon rising, he must dress himself in state-owned clothes. Perhaps he cannot find the right size pants and must hold his trousers up with one hand all day long because his belt has been confiscated. Picture this person unable to obtain use of his grooming aids, and further imagine him walking unsteadily and slurring his speech as a result of massive doses of tranquilizers. It’s easy to view this person as “sick” because he looks different than we do. It’s somewhat harder to offer him the dignity and respect he deserves as a human being.

The new patient is at first unoriented in his new home. Nobody bothers to show him around the ward, or to introduce him to the other residents, who may, out of shyness, not introduce themselves. All the new patient knows is that he is locked up with a bunch of “nuts” and he is definitely not nuts. From this, it logically follows that he doesn’t belong where he is, and most patients don’t hesitate to let this be known. This is regarded as a sign of sickness and “lack of insight” by staff.

The new patient is told he can see the social worker, who makes all outside contacts for him, whenever he wishes, but in fact, it’s difficult for a patient to actually see the social worker. The patient, put off again and again by staff, becomes persistent and asks over and over when he will be allowed to see his social worker. Staff, although it is they who are giving the patient the runaround, usually show no insight into the feelings of the patient and chalk his actions up as part of his “illness,” when all the patient wants is a straight answer.

The chronic wards at Hospital X are perhaps one of the most depressing sights on Earth. Unkempt and ragged, often dressed in clothes that can perhaps best be described as rags, the patients sit in regimentation— up against the wall in the low-slung Ames chairs so common in mental hospitals. These individuals are extremely ill. Many of them don’t bother to go to the bathroom before eliminating, and many cannot or will not answer to their names.

The visitor to such a ward, although perhaps feeling initially shocked, can use such patients as a justification for Hospital X’s existence, and can alleviate some of his guilt feelings. His logic: if such people exist— and they do because I am looking at them as I write this— then they must be hospitalized for their own good and for that of society. The visitor doesn’t realize the primary reason for the patients being as sick as they are is the institution itself.

As I previously mentioned, the patient who antagonizes or annoys ward staff is in for trouble. And to antagonize or annoy ward staff isn’t hard; just ask to be treated properly. Or consistently.

Most of the patients at Hospital X receive tranquilizers daily, usually one of the phenothiazines. Thorazine and Mellaril are the two most commonly used at Hospital X. In addition to prescribed daily doses, many patients have a standing order for a “P.R.N.” This is usually an intramuscular injection which is to be given only for extreme agitation. But these P.R.N.s are often administered as punishments. Patients can get a shot for merely disregarding an aide’s verbal order.

The patient dreads these injections and learns to avoid them at all cost. Since he can get a P.R.N. for crying or expressing hostility, he learns not to do these things. “Flat effect,” says the doctor. He can get a P.R.N. for acting boisterous, so be learns to sit quietly in his chair. “Withdrawn,” says the doctor.

Given a person’s natural feeling toward being imprisoned and the pressures towards becoming institutionalized, it’s no wonder the patients, especially the older ones, learn to sit quietly in their chairs. They are also practically “tranquillized out of existence,” as Ken Kesey put it in One Flew Over the Cuckoo’s Nest, and, it being the easier course to sit quietly rather than fight the drug, and it being human nature sometimes to follow the easier course, the patient becomes a confirmed sitter.

The atmosphere of a ward is dull and depressing, to say the least (at least at Hospital X). Dull walls alternate with duller wall ornamentations. The patient who sits all day in such an environment soon begins to exhibit signs of sensory deprivation. Mealtime, with its tasteless offering, is no treat, either. The patient can become psychotic as a result of this sensory deprivation. And when such a “transient” psychosis lasts for twenty of more years, who knows what effects it has? I think that chronic patients in mental hospitals are more the victims of sensory deprivation than of whatever ravages sent them to Hospital X in the first place.

One thing is certain. After an extended period in a mental hospital, there is little chance that a person can ever function in society. But he has done a remarkable job of adapting to his environment.



Physicians at mental hospitals in the state of Tennessee need not be licensed to practice medicine. As a result, the majority of the doctors at places like Hospital X are foreigners who must establish a residency before opening private practice. Many of these physicians, besides having little training or interest in psychological or psychiatric techniques, have difficulty understanding English and often have terrible. problems in making themselves understood. And a patient who has a speech impediment (which may well be caused by tranquilizing drugs) and can hardly be understood by a native-born American is unintelligible to these doctors. Many persons in mental hospitals have speech defects, either as a result of developmental processes, genetic makeup, or trauma.

Psychologists determine mental ability and personality development and signs of psychopathology primarily by means of instruments such as the MMPI (Minnesota Multiphasic Personality Inventory) WAIS (Weschler Adult Intelligence Scale), and other psychological tests. But many persons in mental hospitals are poor test-takers or are so affected by medications that they do poorly on these tests. Since there is such a poor psychologist to patient ratio, the psychologist cannot know the patient personally, and must rely on his instruments as tools not only for diagnosis, but as a criterion for release from the institution. The aides— those who live with the patient for eight hours a day, and so know him best, aren’t included in staff meetings, which are comprised of nurses, doctors, social workers, and psychologists, some of whom may never have seen the patient they are discussing. If an aide happens to be, present, his word is taken lightly.

Minimum requirements for ward staff at hospital X are an eighth grade education and an I.Q. of ninety. Many aides hired before the minimum requirements were instituted are still employed, and couldn’t possibly meet them. At the same time, many aides are college students, graduates, or graduate students, often with majors in relevant fields. Medical school seniors, if employed, although soon to be doctors, cannot give intramuscular medications or oral medications unless they attend a thirteen-week course taught by nursing staff. This course is conducted at an elementary and superficial level, which results in profound boredom on the part of the more intelligent and knowledgeable aides.

Those members of ward staff who are in positions of authority tend to be those who have been employed longest. These people are often ill-trained and ill-educated. Authoritarian types abound at petty supervisory levels, making life difficult for those with stations below theirs. Such people know of only one way to do something, and variations of this method are not tolerated— to the extreme frustration of those more educated, more intelligent, and less authoritarian than themselves.

Better-educated aides, who often are concerned, humanitarian types, often cannot take being supervised by this type of person for long, and resign. (These people are also often put off by ward conditions and by inhumane treatment of patients.)

Thus the system perpetuates itself. Those more capable move on, while those who are of borderline intelligence, and those with psychological problems, stay. Every type of staff operates in a separate plane, with little communication between planes. It is easy to insulate oneself from the patients as people, and this is done at all levels of staff. Pseudo-psychological and quasi-psychiatric terminology abound, and misuse of terms is not uncommon. What is more ludicrous than an individual with an I.Q. of 85, an eighth-grade education, and no formal training saying, “He’s definitely paranoid schiz.”


The System

Everybody plays the system: the doctors, the nurses, the aides, the patients. Everybody has a role and had best stick to it. Every­body has a status and had best not extend themselves beyond their level of authority.

Those on top of the pile are the doctors— especially the psychiatrists. Their powers are unlimited. The antiquated medical model rotates around the doctors, with nurses as their avenging angels. What a doctor says, goes. And the power! The patients must respect the doctor; so also must the ward staff and nurses.

He who is on be bottom of the hierarchy had best stay within rigid limits. He must watch what he says and does. His every move is subject to misinterpretation and criticism. Every move towards autonomy or creativity or towards helping the patients is squelched. The result is that the aide, like the patient, becomes institutionalized, and thus deadly inefficient at the job he does. I say deadly because it is the patient who suffers for this.

Psychologists play an interesting role. They give tests, draw up behavior programs, and hold group-therapy sessions, but their authority is limited, for they, too, must stay within clearly defined limits. For all their worth, they might as well be nonexistent.

Only with the discontinuation of the medical, model and the treatment of the patient as an individual human being— only with the cessation of such deadly, role playing— only with drastic changes— can there be any hope for Hospital X— and its residents.


Postscript, 2013

Following are some of the things I penned some on official patient observation notes) at Central State in the evening hours after the patients were in bed. There was nothing to do between about 9 pm and the end of shift at 11:15, so I would read, pay bills, and write on whatever was handy.