'Social' vs. 'medical' model – a breakdown

Deinstitutionalisation requires a paradigmatic change on several levels. The patterns of organisation, spatial arrangements, relationships and approaches as well as how we understand the disability, the needs, care and support must take completely other turn. The changes are usually subsumed into change from ‘medical’ to ‘social model’ (Oliver 1990). The basic idea is that – no matter how much an impairment is physical, biological, seated in the body, the disability itself is constructed socially. Various social arrangements, ranging from architectural barriers to the stigmatisation, labelling, devalued social roles, as well the treatment and care, disable people to fully exercise their faculties, their right, participate in society and be fully included in it. 

This paradigmatic change is about not only how we understand and explain the disability but also how we act, how support is provided and organised. Because the distinction between ‘medical’ and ‘social’ models is to a great degree summative, it has become a powerful and mobilising idea but on other hand blurring important distinctions between the explanation and action. Models can be understood as modelling understanding and explaining disability but also as modelling approaches to it (i.e. ‘treatment’), and how the care and support is organised. To be more accurate there is a need to distinguish between the explanatory, treatment and organisation models.

Explanatory models can be divided into reductive explanations reducing human complexity to one dimension (illness, legal norm, psyche etc.) and transversal explanations enabling syntheses of various planes of functioning and existence. Transversalitiy is imminent, ‘natural’ to everyday reasoning and ordinary (pre—or non-scientific) knowledge, but also to comprehensive sciences like anthropology, social work, management sciences.[1] As platforms of action the reductive explanations foster separation, competition and dominance of a particular explanation in a particular academic, professional, or sectorial (health, justice) milieus or even in society at large. The transversal synthetic explanations encourage interdisciplinary cooperation, pluralism of ideas and approaches, their complementarity based on ethical consistency, thus positioning humanism as a leading idea.

Treatment[2] models, we can divide into corrective and enabling approaches. Corrective approaches are based on the supremacy of the professionals, which draw their mandate to act upon a person on the supposed deficit, inadequacy or failure of the person, for which there is a special competency (or more truly a social authorisation) to deal with by special means – medication, psychotherapy or other psycho-pedagogical intervention, or administrative measures. These approaches are imminently disempowering and disabling. Their opposite are enabling approaches, in principle they are based on the general human rights and seek many ways to empower people in need. This can be done only through non-conditional inclusion and by sponsoring and supporting people in a variety of everyday life activities (thus enabling people to take risks instead of avoiding them).

Two dominant organisation models in care provision can be distinguished. One is institutional based on segregation, innate hierarchy (staff – residents, but also within the staff and residents groups), collective living and provision and providing ‘care’ in totality – one authority providing and regimenting everything that a person needs.[3] Community model, as an alternative to the institutional, is not only community-based but is oriented to community participation, thus creating new connections not only from services users to community member, but also in the community itself. The relationships in community provision tend to be egalitarian and while inclusive, person centred.

On the whole, the ‘medical’ model is reductive in explanation, reducing the disability to one dimension; it is corrective in its approach to the people – adapting them to the society; and it is institutional in the way it organises the services. Social model on other hand is transversal in explanations taking into account diverse plateaux of human existence, enabling in its approach to the people in need and community based in organisation of the service provision. The distinctions into explanatory, treatment and organisation models are important (apart from fending off sloganizing the issue of models) to note the diverse planes of modelling and, on the other hand to make distinctions between certain ways of sub-modelling and existence of mixed models.

For example, community psychiatry still to great extent adheres to medical explanation of the mental distress, however, it is abandoning hospital as it organisational base and is by necessity using a mixed approach (medication and inclusion). On the other hand, a psychotherapist may not have a narrow medical explanation, but the explanation may be as reductive as the medical one and his or her approach will be corrective, but he or she will not be practising in an institution, however, the practice could be supporting, be complementary to institutions. Conversely, there can exist a transversal understanding of human need or misery, but if there is a lack of skill in approach or organisational framework that would allow the transversal syntheses to become active, a knowledge remains impotent.  Or, services can be translocated into the community – but if the approach and understanding remain solely correcting and reductive, the community provision will be inadequate, in fact more alike to institutional care than what is considered a truly community-based service.

The paradigm shift entails two similar, complementary and yet opposite processes. First, there is a transition period characterised by a ‘mixed regime’ of various models. Second, the new paradigm needs to subsume and incorporate the old paradigm into the new one. There is a space for medical, juridical or other reductive knowledge in social model, corrective devices and intervention such as medication, psychotherapy etc. can be used to empower people, yield inclusion or support people in their activities; collective provision such as camps, work-cooperatives etc. can be a potent part of community services, if limited in time and scope.

These transitory phenomena are very conspicuous in Macedonian present-day practice. The ‘social model’ was introduced and is known. However, in practice ‘medical’ model still prevails (not only in health care). An obvious reason for such state of the art is that a lack of opportunity to practice new models since the services, which provide a space to practice them, are not developed as is the case with skills and approaches. However, also on the level of knowledge in terms of explanation and understanding there are inconsistencies not only in medicine and nursing, but also in special education (defectology!) and even social work. E.g., there is still strong adherence to the diagnostics and diagnostic labels. This in itself would not be a problem if it would not cement the disabling beliefs and prevent affirmative, enabling action. For example, during the student camp there were students and professionals who deemed efforts to enable residents to participate in the activities like assemblies as futile by saying: “Can’t you see – they are severely disabled!” One would be tempted to postulate that there should be conceptual purity in order to implement changes on the practical level. Even if this may be true on the strategical level, it does not seem to be spot-on on the practical level. There the logic might be inverse that we need to get rid of institutional spaces and organisational models in order to practice and understand in the new – enabling and transversal ways.

Claimer: This blog is intended as a part of Situation Analysis and Assessment/ Evaluation Report of Implementation of National Strategy on Deinstitutionalisation 2008-2018 which will be soon presented to the public within the EU framework project Technical assistance support for the deinstitutionalization process in social sector.

References:

Flaker, V. (2006) 'Social work as a science of doing: in the praise of a minor profession' in Von der Idee zur Forschungsarbeit: Forschen in Sozialarbeit und Sozialwissenschaft, V. Flaker & T. Schmid, T. eds Böhlau Verlag, Wien.

Oliver, M. (1990). The Politics of Disablement. London: Macmillan.

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[1] A significant difference between anthropology and social work in their respective transversalities is that anthropology is an explanatory science, while social work is a science of doing (Flaker, 2006) and is transversal not only in knowing but also in acting – on various registers of social intervention.

[2] Treatment should be understood in this context wider than its narrow meaning – as an approach to people in need and not treating 'somebody' or 'something' – this is the characteristic of the corrective approach.

[3] As such a total institution is deeply rooted in feudal (guardian) patterns of relationships.