The table above summarizes a progression from a narrower "medical model" that we have argued has real but limited value in relation to many issues of mental health and a broader "biological/neurobiological/cultural model" that we believe provides a more appropriate approach in this realm. In laying out this progression, we have tried to illustrate a process in which alternate perspectives are not set against one another but rather used to develop still broader perspectives that correct known problems with more restricted ones. As indicated in the table, we do not regard the "biological/neurobiological/cultural model" as the final stage of such a process but rather, inevitably, as a new building block for continuing evolution. We hope it is useful in the present but are at least as interested in what new directions may emerge from it in the future. In the following we sketch what we think are some desirable further directions of evolution.

Human suffering

Not only the "medical model" but a variety of other perspectives on human health and mental health set themselves the in principle task of eliminating human suffering. In lieu of a conceivable "ideal world", this is probably not only an overly ambitious task but one whose very definition creates problems (who is to decide who is/is not suffering?). Moreover, there is in the biological/neurobiological/cultural model some suggestion that suffering is not always "bad", that some discomfort may be an important element in producing ongoing revision of both individual and cultural identities. One direction in which we suspect further development is needed is in relation to the problem of how to define "suffering" and when it is and is not desirable to act to alleviate it. Making use of insights gained from some eastern and ascetic traditions may be helpful along these lines.

Professional responsibility, expertise

There are three distinct issues involved in "professional responsibility". One is the willingness to take on some responsibility for the lives of other people. A second is having authority over other people. And a third is the possession of information/skills/and perspectives that may be helpful to other people and/or are wanted by them. By and large, not only the medical model but a variety of other perspectives conflate the three: authority derives from willingness to take on responsibility together with "expertise". The biological/neurobiological/cultural model begins to dissociate the three issues, and suggests it may be useful in the future to further examine each of the three separately. If "expertise" is always context-specific, it may or may not be relevant to particular individuals. If each person is engaged in their own process of self-definition, the value of "authority" needs to be explored anew, and perhaps replaced with the notion that one is committed to helping others evolve rather than to being for them an "authoritative" figure. Finally, there is an interesting question whether a willingness/ability to take on responsibility for aspects of other people's lives ought to be regarded as a "professional" characteristic or a common human one. The concerns here are not dissimilar from those in family structure or in educational environments and so the perspectives of people with experience in those realms may be helpful.

Fixed ideals and categories versus ongoing evolution

In the "medical model" as well as from a variety of other perspectives, there exist presumptions of "ideal" states against which current states can be measured. These "ideals" are frequently treated as more or less common to all human beings, and so the therapeutic task is well-defined in terms of moving people as rapidly as possible from wherever they are to such ideal states. The "biological/neurobiological/cultural model" on the other hand, consistent with current understandings of biological evolution, denies the existence of "ideal" states, and treats diversity and change as the baseline desirable condition. It also blurs the border between "objective" and "subjective". This is a major switch in perspective, but one we will to be particularly necessary in the mental health realm. The questions that obviously arise from it have to do with how, in the absence of an ideal, one decides who needs assistance and how that assistance should be provided. One suggestion that we have offered is that the overall task should be conceived as facilitating the ability ofindividuals to conceive and reconceive their own identities, and more immediate therapeutic decisions should be made based on this general criterion rather than on fixed ideals or fixed categories. That there is of necessity a "subjective" element in such decisions seems to us to enhance rather than to detract from this direction of thinking. The devil, of course, is in the details, and we think the widest variety of current mental health care providers, including many not generally regarded as falling into this professional category (cf The Work of Byron Catie and Buddhist Meditation and Personal Construct Psychology), could usefully provide new insights along these lines.

Materialism and religious/spiritual perspectives

The "medical model" derives from a long history of success in alleviating aspects of human suffering in ways that involve material manipulation of material structures. At the same time, it is clear that some kinds of human suffering have been resistant to such approaches; the "medical model" tends to treat these as outside its sphere of expertise. It is equally clear that there exist approaches to dealing with human suffering that do not make a materialistic assumption. How the "medical model" relates to these is a matter of continuing negotiation, with some tendency to disparage those that don't fit comfortably within the norms of the medical model at any given time.

The "biological/neurobiological/cultural model" is more broadly "materialistic", reflecting increasing evidence that all human experience is a function of the brain. For the same reason, it is less dismissive of ideas and insights that cannot currently be accounted for in material terms. Ways of dealing with human suffering that invoke non-material influences are not rejected out of hand in the "biological/neurobiological/cultural model" but are instead valued challenges to the further development of such a model. For this reason, as well as in the interests of the development of the still broader perspectives that will ultimately replace the "biological/neurobiological model", it is clear that useful contributions to discussions of mental health can and should come from non-materialist as well as materialist perspectives.

We believe the materialism presumption is a useful one at the present time not in that it is "right" in any permanent sense but rather in that it provides a shared foundation in phenomena that can be commonly experienced and talked about. We are comfortable working from this foundation and leaving for the future the question of whether it is or is not useful to add genuinely non-material forces (about which there are an array of substantially different perspectives) to the list of things required in a broader discussion of mental health.

Individual and cultural change

The "medical model" focuses on individual humans and their suffering without concern for the broader cultural context within which those humans are living (or, probably more accurately, with a presumption that that cultural context is a given). While this simplification has demonstrable advantages and successes in a number of contexts, it is clearly inadequate to meet a number of more complex situations, including many of those in the area of mental health. What is needed in these cases is a clear acknowledgement that human suffering may be as much a response to the cultural context as anything inherent in the individual.

This in turn raises a host of new issues. What are the potentials and limits of individual change? What are the advantages and disadvantages of culture and what are its potentials and limits of change? And how do individual and cultural change relate to one another?

Inherent in these sorts of questions are quite significant matters of personal responsibility. The "medical model" largely avoids these by focusing on situations where one might reasonably say that an individual is not personally responsible for their own suffering. The problem with this approach is that it fails to acknowledge situations where some degree of personal responsibility may in fact be present and, in general, fails to encourage further development of personal agency. One does not, however, at all want to move to the other extreme, and treat individuals in all cases as solely responsible for their situations. What the "biological/neurobiological/cultural" model does is not to deny constraints on individuals due to either internal or cultural factors but rather to encourage in any given situation an ongoing development of personal agency. And to admit that while some productive change is always possible, particular changes, both individual and cultural, may be at any given time either impossible or slow to achieve.

Many health care professionals may feel that raising these sorts of issues detracts from their ability to do their jobs. Our feeling is very much the opposite, that part of the excitement of a broader perspective is that it invites explicit consideration of these issues as a necessary and central feature of mental health practice, and encourages mental health professionals to incorporate into their activities an active engagement with facilitating the reshaping of not only individual lives but culture as well. If one talks the biological/neurobiological cultural model seriously, it points in some quite significant general directions for cultural change:

Whether one is or is not comfortable with this particular line of development, it seems apparent that useful contributions to discussions of mental health could and should come from the perspectives of anthropology, politics, law and social activism.

Conclusions

Our concern here is not to do away with the "medical model", a perspective that we feel has significant and demonstrated value in particular circumstances but rather to argue that the medical model (like all perspectives) has limits to its usefulness that have become particularly clear in the context of many challenges in the area of mental health. We believe the appropriate response to those limitations is not to dismiss the medical model, or any other particular perspective, but rather to be aware of the limitations of existing perspectives and to seek in a synthesis of these a wider perspective having more general applicability. Drawing on aspects of biology, neurobiology, and cultural studies not present in the "medical model" we have offered as an example of such a synthetic perspective, the "biological/neurobiological/cultural model". We believe it to provide a wider and more useful perspective in the mental health arena, but recognize that it too is of course limited and have suggested some additional areas that might usefully be considered in efforts to achieve a still broader perspective. We invite others to contribute their own thoughts in the ongoing process of "getting it less wrong" in the mental health arena.

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