The InterPsych Newsletter 2(1)
IPN 2(1) Section D: Article
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VOLUME 2, ISSUE 1 THE INTERPSYCH NEWSLETTER AUG-OCT, 1994
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SECTION D: ARTICLE
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| In this section is an non-reviewed article |
| submitted by Dr. Schaler. In the future, this |
| section will be devoted to refereed research |
| articles. To submit an article to this section, |
| please send an ASCII version of the manuscript |
| to the IPN Mailbox (udipn@badlands.nodak.edu). |
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U.S. HEALTH CARE REFORM AND THE THERAPEUTIC STATE
Jeffrey A. Schaler
"What has allowed us to get to the point where mental
illness and substance abuse services are viewed as
essential components of a comprehensive medical bene-
fit package," explains Tipper Gore, holder of a
master's degree in psychology and wife of Vice Pres.
Gore, is that as a country, "we have come to recognize
that mental and addictive disorders are real medical
disorders just like other physical illnesses; they are
diagnosable and treatable," (1). Ms. Gore says that 23
percent of people between the ages of 15 and 54, and
16 percent of Americans ages 65 and older, suffer from
"depression." Five percent of all children under
the age of 8 have "severe emotional disturbances"
and at least 10 percent of children in the U.S.
manifest a specific "learning disability." Alcohol
use disorders allegedly affect approximately 23 % of
the population, and drug use disorders affect about 12
%. On the basis of these statistics, it would appear
that 89 percent of the American population suffers
from mental and addictive disorders. In other words,
almost everyone is sick. I think we need to take
another look at the difference between mental [fake]
and physical [real] illness. For the policies that we
implement based on explanations for behaviors and ill-
ness can vary significantly. "Ideas," wrote Richard
Weaver, "have consequences," (2). Ms. Gore endorses
the "medical model" of behavior. She advances the idea
that biological factors determine "mental disorders."
There two other explanatory models used by social
scientists - and the public is generally unaware of
that. Psychological models focus on self-environment
interaction. Those may include free-will oriented,
existential perspectives on human behavior, as well as
deterministic approaches such as psychoanalysis and
behaviorism. Those may also include volitional-
learning approaches such as social-cognitive theory.
Sociocultural models explain abnormal behaviors
through norms and mores. Those proponents may
question the existence of mental disorders, i.e.,
that they are social inventions, not scientific
discoveries. For example, they view homelessness as a
socioeconomic problem. Ms. Gore sees it as untreated
mental illness. What we may do [or won't do] about
homelessness varies by the explanation that we give
for it. It's important for the public to realize that
psychology and psychiatry are not "hard" sciences like
chemistry or engineering. Behavior is choice, the
function of moral agency. Thus, the state should con-
sider the view that mental disorders are unlike
physical illnesses, before it gets too involved in the
"diagnosis" and "treatment" field. There are good
arguments against the idea that mental illness and
addictive disorders even exist. Certainly, the
medical model dominates public policy. However, by
scrutinizing mental and physical illness we may con-
clude that the two are quite different. Policy makers
should take these points in consideration. For
example, mental and addictive disorders are
"diagnosed" and "treated" based on symptoms, or sub-
jective complaints. Medical disorders are usually
diagnosed and treated based on signs, or objective
tests.
In mental and addictive disorders, people are
designated "patients" against their consent. In
medical disorders, treatment without consent occurs
only in cases of unconsciousness, for children, and
contagious disease. Real diseases occur in the body,
usually involve lesions, and are present at death.
That's not true for mental and addictive disorders.
There are no definitive lesions for any of the mental
and addictive disorders. Mental and addictive dis-
orders are diagnosed by something that a person does
and feels, e.g., acting in a peculiar fashion,
complaining of hopelessness. Real diseases are some-
thing that a person has, e.g., a person has cancer,
diabetes, or heart disease.
Mental and addictive disorders are behaviors and
thus a function of personal values. Real diseases have
little to do with morality. Clearly certain behaviors
may lead to disease: Smoking is a behavior that may
lead to cancer. Heavy drinking is a behavior that may
lead to liver disease. No matter how "good" or "bad"
people are, they're equally susceptible to con-
tracting a disease, e.g., AIDS. Furthermore, people
can change behaviors through desire, but they cannot
change their disease by desiring to be well. People
labeled with addictive disorder are often "treated"
with spiritual-conversion experience, e.g., "turning
one's life over to a higher power" as in Alcoholics
Anonymous. That's not so for physical diseases. More-
over, drug addicts get "better" when they give up
heroin and cocaine. Diabetics get worse when they give
up insulin (3). Finally, real diseases are listed in
standard textbooks on pathology. Mental and addictive
disorders are not. Most behaviors referred to as
mental and addictive disorders are categorized in the
Diagnostic and Statistical Manual of the American
Psychiatric Association as not having an organic base:
"The diagnosis is made only when it cannot be establi-
shed that an organic factor initiated and maintained
the disturbance," here referring to "schizophrenia,"
(4). As Thomas Szasz explains, the medicalization of
socially deviant behavior is moralism masquerading as
medicine, (5). The government has no place telling
people how to behave, when their behavior harms no one
but themselves. I submit that the government has no
place telling people how they should regard them-
selves, e.g., dictating self concept. When government
gets involved in "treating" mental disorders that's
exactly what it ends up doing - dictating an
"appropriate" way for people to think about themselves
and the world. As constitutional scholar Lawrence
Tribe wrote: "Not surprisingly the [Supreme] Court has
insisted that activities actually going on within the
head are absolutely beyond the power of government to
control. In a society whose whole constitutional
heritage rebels at the thought of giving the govern-
ment the power to control men's minds, the governing
institutions, and especially the courts, must not only
reject direct attempts to exercise forbidden
domination over mental processes; they must strictly
examine as well oblique intrusions likely to produce,
or designed to produce, the same result," (6) That
church-state entanglement through health-care reform
may bring unanticipated conflict regarding First
Amendment rights violations is one reason why
coverage for mental and addictive disorders is
inappropriate. The fact that mental and addictive dis-
orders are quite different from "real" diseases is
another. The economic drain on coverage for legitimate
diseases that people cannot control because of
"mental-health coverage" is perhaps the most
important, (7). While Ms. Gore, as Mental Health Ad-
visor to Pres. Clinton, asserts that people with
"mental illness" and "drug addictions are just like
those with cancer, diabetes, AIDS, and heart disease,
a person with diabetes is hardly like a heroin addict.
Those struggling with cancer are hardly like people
labeled "manic-depressive." Psychiatry and psycho-
therapy should remain personal, contractual engage-
ments and belong in the private sector, free of any
and all state intrusion and involvement.
Notes
1. Gore, T. (1994). Moving policy toward medical
reality: Mental and addictive disorders and
the Health Security Act. Treatment Today,
Vol. 6., No. 1, 6-9.
2. Weaver, R. (1962). Ideas have consequences.
Chicago: Phoenix Books.
3. The idea was suggested to me by Nelson Bolero,
MD, in 1989.
4. American Psychiatric Association. (1987).
DST-III-R. Washington, D.C.; American
Psychiatric Association, p. 187.
5. Szasz, T. (1994). Cruel compassion:
Psychiatric control of society Us unwanted.
New York: Wiley.
6. Tribe, L. (1988). Constitutional law, 2nd
Ed., p. 1315.
7. Hilzenrath, D.S. (1994). The quandary over
Mental health care costs. The Washington
Post, July 25, A6.