________________________________________________________________ VOLUME 2, ISSUE 1 THE INTERPSYCH NEWSLETTER AUG-OCT, 1994 ________________________________________________________________ SECTION D: ARTICLE ---------------------------------------------------- | 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 (email@example.com). | --------------------------------------------------- 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.