Some specific aspects of politics and economy play an important role in the shaping of psychology – as in any other aspect of our life – and sometimes pose ethical challenges for practitioners. That is the case of the so-called managed care, of growing importance in the last decades in countries like the United States. The name refers to a set of techniques intended to reduce the cost and improve the quality of health benefits – which in practice promotes short, routinised and cheap mental health treatments. Treatment goals are often limited to superficial improvements, and drugs are used as a quick solution instead of in-depth longer-term therapy.
Managed care sometimes brings ethical dilemmas to psychologists participating in the system, such as breaches of confidentiality or ‘gag’ rules that limit what therapists are permitted to say to their clients about treatment options.
This issue is not too different from the growing intrusion of drug companies in the field of mental health. Expensive effort to market their products lead people to hold falsely optimistic expectations, encouraging them to take medication for minor difficulties, promoting the idea that most psychological problems are caused by brain or bodily malfunctions, and fostering a medicalised view of mental health that may discourage people from investing effort and time in psychotherapy.
The Diagnostic and Statistical Manual (DSM) and the American Psychiatric Association (APA) is the object of a strong controversy in this regard. The DSM is the most commonly used compendium of diagnostic categories for mental problems. By categorising and naming psychological difficulties, the DSM has considerable benefits for clinical practice and research: it permits the accumulation and synthesis of knowledge and experience, and provides professionals with a common language. As Mary Wylie indicated in 1995, the DSM is the official lingua franca of the mental health establishment. It not only influences diagnostic and treatment decisions, but it has also important legal, educational, institutional and monetary implications.
But many argue that the DSM not only reflects the social prejudices of the predominantly White, male, etc., persons responsible for its writing and update, but also strong economic pressures – mostly from the pharmaceutic industry. Its critics argue that this is evident in the manual’s growing emphasis on possible biological and heritable aspects, in the fact that psychiatric conditions are defined by a list of symptoms that mimic the style of biomedical diagnostic categories, and even in the terms utilised (disease, symptom, patient, syndrome, relapse). With huge fortunes at the stake, some wonder whether this is not part of a movement to definitely medicalise mental health.
It is obvious that psychologists’ ideas of normality of abnormality – as reflected in the DSM and other diagnostic criteria – do influence their diagnosis, the goals that they set for their clients and the options of treatment. But there are enormous social, cultural and historical variations in what is considered as normal or abnormal. Cultural differences can easily mislead interpretations of behaviour, resulting in over- or under– diagnosis.
If you tell your practitioner that you hear a recently dead relative speaking to you, and that you also speak to that person, you are a serious candidate to be diagnosed with some mental illness. Unless, of course, you belong to one of the several cultures where deceased members of the family are expected to communicate with their living relatives shortly after they pass away – as a sort of late goodbye in their departure from this world. Hearing dead people speaking is no cause of alarm for them.
Does it mean that the Western concept of normality does not apply to other cultures? You should be able to answer this question by now.
The growing number of diagnostic categories in the successive editions of the DSM also reflects a worrisome reality – that more and more behaviours formerly regarded as eccentricities, sins, crimes or ordinary life worries are being regarded as diseases or ‘conditions’. Restless children like Elvis Presley, John Lennon or John Fitzgerald Kennedy would today be diagnosed with attention deficit hyperactivity disorder – just to mention an example.
The proliferation of diagnoses also contributes to what has been called ‘the diffusion of deficit’, or tendency to label everyday obstacles, shortcomings and disappointments as pathological – and diminishes our control on our own personal life, putting it under increasing scrutiny and regulation by socially sanctioned experts.
In some instances, the new diagnostic categories may be more related to social issues than to actual mental disorders. In 1993, Leslie Camhi published an interesting article where she argued that the diagnosis of kleptomania originated in parallel with the invention of large department stores. Shoppers of all social class stole – particularly women – but the authorities tended to consider lower- class women who stole as thieves, whereas upper-class women’s theft was rather explained as a mental illness – thus preserving their moral superiority.
Perhaps even more revealing is the proposal in 1851 by the American physician Samuel Cartwright, of the diagnostic category of drapetomania.
He argued that this was a mental illness in Black slaves that provoked an irresistible urge to run away from captivity. The treatment of slaves as equals by their masters was presented as the cause of this presumed illness, which could be cured with ‘proper medical advice’ and removing both big toes to make physical running impossible. But of course, drapetomania could be prevented if, following Dr. Cartwright’s advice, the devil was whipped out of the slave at the first sign of dissatisfaction.
Another well-known instance of socially tinted diagnosis proved that Sigmund Freud’s ideas were also the product of his era and social context. Dora was a teenager from Vienna who presented persistent cough and frequent headaches, and who complained of the sexual advances that a respectable adult friend of his father, Herr K., made on her. Analysing the case from his patriarchal perspective, Freud assumed that any girl would appreciate the attentions of a man in the position of Herr K. and concluded that Dora’s cough and headaches were hysterical symptoms of her disguised sexual desires for him. Dora then decided to quit therapy, which drove Freud to enrich his diagnosis with the additional labels of disagreeable, untruthful and vengeful. But shocking as the case is, we must not be surprised that mental health conceptions reflect not just the knowledge, but also the values of each era. As Jeanne Marecek and Rachel Hare-Mustin highlight, at the end of the 19th century many women were considered as afflicted by a mental disorder then called neurasthenia, a condition that combined aspects of what today might be labelled chronic fatigue syndrome, premenstrual syndrome and depression. One acclaimed treatment involved compulsory bed rest, the forced deprivation of mental stimulation, isolation from adult company and constant heavy feeding, leading to weight gains of 25 kilograms or more.
Camhi, L. (1993). Stealing Femininity: Department Store Kleptomania as Sexual Disorder. Differences 5(1), 26-50.
Cartwright, S. A. (1851). Report on the Diseases and Physical Peculiarities of the Negro Race. The New Orleans Medical and Surgical Journal, May, 691-715. Retrieved from Google Books: https://books.qooqle.co.uk/books?id=ofMcAAAAIAAJ&redir esc=v
Marecek, J., & Hare-Mustin, R. T. (2009). Clinical psychology: The politics of madness. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical psychology: An introduction (2nd ed., pp. 75-92). London: Sage.
Wylie, M. S. (1995). The power of DSM-IV: Diagnosing for dollars. Family Therapy Networker, 19(3), 22-32.
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