Abstract
This paper aims to elucidate some dysfunctional aspects of health care utilisation by combining concepts from modern systems theory and from psychoanalysis. Contemporary health care in industrialised countries can be conceived as a social system in terms of modern systems theory. According to this theory, social systems are operating on the basis of a ‘guiding difference,’ which in the case of health care is the distinction between ‘healthy’ and ‘ill.’ Its rigidity in adhering to the healthy-ill dichotomy exposes health care to being collusively entangled in the interpersonal defence arrangements of patients. In the psychoanalytic view, individual conflicts can be warded off from consciousness not only by intrapsychic defence, but also by interpersonal defence mechanisms. These mechanisms involve the patients’ close social environment, often including doctors and hospitals. The functioning and the motivational structure of health care itself shows features of neurotic defence: Not only its representatives, but health care as a whole act in a rigid, obsessive manner in order to separate the healthy from the ill and to battle against (presumed) diseases. This obsession sometimes results in excessive diagnostic activism and in inconsiderate application of aggressive medical treatments. Both are inappropriate with regard to the salient problem of modern medicine: the increase of chronic nonfatal diseases like depression and chronic pain. The described defence mechanisms are unconscious not only to patients but also to health care professionals (let alone health politicians), and are contributing to dysfunctional health care overuse.
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Allison TR, Symmons DPM, Brammahn T, Haynes P, Rogers A, Roxby M, Urwin M (2002) Musculoskeletal pain is more generalised among people from ethnic minorities than among white people in greater Manchester. Ann Rheum Dis 61:151–156
Andersen RM (1995) Revisiting the behavioural model and access to medical care: does it matter? J Health Soc Behav 36:1–10
Balls OP, Miranda J (1991) Psychosomatic symtoms in medical outpatients: an investigation of self-handicapping theory. Health Psychol 10:427–431
Baker R, Mainous AG, Gray DP, Love MM (2003) Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors. Scand J Prim Health Care 21:27–32
Berger M (2002) Chronically diseased patients and their doctors. Med Teach 24:642–624
Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A, Bury G (2003) Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med 41:309–318
Cassidy JD, Carroll LJ, Côté P, Lemstra M, Berglund A, Nygren Å (2000) Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplsh injury. N Engl J Med 342:1179–1186
Croft PR, Rigby AS (1994) Socioeconomic influences on back problems in the community in Britain. J Epidemiol Commun Health 48:166–170
Domenighetti G, D’Avanzo B, Bisig B (2001) Health effects of job insecurity among employees in the swiss general population. Int J Health Serv 30:477–490
Elks ML (1997) ‘I’m ok; you’re not’: medical socialization and psychosomatic illness. Med Hypotheses 48:33–36
Freud S (1917) Introductory lectures on psycho-analysis. Lecture XXIV: The common neurotic state. In: The standard edition of the complete works of Sigmund Freud, vol XVI. The Hogart Press, London, p 378
Freud S (1930) Civilization and its discontents. In: The standard edition of the complete works of Sigmund Freud, vol XXI. The Hogart Press, London, p 64
Goldstein AP (1994) The ecology of aggression. Plenum Publishing Corporation, New York
Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS (1994) The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol 47:647–657
Hart JT (2001) Unhappyness will be defeated when doctors accept full social responsibility. Br Med J 322:1361
Hiller W, Fichter MM (2004) High utilises of medical care. A crucial subgroup among somatizing patients. J Psychosom Res 56:437–443
Holman EA, Cohen SR, Waitzkin H (2000) Traumatic life events in primary care patients. Arch Fam Med 9:802–810
Jureidini JN, Shafer AT, Donald TG (2003) “Munchausen by proxy syndrome”: Not only pathological parenting but also problematic doctoring? Med J Aust 178:130–132
Kalanithi P (2001) The mediacalization of personality: mind-body relations in scientific culture. Princeton J Bioeth 4:46–63
Lings P, Evans P, Seamark D, Sweeney K, Dixon M, Grey DP (2003) The doctor-patient relationship in US primary care. J R Soc Med 96:180–184
Luhmann N (1990) The world society as a social system. In his: essays on self-reference. Columbia University Press, New York
Luhman N (1995) Social systems. Stanford University Press
Malleson A (2002) Whiplash and other useful illnesses. McGill-Queen's University Press, Montreal
Marin B, Prinz C (2003) Facts and Figures on Disability Welfare. A Pictographic Portrait of an OECD Report. European Centre for Social Welfare Policy and Research, Vienna
Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA (1997) Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome. Arch Intern Med 157:1482–1488
Mechanic D (1992) Health and illness behaviour and patient-practitioner relationships. Soc Sci Med 34:1345–1350
Moynihan R, Smith R (2002) Too much medicine? Br Med J 324:859–860
Murray CJL, Lopez Murr AD, eds (1996) Global burden of disease. A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard University Press, Cambridge, MA
National Institute of Mental Health (2001) Mental disorders in America. Online: www.nimh.nih.gov/publicat/numbers.cfm 2001
Nye RA (2003) The evolution of the concept of medicalization in the late twentieth century. J Hist Behav Sci 39:115–129
Parsons T (1968) On the concept of value-commitments. Soc Inq 38:135–160
Pearson SD, Katzelnick DJ, Simon GE, Manning WG, Helstad CP, Henk HJ (1999) Depression among high utilizers of medical care. J Gen Intern Med 14:461–468
Plsek PE, Wilson T (2001) Complexity, leadership, and management in healthcare organisations. Br Med J 323:746–749
Rosenberg CE (2002) The tyrrany of diagnosis: specific entities and individual experience. Milbank Q 80:237–260
Schimmel P (1998) Medicine and the manic defence. Australian New Zealand J Psychiatry 32:392–397
Steen E, Haugli L (2000) Generalised chronic musculoskeletal pain as a rational reaction to a life situation? Theor Med Bioeth 21:581–599
Sun BC, Burstin HR, Brennan TA (2003) Predictors and outcomes of frequent emergency department users. Acad Emerg Med 10:320–328
Tilanus-Lindthorst MM, Kriege M, Boetes C, Hop WC, Obdeijn IM, Oosterwijk JC, et al (2005) Hereditary breast cancer growth rates and its impact on screening policy. Eur J Cancer 41:1610–7
Vaillant GE (1977) Adaption to life. Little, Brown & Co., Boston
Van Der Heyden JH, Demarest S, Tafforeau J, Van Oyen H (2003) Socio-economic differences in the Utilisation of health services in Belgium. Health Policy 65:153–165
Van Hemert AM, Bakker CH, Vandenbroucke JP, Valkenburg HA (1993) Psychologic distress as a longterm predictor of medical utilisation. Int J Psychiatry Med 23:295–305
Vliet Vlieland TPM (2002) Managing chronic disease: Evidence-based medicine or patient centred medicine? Health Care Anal 10:289–298
Weinryb R, Barany F (1987) The psychological facet of psychosomatic disturbances. Scand J Gastroenterol (Suppl.) 130:47–54
Westerman MA (1998) Reconceptualizing defense as a special type of problematic interpersonal behaviour pattern: A fundamental breach by an agent-in-a-situation. J Mind Behav 19:257–302
Willi J (1984) The concept of collusion: A combined systemic-psychodynamic approach to marital therapy. Fam Process 23:177–185
Yui K (2004) Health as a symbolic media interchanging between body and social system. Discussion paper 04/24E. Center for Legal Dynamics of Advanced Market Societies, Kobe University. Online: http://www.cdams.kobe-u.ac.jp/archive/dp04-24.pdf
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Maier, T. Psychosocial and Psychodynamic Factors Influencing Health Care Utilisation. Health Care Anal 14, 69–78 (2006). https://doi.org/10.1007/s10728-006-0013-9
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DOI: https://doi.org/10.1007/s10728-006-0013-9