Abstract
Any human artifact has a design, and those artifacts that serve ends we value ought presumptively to be designed to achieve those ends and to achieve them efficiently and effectively. Our system for psychiatric care is such an artifact, although complex and the result of many individual decisions as well as public policy initiatives and other factors, and its very form is being transformed. The traditional Freudian model of open-ended therapy, one-on-one, psychiatrist and patient, is being replaced by a few consultations and medication. The driving force behind this momentous change is not a calculated decision that the ends our psychiatric care ought to achieve can be better achieved through the transformation, although that motivation no doubt plays a causal role. The driving forces are economic: the creation of new drugs that produce some of the effects psychiatric care is intended to produce and the crimping hand of health maintenance organizations that have radically cut access to psychiatric services and made the traditional model unaffordable except for the very wealthy. The transformation in the form of psychiatric care is not without its benefits, but it is a distressing feature of the changes that they are motivated not primarily by a rational consideration of means to ends, but by factors that ought to be secondary in considering any health care system.
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Notes and References
I do not mean to imply that these features are exhaustive of psychiatric practice, only that they are complete enough to give us an understanding of how it differs from, say, medical practice and of what some of its more essential features are.
For a more extended, but still brief analysis of the concept, see Robison, W. L. (1995) Decisions in Doubt: The Environment and Public Policy,University Press of New England, Hanover, NH, chap. 2.
Regarding this see,for example, Cavell, S. (1969) Must We Mean What We Say? Scribner, New York, pp. 1–43.
For depressing examples of how, for example, commercial pressures can alter even natural phenomena, consider how fruits and vegetables have been altered by their commercialization. The commercialization affects not only the varieties available but also the characteristics of those varieties and the research to produce those characteristics. For a delightful analysis of this process in regard to tomatoes, including a description of the MH-1, a tomato that will rupture only after hitting an impact speed greater than 13.4 miles per hour, “more than two and a half times the speed which federal auto-bumper safety standards [used to] provide for the minimum safety of current models,” see Whiteside, T. (1977) A Reporter at large: tomatoes, The New Yorker 52, January 24, 36–61; quoted remarks from p. 61.
Naturalists have long thought it appropriate to stock streams with farm-bred trout. The demand for such stocking comes primarily from those who fish and those who profit from selling to those who fish, but the program seems innocent in any case. What can be the harm in artificially increasing the number and quality of trout in a stream?
One difficulty is that such fish are unaccustomed to the warning signs—spreading of fins, for instance—of native trout and the two groups exhausted themselves in territorial fights. The native trout are reduced in number, overcome by the initially larger hatchery-raised trout, but the latter, raised in the ease of life of trout farms, are not subjected to the winnowing process that occurs in a natural environment and they fall prey much more readily than native trout to disease and “stupid” mistakes. Thus, they “fed inefficiently, expended too much energy, grew thinner and often died” [Stevens, W. K. (1991) Hatched and wild fish: clash of cultures, New York Times,p. B5]. The hatchery-bred trout replace,rather than supplement, the native trout and they then die off more rapidly.
Thus, stocking streams with farm-bred trout is actually counterproductive, producing fewer and less healthy trout in streams than would have existed without the stocking. Similar problems occur when non-native fish are introduced into a new habitat. In California, the introduction of non-native brown trout has decimated the native gold trout [Luoma, J. R. (1992) Boon to anglers turns into a disaster for lakes and streams, New York Times November 17, p. C4].
The lesson here is that trying to change a complex social system is much more difficult than one might think. If we cannot successfully alter the balance of fish in a trout stream, but actually do harm, it is not obvious that we can succeed in altering our health care of psychiatric care systems in any easy way.
Similar examples of how readily we can produce the opposite of what we intend abound. Nothing could seem more innocent than putting up nesting boxes for wild wood ducks, but it is a policy that serves to reduce the wood duck population when, as has happened, the boxes are put in places too easily spotted by other wood ducks. The females are as opportunistic as cowbirds and, when they can, lay their eggs in the nests of other wood ducks. Some nesting boxes have been found with as many as 50 eggs laid in them—each a loss [Anon. (1992) Birdhouses for ducks may harm breeding, New York Times May 19, p. C4].
Farmers in Florida have discovered that a fungicide, Benlate, used to control molds and fungi to protect millions of dollars worth of crops so poisons the soil that “even weeds will not grow. Cucumber seeds will not germinate. Broccoli plants wither and die” [Raver, A. (1992) Farmers worried as a chemical friend turns foe, New York Times February 24, pp. Al and 14].
Goleman, D. (1995) Emotional Intelligence, Bantam Books, New York, p. 16.
The material that follows is drawn from a great deal of reading on the problem of abusive behavior and its causes. Much of the literature is of the popular self-help variety and is painful reading for anyone interested in the theory behind the current research or even in the current research. Among the best of the genre, despite the title, is Terrence Real’s I Don’t Want to Talk About It (Scribner, New York; 1997). Among the more theoretically interesting works are Alice Miller’s For Your Own Good: Hidden Cruelty in Child-Rearing and the Roots of Violence (Noonday, New York; 1983 ) and Robert Kegan’s The Evolving Self: Problem and Process in Human Development ( Harvard University Press, Cambridge, MA, 1982 ).
Real, T. I Don’t Want to Talk About It,p. 16.
Ibid., p. 22.
Goldman, D (1995) Brain may tag all perceptions with a value. New York Times August 8, pp. Cl and C10.
Our problem with coming to grips with what we have done—are doing in the sense that our flooded brain is still supporting our original response—is compounded by what ought to be the reaction of the person we have just unjustly harmed, for that person ought to feel indignant and we must try to atone for what we have just done while also trying to overcome the messages our flooded brain is sending to us.
Bargh, J. A., Chen, M. and Burrows, L. (1996) Automaticity of social behavior: direct effects of trait construct and stereotype activation on action. J. Personality and Social Psychology 71 (2), 241.
Lemisch, J. (1992) Do they want my wife to die? New York Times April 15, p. A27.
Goleman, D. (1991) Battle of insurers vs. Therapists. New York Times October 24, p. D 1.
Ibid., p. D9.
Anon. (1992) California’s medical model New York Times February 17, p. A16.
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Robison, W.L. (2002). The Changing Form of Psychiatric Care. In: Humber, J.M., Almeder, R.F. (eds) Mental Illness and Public Health Care. Biomedical Ethics Reviews. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-088-9_5
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