Mental Health Parity, Depression as Specialness, and the Difference Between Mental Illness and Terrorism

November 10, 2009 at 4:57 am | Posted in Fighting Prejudice, In the News, Philosophical Problems, The Heath Care System | 1 Comment

In all the excitement over heath care reform passing the House, it’s easy to overlook another huge (if equivocal) step: the mental health parity law that will take effect next year. The New York Times offers this sweetly naive guide to taking advantage of mental health care under the new system. I’m not sure that my advice would be any better, but, man, there’s something downright dewy-eyed about suggesting that we “be pushy” in asking for care.

A little background: the law requires that large employers offer the same coverage for mental health and substance abuse programs as they do for physical health. The practical results are twofold. First, many plans will remove arbitrary limits, such as caps on the number of appointments available for mental health care. My employer-provided health insurance will be doing just that, in fact. I haven’t checked specifically, but I wouldn’t be surprised if they’ve taken another common step, which is to throw up additional barriers to care, such as requirements for precertification. The Times’ advice on how to negotiate the system? Well, it’s sensible. Be persistent. Make those phone calls. Negotiate lower rates with your provider.

Unfortunately, when people are suffering from depression, anxiety, or chronic mental illness such as schizophrenia, it’s difficult if not impossible to take these steps. One book that I read on bipolar disorder (I wish I could remember which one) explained precisely why bipolar people are typically at a disadvantage when making calls to a customer “service” line: difficulties with short-term memory and executive function make it hard for us to organize our thoughts and follow a complicated, emotionally charged discussion of the sort required to get precertification. Your hatred of calls to 800 numbers is not mere whim or laziness — we are actually at a disadvantage when it comes to these sorts of conversations, and it’s natural that we should dread and avoid them. Thus it’s cruel — but not surprising — that insurers will require us to go through such an exercise before qualifying to receive help that we desperately need. Just another one of the sweet ironies of mental illness.

Over on Knowledge is Necessity, John McManamy considers a problem that we’ve all wrestled with: Is my depression pathological, or is it a fundamental part of who I am? Is there some sort of trade-off that is lost when we erase depression? I find myself thinking, Hell, no, there’s no value in depression. I want to pop that happy pill and dissolve this “deep” self. Of course, if a biotech cure for bipolar disorder were available, I would happily serve it to any children I had with breakfast; some people would consider this one step in genocide of a special population; I would consider it a mercy. I can very much understand the first view, but I would definitely rather be healthy than special, and I wouldn’t wish this sort of specialness on any child of mine.

That last was part of a wide-ranging discussion I had with my parents on Saturday, a conversation that covered everything from my Dad’s advice on how to handle freeway tailgaters to how we cope with choosing the slow line at the grocery store to why micromanagement is so agonizing to the managee. I wish I had a transcript or a YouTube video for you all — perhaps we’ll record future conversations for podcasting purposes.

McManamy recommends Therese Bouchard’s blog Beyond Blue, and, boy, so do I. She’s focused on wellness, but acknowledges the mourning process involved in accepting a chronic illness. It’s a good combination of reminiscence and practical advice, most recently on combating anxiety.

Philip Dawdy at Furious Seasons feels no empathy whatsoever for the Ft. Hood shooter, calling him a “loser” and a “domestic terrorist.” Hmm. I’m surprised that someone who covers mental health news so closely would fail to see the tragedy of Maj. Hasan’s situation. It’s easy to feel for the victims, and to be inspired by the courage of the first responder who ended the disaster at the cost of an injury to herself. To me, however (and feel free to spray vitriol at me for this position), if we hope to end the War on Terror more successfully than we did the War on Drugs (remember that?), then we need to understand how trapped and desperate Hasan and many other Islamic people feel both in the U.S. and abroad.

Hasan believed that he would be sent abroad to fight people of his own apparently deeply held religion, perhaps at the cost of his soul. Setting aside souls for the moment, it’s not a bad exercise to imagine how you would feel if you had to fight against American troops, and if that war were promoted precisely as an ideological battle against, say, capitalism and democracy. Not so easy, hm? Sure, it’s a volunteer army and he may have been able to claim conscientious objector status, but do you think that in his position he really got accurate or helpful advice about how to do that? In all honesty, I think that his situation was genuinely tragic. Obviously, shooting up Ft. Hood was not the answer. But imagine how trapped he must have felt to even consider such a horrific step.

In the end, I believe that this is how the debate will go surrounding Hasan’s act, if there is, indeed, a debate. Commentators will paint him as either “crazy” — i.e., entirely irrational and inexplicable (unlike “mentally ill,” which implies a diagnosis and an effort to understand) — or a “terrorist.” Both labels are designed to allow us to ignore the very real contents of his madness and disaffection, and to avoid considering how the institutions around him shaped his actions. A professor of mine at the University of Arizona who studied assassinations points out that when we don’t like assassins’ politics, we brand them crazy and ignore the crucial social and political dimensions of their acts. This prevents us from seeing and perhaps correcting the brutality of our own institutions and political discourse. We wouldn’t re-enslave Black people as a result of understanding why Boothe shot Lincoln, but such an understanding will prove a much more effective way of preventing domestic terrorism than simply branding terrorist acts as crazy.

To bring things to a more concrete level, I’m surprised at Dawdy’s stance because labeling Hasan as a crazy loser tends to worsen the stigma surrounding mental illness. If we reduce his act, with its undeniable political elements, to “madness,” then we obscure crucial facts about both mass murder and mental illness. The facts on the latter should be familiar to all of us: insofar as anyone has bothered to measure, the mentally ill are no more likely than the general population (whatever that is) to commit violent acts. To suggest that Hasan was just crazy is a very real insult to the mentally ill.

At the same time, mass murder may be difficult to explain rationally, but it is not mere madness, with no logic or reason behind it. Quite the contrary. Hasan’s logic is horrifying, but hardly difficult to follow. By refusing to follow or acknowledge it, we refuse to see ourselves, our weaknesses, and our institutions more clearly.

Enough of that. I realize that this whole discussion will be offensive to many of you, and I apologize for that. I do feel strongly, though, that this point ought to be made somewhere, by someone.


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  1. What’s also interesting is that now an days we label regular americans who do such things as crazy. If they are muslim we say they are radical muslim or just muslim. We don’t say the guy was Catholic or a Christian sympathizer.

    Also as I have said before, I think a lot of depression comes from are modern environment. This is the first time humans have lived the way we do. It is bound to have adverse affects.

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