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Closing Remarks on the Consequences of Conceptualization

When they are “brought to life” by looking at what they are like in practice for patients, psychiatrists, and other therapists, comparing biomedical and biopsychosocial disease concepts in psychiatry results in the following image.

Due to the enormous development of expertise and skills the biomedical disease concept has become a territorial disease concept. In this territory only physicians understand the secret jargon and only they are qualified and skilled. This conceptualization has led to large medical successes. Physicians became professionals. The territorial features of this disease concept and the professionalization of physicians augmented each other until physicians became the exclusive experts on disease. Disease became so synonymous to organic aberration that the concept became more and more reified.

Psychiatrists’ main dilemma as helping professionals is whether they should assume that disorders are things that their patients have and are beyond their own control, or that patients can influence their disorders by changing or actively accepting the challenge to change. The idea that people cannot be held responsible for their illnesses, and so also not for their psychiatric disorders, liberates them from responsibility and thus also from blame. It also tempts them to assume a passive attitude towards the helping professional.

In general it can be said that taking responsibility for what one makes of his life and thus also for the hermeneutical aspects of a psychiatric disorder is essential for self-realization. Therefore confronting patients with the fact that they are the one and only person responsible for what they make of their lives is essential to psychiatric therapy. Only when patients’ powerlessness and helplessness is so obvious that their therapist shares their conviction that they are really not capable of changing the situation is acceptance of this helplessness inescapable and proper. In these situations, too, the challenge to confront people with their co-responsibility for the future remains.

Several rights and obligations of sick people have developed in the sick role: the privilege of not having to fulfill daily duties and responsibilities in addition to the moral obligation of calling in medical assistance and behaving according to the physician’s advice. Dependence on the physician is more or less a clear factor in the sick role too. The attractive perspectives of the sick role necessitate limiting citizens’ self-determination in this aspect. Physicians took the role of referee upon themselves. Who else would do it? After all, are not they the only ones who have the expertise? So in addition to their role as therapists, physicians took the role of social arbitrator upon themselves. This role gradually became more important as the question of illness became increasingly central to social developments and decisions. I offered the example of granting or refusing abortion. Other examples are granting declarations of urgency for dwellings* and psychiatric evaluations for trials. Further reification of the disease concept was unavoidable for these purposes.

Other recent developments are increasing state intervention with the organization of health care. On the one hand this has regulated, and so limited the power of the medical industry. On the other hand, that which the state supports can count on its backing. Mega-institutions, regionalization, uniformity, and bureaucratization have made their inroads. Competition and direct feedback on the functioning of facilities are suppressed. Augmented stated influence has made physicians’ loyalty to the state an existential necessity, even when such loyalty conflicts with felt loyalty to patients. Psychotherapists hardly seem to object to obligatory evaluative reports that crack open the absolute confidentiality of psychotherapy. By threatening to withhold payment it is possible to compel psychiatrists and other therapists to reveal information about their patients, which compromises the oath of confidentiality. This is one reason that the state, the institutions that pay, and physicians are involved in increasingly intensive negotiations. Patients are scarcely a party to these negotiations.

Psychiatrists’ loyalty has become increasingly divided. In addition to the primary loyalty to the patient there are loyalties to other members of the therapeutic team, the institution of employment, medical insurance, and the state. This has happened without consideration of what would happen when these loyalties conflict.

In addition to describing disease as a theoretical and scientific concept these developments make it necessary to consider three adjacent definitions of illness:
  • a form of human misery arising from physicians’ professionalization;
  • a form of human misery imparting a social role entailing privileges and obligations;
  • a from of human misery that gave rise to the social institution of health care which can be characterized as a medical-industrial complex, a definition derived from the fact that health care has developed into a powerful social institution.
This entire development is based on the idea that disease is an existential fact which can be clearly and concretely demonstrated and demarcated, in short, a scientific fact. This premise on which health care is founded is, however, not solid. While the developments sketched above demanded “harder” definitions of being sick, the biomedical disease concept was found to present so many objections, and to correspond so poorly to the reality of being ill, that it became necessary to seek alternative concepts. The biomedical concept can be fruitfully applied as a sub-concept in specialist somatic medicine. Its absoluteness is untenable in family medicine and psychiatry. Although the entire system of health care as set up and regulated by the state is based on the biomedical disease concept, in practice in family medicine and psychiatryit has been largely abandoned already.

In the development sketched above psychiatrists’ role as therapists, made difficult as it is by the problems that being psychiatrically ill poses, is sketched as an authentic medical role, even though there are all kinds of gradual differences from other branches of medicine. The role of social arbitrator poses concern because moral and political considerations are unavoidable. Psychiatrists’ conceptualization of illness cannot be made to fit the standard of large-scale, bureaucratic health care.

The biopsychosocial disease concept is broader and can therefore be less easily reified as a disease concept. It is irreconcilable with an exclusive territory for physicians. It assigns a place for patients as experts on their own health. It returns to disease its just nature as a value concept. It offers the opportunity of a health care which is humane in addition to technologically developed. It reflects reality better than the biomedical disease concept. But it is not possible to accept this disease concept and at the same time act as though diseases are proven facts in the sense of the biomedical disease concept.

This is all the more significant in psychiatry because psychiatry has social functions in addition to therapeutic functions. The seriousness and admissibility of decisions as opposed to the scant accurate formulation of the grounds on which those decisions are made – namely the conceptualization of what psychiatric disorders are – is perhaps most noticeable when carrying out laws that are based on psychiatric insights. This problem will be discussed in Chapter VII.

*In the Netherlands the allocation of “affordable” housing is strictly regulated by state and local government. – translator
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