Modern medical practice likes codes. For some reason, people may actually believe that there is something scientific about codes. Numbers seem to confirm some mathematical validity. In child mental health there are “criteria required” to gain a number, almost none of which are evidence-based. The lists of criteria lend the impression of being rigorously systematic, belying the simple truth that they are sloppy and arbitrary. Diagnostic “coding” has nothing whatever to do with science and everything to do with the economics of health care. In the 1970’s health insurers created ”Diagnosis Related Groups” to justify limiting hospitalization coverage according to the diagnostic code. Mental health services joined the conundrum in the 1980’s with the DSM “bibles.” The DSMs managed to exclude any diagnosis that did not justify a medication. The last to go was “Hysterical Psychosis” which might have justified the remuneration for talking to the patient.
Limited to “in-house” mental health decisions, these codes do shorten discussion and communication, albeit at times at the cost of deeper thinking that defies coding. One would imagine that these codes would stop there, in the clinic or hospital. One would insist that privacy considerations would deny access to these codes to any but mental health professional. One would be certain that no other public agencies would make any use of these codes. Especially with children.
But in the State of Israel one would be in for a rude shock. In fact the state agencies routinely demand mental health coding and make extensive use of the codes in decisions made “in the child’s best interests.”
A number of mental health disabilities come with disability entitlements. The Social Security Agency will grant these entitlements only after receiving a properly coded application. Physicians are essentially forced to not only provide but also “justify” the code by listing the “criteria” that are present, so the person fits the profile. Since the entitlement is often rejected at the first hearing, lawyers are now routinely requiring psychiatrists who write opinions in support of an appeal motion to more or less “copy/paste” the criteria that justify the code.
The Ministry of Education goes one step further. It actually provides a list of the codes that justify “differential educational support.” A parents who wants a child mainstreamed, say from special educational classes to regular classes but with personal support, is required to provide a code from the list to justify this! Now the privacy of medical records in every modern state is carefully legislated. All the more so with mental health. Yet the Ministry of Education, to the best of my knowledge after many inquiries, requires what amounts to a coded mental health document despite the fact that it has no adequate provision for securing privacy. No one actually knows how these records are kept and who has access to them!
Now in terms of the function of disability and educational agencies, what is requires ia a descriptive assessments of the child’s function, not diagnostic codes. There is no scientific justification for requiring purely medical – and psychiatric – coding in order to make a functional evaluation. It would seem that a child’s right to privacy does not really exist in Israel.
This raises a question best discussed in the context of the term dispotif coined and used extensively by the French social critic Michel Foucault. I have discussed various aspects of this term in my Losing It (Hadassa Word Press, 2015). The term invites an inquiry into the way things are actually handle in a a given society. Foucault suggested that in the West, the European states moved from a “pastoral” to a “governmental” dispotif after the Treaty of Westphalia in 1648. Continuous with the Christianized Roman Empire, the “pastoral” dispotif saw in the emperor the spiritual “shepherd” of the people, responsible for the salvation of each individual citizen of the Empire. That, of course, was “Plan A,” honored more in its breach than in its fulfillment. The European state fought their bloody wars over who got to be the emperor. After Westphalia, the states agreed that there would be no emperor and the modern “Westphalian” state emerged. Each state now required a balance with its neighbors that would ensure the sustainability of each state. In the forefront were the needs to keep security and wealth in balance. A new dispotif emerged that now used the population (a newly emergent term) to sustain the balance. People were in practice to ask not what such a state could do for them but how they could be used by the state. Many states made “pastoral” statements of intent (especially around election time) but the budgets were always “governmental” – ensuring that the population provide for the security and economic requirements of the state.
How do mental health codes figure here? Mental health is probably the most prominent representative of the “pastoral” promise. Sanity is the closest secularized equivalent of “salvation.” In the USA, for example, “pursuit of happiness” is an individual right, but it is not the state’s business to provide that happiness. Mental health, however, became the state’s business from about 1830. Once the state required a distinction between those citizens who disturbed the public space out of malice (criminals) and those who did so out of madness (the insane), the state required functionaries – not doctors at that time – who could tell the difference. Modern psychiatry emerged to fill the function within the governmental dispotif of creating two different kinds of asylums. But within each type of asylum, a pastoral dispotif emerged, striving to redeem the inmate. In the 19th century psychiatric treatment of criminal rehabilitation looked very similar, since moral and political authority was assumed over the individual. Over time, the governmental dispotif reconnected, as criminals and patients were “put to work” for their own good but also to return them to the “work force” that the state required. When I was a boy living on the grounds of the immense Foxborough State Hospital, where my father worked as pathologist, the intricate muddle of pastoral and governmental was so thick that patients were both lobotomized (making their disturbances less costly to the state) and put to farming the huge fields to pay for some of this incarceration – all in the name of sanity.
There was a brief flourishing of an alternative to this handling of mental health from the 1950’s to the 1980s in the USA. This different, far more “pastoral” function was led mainly by the psychoanalytic movement. Freud has created a different, more “pastoral” approach top metal health. In the USA, this was supported and funded so long as it promised governmental results. During this period, in which I was trained, the secrecy of any information regarding mental health was carefully protected. No one could fully engage in this treatment if it were not kept secret. Freud’s view of the individual and the state required a sort of “pastoral respite” from the demands of the state for the individual to become free of the neurotic complications which were partly created by the demands of the state. As such, total secrecy was not only a technical requirement fo p[psychoanalysis, it was deeply enmeshed in its world-view. By the 1970’s, psychoanalysis had not produced any measureable assets to the state’s security and wealth, and some of the anti-war sentiments were blamed on it. This brief “pastoral” flourishing o fm mental health in the USA took a nose dive.
To put it bluntly, the governmental state is always suspect of using “pastoral” mental health claims to justify its governmental functions. Here we come to the “codes.” Since the 1980’s, Western (mainly USA) psychiatry has been making the yet to be redeemed claim that the way back to sanity is pharmacological (“Your pastor is your pill). Evoking the yet to be proven precision of the right drug for every disorder, people needed to be precisely coded so that the right drug could save their sanity. Sure enough, psychiatric “research” became inundated with coded “RCT” [randomized controlled trials] studies, which usually were contradicted within 6 months and lost all validity every 5 years when a “meta-analysis” washed the slate clean. These studies required coding. This would turn out to be a total failure of the “pastoral” claim. The codes never helped any patient. In the meantime reimbursement was “coded” usually to the detriment of the patient. There was nothing inherent in being coded and drugged that required anonymity, as there was in psychoanalysis.
We can see in the state’s assumption of its access to mental health codes, that these codes are handled in reality (dispotif) as the property of the state, not the individual. Essentially, any possible “pastoral” meaning to the coding has been eliminated. Mental health practitioners have returned to being functionaries of the state, who are responsible for limiting the economic and security liabilities of deviant populations. In Israel, the psychoanalytic tradition survived somewhat longer than in the USA but is currently in a parallel if belated nose dive. It might be mentioned that some prominent analysts have been “peaceniks”. Psychiatry has become entirely biological and the only psychotherapies supported seriously are brief “Cognitive Behavioral Treatments”. None of these treatments inherently justify confidentiality, “CBT” is even “manualized”, one treatment for all.
When I am required to report a diagnostic code of a child to her school, I am surrendering “mental health” to become a servant of state population policies. The individual and her need for confidentiality and freedom in order to engage in personal treatment has been erased from the Israeli dispotif. I thought some readers might want to know this