To understand the potential danger of carving behavioral care into an integrated system, consider the case of a 15-year-old girl we'll call Carrie. Each morning, she would say goodbye to her mom and walk toward the bus stop near her home in one of the pleasantly named, planned communities that form the suburbs of a large southeastern city. But instead of getting on the bus, she'd walk to a friend's house, where she would spend the day, returning home just as the afternoon bus drove down the street. If not for the notices the school eventually mailed home, her family might never have learned what was going on.
Perplexed about her aversion to school, weary of her rebelliousness and her contentious attitude and frightened by her profound sadness, Carrie's mom took her to the family's HMO. A doctor there noted Carrie's depression, prescribed an antidepressant and recommended psychotherapy. During her visit the next week to the therapist to whom she had been referred, Carrie revealed that she'd been going into the kitchen late at night and making scratches on her arms and legs with a knife. The alarmed therapist admitted Carrie to the hospital. After three nights, she was diagnosed with depression and sent home with orders to take her meds, see the therapist regularly and come back to the hospital psychiatrist on a monthly basis.
In this case, the early referral for psychotherapy was no panacea. Carrie's therapist saw a collection of symptoms rather than a person and focused on alleviating those symptoms with the most efficient intervention at hand--medication. What happened next reflects the pitfalls of applying the medical model to complex interactional problems--when people don't respond to prescribed treatment, they are seen as "resistors" and, when in doubt, a hierarchical, medical system is likely to escalate its "treatments" in ways that compound, rather than resolve, problems.
Carrie didn't want to take the antidepressant prescribed--she said it "made her skin crawl." But in the face of the authority of the medical system, and at the insistence of her mother and the therapist, she took it anyway, and continued to feel bad and cut herself. Once, she even ran into traffic in an attempt to still the tumult inside her. Her friends ran after her, calmed her down and made sure she took her next dose of medication. But when her mother saw the scratches and the continued despair, she called the therapist and, in the next stage in the escalation of her treatment, Carrie again found herself in the hospital. At the hospital, the doctor diagnosed a Bipolar Disorder and added an anticonvulsant to her medication regimen.