But Carrie didn't want more medication--she hated the way she felt when she took the pills, and she wanted to "rule" her feelings without drugs. She just wished she didn't feel so sad. But the therapist and other health care professionals involved with her believed they knew the root of Carrie's problem--Bipolar Disorder--and were emphatic about the importance of the medication, reminding Carrie's mother that it was her legal responsibility to ensure that her daughter never missed a dose. Responding to the therapist's warning, Carrie's mom continued encouraging her daughter to take her pills and Carrie persisted in cutting herself to relieve her distress. All told, she was admitted three times to the hospital, was variously diagnosed with depression, Bipolar Disorder and Borderline Personality Disorder and was prescribed several antidepressants, lithium and an anticonvulsant.
Fortunately for her, Carrie's story doesn't end here, but let's pause to contemplate the mental health care she received in a system insidiously dominated by diagnostic thinking and a hierarchical treatment model. Even in an HMO in which therapists were closely involved early on in treatment, just as is proposed in the integrated care model of the future, Carrie was first required to be a patient; second, to see her problems as medical; and third, to listen and follow orders--her own capabilities and perspective on her problems were never enlisted in her treatment. No one ever really asked her what she wanted, or formed a personal connection with her.
Integrated care, in and of itself, does not provide safeguards that would prevent the kind of treatment Carrie received. In fact, the monolithic power of such a consolidated system, becoming, in effect, a court of last resort for health care, should alert us to its possible dangers. Of particular concern should be an element that its proponents consider a cornerstone of the health care of tomorrow--the integrated data base. With such a comprehensive, computerized record-keeping system of a patient's entire medical and psychiatric history, Carrie's treatment would permanently follow her, available to anyone with access to the system. Ten years from now, she might be unable to get insurance or join the military. And her history of suicide attempts and diagnoses of Bipolar and Borderline Personality disorders could easily affect her career prospects and even her personal relationships. Employers and colleges routinely question applicants about medical history. DSM disorders hardly qualify as preferred credentials on such applications, nor is a history of mental treatment usually included on a resume. In fact, background checks for any reason would take on ominous overtones in a system that would document "mental illness" as part of the medical record.
As it was, Carrie's treatment took an unexpected and fortuitous turn. Her truancy triggered involvement by juvenile authorities, who ordered her to receive treatment from a home-based therapist. Now outside the domain of the medical system, the focus of treatment shifted from Carrie's individual symptoms to understanding the fuller context of her life. The new therapist's first step was to include all Carrie's family members, not just her mother, in treatment. With their help, she began to develop a more complete picture of Carrie--that she was everyone's pet, and everyone's headache. The therapist learned about her karate class, about her love for the horses she cared for on the weekends and about her passion for Egyptian archaeology. The family began a home-schooling program and Carrie's mother took on responsibility for helping her daughter with her daily schoolwork. The therapist also learned, for the first time, that Carrie had been sexually abused by a friend's father.