Bureaucratically Incompetent: Mental Illness and Government Intervention

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It
seems that every aspect of life suffers from government intervention
and power grabs. This is especially true for those problems that
seem to be intractable. The management and treatment of mental illness
is foremost in this category. It is common even for people with
libertarian leanings to concede that this is a valid government
concern. Consistent libertarians are the first to warn against any
government interference in private life. Thomas
Szasz
has gone so far as to question the existence of mental
illness. I disagree with his conclusion but I recognize that governments
have commonly stigmatized the people they want to control as mentally
ill. Rob
Murphy
has written about a recent example of this process on
Long Island. Ron
Paul
has eloquently described the latest Congressional manifestation
of government intrusion, the attempt to label millions of school
children as mentally ill. This effort follows the pattern of categorizing
all problems of behavior as mental illness instead of considering
character. This is a political ploy intended to expand an interest
group, not a fresh, positive approach to a difficult problem. In
this essay I will describe why, in fact, government is particularly
ill suited, to the point of being incompetent, to deal with mental
illness; because mental illness is a human problem, while
the fundamental nature of government is bureaucracy.


Everyone has been in a situation with a clerk where a rule comes
before thought, before even the obvious. Unfortunately, the characteristics
of mental illness force patients and loved ones to interact with
many bureaucracies where this clerk mentality is prevalent. These
interactions can be extremely frustrating because mental illness
is a human problem that requires judgment by those with intimate
knowledge of the patient for its treatment. However, bureaucracies
are specifically designed to function with minimal judgment; therefore,
they provide inadequate care or even exacerbate problems.

The
nature of a bureaucracy is a topic that has been considered by many
authors including Mises.
I cannot say exactly what I have taken from my reading and my own
experience. My analysis of bureaucracy specifically regards human
problems. As organizations become large (though everything discussed
here might also apply to a group as small as two people) a method
of management must be put in place to direct individuals in the
organization towards its goals. A minimal management approach would
simply state the goal with no direction as to how the goal should
be achieved. But typically there are many rules employed to constrain
individual behavior. As the number of constraints increases, the
role of individual judgment decreases. In effect, individuals are
taught not to think.

The
clerk mentality is widespread and for good reason. The advantage
to the clerk for thinking is minimal to nonexistent when his thought
results in a positive consequence. This is true because those positive
consequences are usually difficult to measure in that they may be
no more than what a customer or client expects. However, penalties
for wrong decisions, especially when they break a rule, are severe.
So when a clerk is asked to break a rule, even in an obvious situation
where the rule does not apply, for the clerk there is the potential
for only pain and no gain.

In
a similar fashion to the development of rules to direct performance,
standards must be implemented to judge performance. Usually these
standards attempt to be objective by using quantifiable measures
of performance. For example, for a sales clerk in a store the counting
measure might be the number of sales. Not included in this measure
of performance is how fellow workers are treated or if dishonesty
and pressure are used to increase sales. Even when subjective measures
of quality are considered almost always the quantifiable measure
becomes the dominant one. In a profession as distinguished as academia,
it is the number of papers published that has become the dominant
measure of scholarship, not necessarily the quality of them.

This
atmosphere, where thought and initiative are punished and where
counting statistics are the only measures of performance results
in bored workers who avoid all effort, other than that directed
towards improving the "count." Here is the source of frustration
in the typical interaction with a bureaucracy.

On
the other hand, is there any other way to run a large organization
like a corporation or the government? Usually the rules are very
sensible. Many people pass fraudulent checks, therefore merchants
require identification. Make it a rule because, to be honest, some
clerks have poor judgment about these things. And anyway, shouldn't
everyone be carrying identification? Certainly we take pride in
our justice system when it follows the rule of law, that
is, rules that apply all the time and to everyone regardless of
his station in life.

A
distinction should be made between government bureaucracies and
private organizations that are bureaucratic. When confronted by
a government bureaucracy the individual typically has no recourse
but to obey. On the contrary, interaction with a private bureaucracy
is voluntary. The individual can resort to a special contract for
the given situation, opposite of the rule of law. In other cases
one can simply walk away; i.e., purchase services elsewhere.

We
live in a society where large organizations provide many useful
functions but must create bureaucracies to run them. In most cases
this arrangement is reasonable and beneficial, even with the aggravations
and drawbacks described above. However, there are some problems
where bureaucracies are inevitably ineffective or even counterproductive.
These are the problems related to the unique nature of individuals.
I call them human problems. Three important human problems in any
society are raising children, helping the poor and treating mental
illness.

Imagine
creating a set of rules for the raising of children. Should children
be guided for a profession from a young age, like Tiger Woods, or
allowed to find their own way? Should a child be punished for a
failing grade or given encouragement? The answer to these questions
is, as all parents know, "it depends." It depends on more
factors about the individual child than I can list in this short
essay which parents take into account in the multitude of day-to-day
decisions associated with raising children. Raising children is
one of the fundamental human problems (perhaps "joys"
is a more appropriate noun than "problems") in society.

A
man and his family live in a town that is devastated by a flood.
He has lost his house and his job. A different young man, the graduate
of a fine college, quits his job after receiving a sizable inheritance.
After a couple of years he has frittered away all of his money on
pleasure such that he is bankrupt. Should both of these poor people
receive cash assistance? Perhaps this is an extreme example but
makes the point that the poor are individuals with unique stories
and needs. The historian Gertrude
Himmelfarb
has described the Victorian sentiment that there
are deserving and undeserving poor. The Victorians were correct,
and they had much success helping the poor, as Himmelfarb has documented.
It requires judgment to help the poor such that they can succeed
in life and not simply take advantage of a handout or become dependent
on a welfare check.

Now
let us examine the human problem that is the focus of this essay,
treating mental illness, in particular manic depression, as I have
much experience helping my brother deal with this disease (described
in our book
). Manic depression is an extremely difficult illness
to manage because it is what I call nonlinear. The patient
goes through periods of depression and euphoria that often become
psychotic. The effects of this illness are felt in virtually every
aspect of a person's life, including the personal, social, financial,
legal and professional, as well as the medical. It is natural to
extrapolate the history of a patient, or the history of other patients,
to some future consequence. Imagine extending a line forward to
predict a future data point. But manic depression is not a line.
Every case is different and every point in time is different for
each person. Thus, any particular rule designed for the general
public is usually detrimental to containing the consequences of
the illness. Even rules specifically designed to deal with the mentally
ill are usually ineffective or counterproductive. Thus, bureaucracies
are not up to the task of considering the implications of manic
depression, because this dehumanizing disease is to the greatest
extent a nonlinear, human problem.

A
key difficulty lies in the atmosphere of the legal system, which
through decades of jurisprudence is favorable towards recognizing
only the rights of the atomized individual. Mediating institutions,
of which by far the most important is the family, are most often
put off in their attempts to influence care. This is a critical
shortcoming of the system because it is vital to have an understanding
of the patient's normal personality and history to facilitate treatment.
Furthermore, it is only the family that can provide the long-term
care and support necessary to achieve a productive life. No paid
employee will ever have the fortitude or opportunity to properly
assist a patient with manic depression. It can be said that the
patience of love is necessary in the long-term assistance of the
mentally ill.

I
have experienced many examples of the clerk mentality in attempting
to help my brother cope with manic depression, which was excused
by claiming civil rights for the patient. This was especially
true when attempting to detain him for treatment. While in a manic,
psychotic state the safest place for my brother, the place where
treatment could begin, was the mental hospital. Obviously this is
where I disagree with Szasz. However, while I do believe the freedom
of the patient should be restricted, I also question why the government
as opposed to other elements in society, specifically the family,
should hold the authority for commitment.

Where
should the power and responsibility for human problems be located?
Raising children is largely left to parents, but with many important
constraints that have gravely affected family life; government has
subsumed helping the poor; and treating mental illness is a hodgepodge
where many important decisions are constrained by bureaucracies.
In all of these cases, an attempt to handle these human problems
adequately requires intimate knowledge of the circumstances and
character of the individuals involved. There is no question that
the greatest knowledge and opportunity for therapy exists within
the family. In a bygone era when most people lived in small communities
people helped others as individuals. The village idiot or town drunk
might not have received an income supplement, but they were known
as individuals. It was not farfetched to viewers of Andy
of Mayberry
that Otis the town drunk would be allowed to
sleep off a bender in the jail.

I
do not intend to romanticize the past; certainly there were many
abuses of the mentally ill. Today intimate communities are few and
far between. My brother often traveled thousands of miles in a psychotic
state and so no community action would have been possible anyway.
Furthermore, families are not always supportive. There are no easy
answers. But only by allowing the lowest level of institutions in
society such as families, churches, volunteer groups and civic organizations
the freedom to make decisions, will there be any chance of treating
manic depression fruitfully. This humane approach to human problems
is very much in sync with the limited government and federalist
principles of the U.S. Constitution and the Catholic principle of
subsidiarity. Both traditions leave a sphere of freedom and
responsibility to the lowest possible orders of society where bureaucracies
and the clerk mentality are less prevalent. The similarity of this
conclusion follows Hayek’s
insight that key information within a society is widely dispersed.

It
has been implicit in the arguments presented in this essay that
families will make decisions with the well being of patients in
mind. Of course this is not always the case for many reasons, including
the simple fact that families can include bad people. But I must
emphasize that creating bureaucracies to overcome this shortcoming
of the human condition has been an ultimate failure through history.
It is the message here to move our society away from these so-called
solutions.

November
9, 2004

Ira
Katz [send him mail] teaches
mechanical engineering at Lafayette College.  He is the co-author
of Handling
Mr. Hyde: Questions and Answers about Manic Depression
and
Introduction
to Fluid Mechanics
.

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