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
