1 Boring Old Man

We hear a lot about Validity and Reliability when we read about diagnosis. What is less often discussed is Legitimacy, though that seems the most important thing on the table at times. Is the illness a legitimate illness? Is it being treated with a legitimate treatment? Is psychiatry even a legitimate medical specialty? This must be a difficult topic, because I’ve followed those opening sentences with four whole posts, erased them, then started over. I had made my own decisions about these things before I started training, having come from Internal Medicine. As a medical practitioner, I’d seen mental illness up close and personal, become interested, and decided that treating it was how I wanted to spend my life. I didn’t myself question the legitimacy of mental illness or if psychiatry was a legitimate medical specialty, but training in the 1970s, I sure heard a lot about that topic – from all sides.

So for a tongue twister, the questions of legitimacy are legitimately legitimate. I met that in my own training. I was an analytic patient as part of my analytic training, and had "good" university insurance. One could also legitimately take the cost of treatment off of income tax as an educational expense. Some of my classmates did both. I didn’t think that was legitimate. There were plenty of people in the mental health field that worked the system that way, taking part-time jobs with "good" insurance to pay for their own therapy – legitimate? The point is that medical insurance was used to pay for treatments that were in the range of choice, not medical necessity. And that avenue was only available to people who could choose jobs with that kind of insurance. Those examples abounded everywhere.

And it wasn’t just psychoanalysis or psychotherapy where the presence or absence of "good" insurance determined treatment. It was true in hospital treatment as well – long expensive hospital stays for milieu therapy were primarily available to sick members of rich families. It’s not that such treatments weren’t effective. It’s that it was not something insurance companies could or should have to deal with – way too arbitrary. The decisions about treatment were made by individual practitioners based on expert opinion – not based on an objective set of mutually validated parameters. It wasn’t even necessarily chicanery. A long stay hospitalization in a good milieu treatment unit is an effective treatment for certain show-stopping personality disorders, sometimes miraculous. But it’s not guaranteed and cost-effective? Forget about it. It’s legitimate illness, legitimate treatment, but is it a legitimate use of the health care dollar? In the area of addiction treatment, for motivated alcoholic patients, the "28 days" in a treatment center is a good way to start a recovery program. But is it necessary? Is it cost effective? What do you mean by "motivated?" Is it legitimate?