The Four Freedoms in Mental Health Care
By Eric Plakun, MD
Originally published on November 22, 2017.
In his January 1941 State of the Union Address, with war clouds growing in Europe and the nation still recovering from the Great Depression, President Franklin Roosevelt enumerated “Four Freedoms” cherished by those living in this country. After the US entered World War II later that year, Stockbridge artist Norman Rockwell began a series of paintings that are among his best known, depicting Roosevelt’s Four Freedoms: freedom of speech, freedom of religion, freedom from fear, and freedom from want.
In my work as director of biopsychosocial advocacy I find it useful to borrow from Roosevelt and Rockwell in thinking about “Four Freedoms” we owe to those struggling with mental disorders. These include:
- Freedom from stigma
- Freedom from dehumanizing treatment
- Freedom to pursue meaning in life and in treatment
- Freedom of choice in access to effective and medically necessary care
Freedom from stigma refers to the right of those struggling with mental health and substance use disorders to be treated the same as people with any other medical problem. The Mental Health Parity and Addiction Equity Act of 2008 (the parity law) supports this freedom from stigma by requiring that access to care for those with mental health and substance use disorders be comparable to access to care for those with medical and surgical needs.
Freedom from dehumanizing treatment means holding in mind that patients are fellow human beings and not diagnostic categories or receptor sites for molecules. It is as essential to understand the person with a disorder as it is to understand what disorder a person has. Treatment should occur in settings without dehumanizing restriction of civil rights based on unwarranted fear of those with mental disorders.
Freedom to pursue meaning in life and in treatment refers to the importance of every person finding access to a meaningful existence built on both our strengths and our vulnerabilities. And in the treatment itself, we should have the right to explore the meaning of our struggles in the context of our life story. This is often best accomplished by psychotherapy or other psychosocial treatments as part of an overall treatment plan.
In terms of freedom of choice in access to effective and medically necessary care, it is good news that we have effective treatments, including psychotherapy and medications, that can be offered in outpatient, inpatient, and intermediate levels of care like residential treatment. Patients deserve a measure of choice in gaining access to these treatments. It is essential to hold in mind that treatment in the “least restrictive” setting refers both to restrictions in a person’s civil rights in the course of treatment AND to restriction in choice among effective treatments. Leaving someone suffering while receiving inadequate treatment in a “least restrictive” setting, while depriving them of access to effective treatment that they voluntarily seek, is cynical and disingenuous. Medical necessity criteria used by third parties who determine access to care must recognize the importance of patient choice as part of what can be unduly restricted—along with restriction in civil rights.
Holding these “Four Freedoms” in mind helps guide the work of biopsychosocial advocacy including
- clinical advocacy for the importance of psychotherapy and other psychosocial treatments as central parts of psychiatric practice and training within a biopsychosocial model;
- social policy advocacy for full implementation of the parity law, including careful review of the ethics of psychiatrist utilization reviews for insurance companies based on standards that are out of compliance with generally accepted standards of care; and
- funding advocacy for a shift in NIMH research funding from an “either/or” focus emphasizing brain and biology research linked to biomarkers to a “both/and” strategy that restores meaningful access to funding for research into clinical treatment methods, especially psychotherapy research.