Psychosocial and psychodynamic factors influencing health care utilisation.

This paper aims to elucidate some dysfunctional aspects of health care utilisation by combining concepts from modern systems theory and from psychoanalysis. Contemporary health care in industrialised countries can be conceived as a social system in terms of modern systems theory. According to this theory, social systems are operating on the basis of a 'guiding difference,' which in the case of health care is the distinction between 'healthy' and 'ill.' Its rigidity in adhering to the healthy-ill dichotomy exposes health care to being collusively entangled in the interpersonal defence arrangements of patients. In the psychoanalytic view, individual conflicts can be warded off from consciousness not only by intrapsychic defence, but also by interpersonal defence mechanisms. These mechanisms involve the patients' close social environment, often including doctors and hospitals. The functioning and the motivational structure of health care itself shows features of neurotic defence: not only its representatives, but health care as a whole act in a rigid, obsessive manner in order to separate the healthy from the ill and to battle against (presumed) diseases. This obsession sometimes results in excessive diagnostic activism and in inconsiderate application of aggressive medical treatments. Both are inappropriate with regard to the salient problem of modern medicine: the increase of chronic nonfatal diseases like depression and chronic pain. The described defence mechanisms are unconscious not only to patients but also to health care professionals (let alone health politicians), and are contributing to dysfunctional health care overuse.