Medical Necessity
“Necessity is the mother of invention, but necessity is in the eye of the beholder.” Adam O’Brien
Introduction
Medical Necessity (MN) is a term that the healthcare industry uses to identify the level of need that a presenting person has to have to justify being diagnosed, receiving medical or psychological services, and to reimburse for insurance. Psychologically, MN is the “measurement” of the level of impact (e.g., inability to work, difficulty maintaining relationships, and the inability to pay taxes) that one’s mental health condition (e.g., diagnoses) has on a client’s life. MN is the threshold for what psychological professions standards use to know what is diagnosable and what is not (HERE). This is mostly for insurance purposes, but ironically not for diagnostic criteria. As MN is not clinically defined; therefore, legally it is mainly for insurance and business purposes that do not have anything to do with diagnostics or pathology, other than to justify using it to limit choices of people looking for services and maintain the guiding professions level of need.
The reality of MN is that it is not clearly defined and is measuring conditions that either do not exist or are socially and culturally appropriated to maintain social status, control, and power (O’Brien, 2024b). MN is the diagnostic privilege that no one is addressing or even talking about because they are so dependent on their professional identity that has become a “personality disorder” that has become the medical issue that needs to be addressed, particularly when Moral-Ethics are at play (O’Brien, 2024b). Therefore, the questions regarding MN become: why would they not clearly define it, how is it used in practice, and why does MN not appear in the DSM-5?
Background to the Problem
Our research and review (e.g., historical context) suggests that professional pathology is at play (O’Brien, 2023a; O’Brien, 2023b; O’Brien, 2024b; O’Brien, 2024c). MN is a legal term that seems pretty important to have accurately defined and clearly stated by professionals who have to clearly define every aspect of their work and personal life to justify their existence. However, the level of impairment and need is defined by a normative culture, which to us, is a huge concern because cultural and therapeutic trends have been wrong before (O’Brien, 2023a; O’Brien, 2024b; O’Brien, 2024c). For example, non-addictive opiates, mental health conditions are due to “chemical imbalances”, and most treatments amount to meditation (O’Brien, 2024c). The fact that addiction being transdiagnostic is the main contention that we will use here, but not having addiction accurately defined, diagnosing normal responses, and not defining the unconscious are all points of contention that are valid in our book (O’Brien, 2023a).
So, MN is not readily psychologically defined, although one can assume that by meeting a certain number of symptoms criteria to qualify for a diagnosis, then one could quality, but this is another contention we have because our work (O’Brien, 2023a) highlights that diagnostic criteria are currently off and are subjective to the normed society that does not see that they are off. As MN stands now, MN is a loosely held threshold (e.g. not clearly defined by research or in the literature) or the industries that uphold them (e.g., the medical model, psychology, business law, finance, and insurance) are not the ones that should be making or influencing the standards. Reasoning being that if they applied a moral standard to their ethical obligation to “do no harm”, then that would put them out of business (O’Brien, 2024b).
In our experience, MN can and is used to deny services for clients and insurance companies to not reimburse clinicians. Because MN is not clearly defined, MN is bound to professional and societal trends or whims, professional intellectual contamination (mass psychosis), and the level of professional ethical and moral level of development of the trained clinicians (and the educational system they come from)(O’Brien, 2024b). In the field of practice and common sense, professionals deduced that if it is worth asking, paying, and telling a licensed stranger about, then it must be bad enough to be diagnosable or need some help with. How this manifests also is that, for example, developmental and attachment trauma are not diagnoses, yet we clinically observe that most feel that these are bigger issues (e.g., the most painful part of their trauma reprocessing), as 75-90% of time spent in therapy relate to these conditions that are not diagnoses. This is because there are mental health conditions that are transdiagnostic (e.g., trauma, dissociation, AND ADDICTION), meaning that they underlie every “diagnosis” in existence (O’Brien, 2023a) and non-existence (O’Brien, 2024c). The transdiagnostic status of trauma, dissociation, and addiction means that diagnostic criteria are off and since these are off, we purpose that there are addiction diagnoses that are not identified (e.g., perfectionism, altruism, and ambition), but should be.
Right or wrong, this is what has to happen for both client and professional to get their needs met and for the show to go on. The agreement of professionals is our contention because our work highlights the key missing ingredient to understanding mental health, pathology, and reality (O’Brien, 2023a). This basically defines an enabling relationship from a profession that is dominated by females. In a practical sense, MN is the line between common sense, fraud, and social control (O’Brien, 2024c). MN was mostly created for billing and legal purposes; however it has unintended clinical and social implications that are worth the general public exploring and knowing. For example, if you are not able to resolve current mental health issues, by diagnostic metrics, within a years’ time, then you can be considered for having a chronic disorder or a personality disorder.
In our clinical experience, the level of functioning and reasons why people are acting “cray-cray” amounts to dysregulation in the unconscious body, which we have identified as the psyche (O’Brien, 2024c). This is another great lie propagated by irrational fears, beliefs, and laws. However, the realities of the “the system” is that having more diagnoses on your electronic and insurance-based “permanent file” can negatively impact you later in life. Also if, as citizens in 2024, we are to believe that our private health information is not being sold to some research conglomerate or that it will not be used against us in the future without our consent or reward, then we are the fools. Realistically, if people present as “bad enough”, then they can be diagnosed with a mental health disorder, can get the medication and services that they feel they need, and the system gets paid for consumers having problems and not knowing what to do about them or where they are coming from.
“The system’s” ability to unconsciously create separation within society for their needs becomes increasing concerning when one of the key reasons why such a term like MN has to exist also produce justifications that can be used in a court of law against people to take away children, claim citizens are insane, and justify social control. Their reasons to classify, name, identify, categories, label, and “other” citizens also create the stigmas that people can believe, internalize, and project. As “the system” “unknowingly” continues to stunt citizens’ moral development (physical, psychological, social/ethical, and spiritual/moral), how and why professionals and citizens interpret the presentation of diagnostics is pretty relevant to common consensus.
Orientation
The MN term is the brainchild of the medical insurance model of care, accounting (taxes), and the law’s unconscious ability to create division between common sense, implicit reasoning, and the greater good. The DSM already provides a standard of who meets certain levels of diagnostic criteria, but as clinical and lived experience has taught us, society and culture are fluid and what one day may be a mental health disorder may one day be a gift. When researching MN on the web (we encourage the reader to do this and see for themselves), standards are a matter of groupthink and common consensus (not common sense). This common agreement is based on a shared understanding of what normal is and has been. When we look at what is “normal”, we see that everyone gets dysregulated, everyone has trauma (even if they do not, they do because not having trauma can be a trauma at some point in the future), everyone dissociates, and everyone is dependent on something “wrong” to be “right” or normal. Nazi Germany also had a legal and business system that justified what they were doing so let’s not confuse compliance with competence. Let’s not confuse obedience with weakness. And let’s not confuse ethics, law, and morals (O’Brien, 2024b) because they are not equal, according to the historical context of research (O’Brien, 2024c).
The words used to explain any phenomena being discussed must have a conceptualization of common agreement, otherwise no consensus can be reached. What is often lost in translation (and creates a lot of miscommunications) are the meaning of the words used because they can mean different things to different parts of us (O’Brien, 2023a). Interpretation is 9/10ths of the law, but what if those who write are the sick ones? We see a healing growth edge with defining MN accurately because MN also creates the conditions for exposing professional gatekeeping and profit motives for businesses, professionals, and professions (O’Brien, 2024b). The growth edge is that by naming that if corporations are people, then they can be sick like people and “treated” with the treatments that are available. In addiction treatment history, those who have cosigned how therapy has justified incarcerating people who are mentally disordered does not look too good for them or their care. Luckily for them, trauma informed care is supportive of their non-stigmatized care and we have evidence-based practices to ensure that they get what they need. However, before that can happen, logic requires that the professions that maintain these sick and dependent corporations, would also have to be sick. What if, as a clinical profession, we were to apply the standards that we have to follow (e.g., MN) to their behavior, reasoning, justification, and projection.
MN is used to justify reimbursing professional services by insurance companies, meaning that they can also be unjustified by denying payment. Insurance companies routinely challenge reimbursement in various ways because it is what they have to do to meet their bottom line. Meeting their bottom line is their job, even though they will sell you it isn’t. Let’s make no mistake about it, MN is used by insurance companies marketing and public relations firm’s goals to stand out as a ploy to provide a service that the government does not want the overhead of. Also, on the other side of things, their marketing and sales pitch is legal and is what their lawyer told them they could get away with selling. What does health insurance cost so much? Is it because colleges, doctors pay, and administration cost so much?
Our clinical issue on this matter comes when we look at the common agreement within the psychological professions (e.g., it was stated in the DSM (1980) that trauma is an “abnormal response to an abnormal event”). As we pointed out in our foundational research (O’Brien, 2023a; O’Brien, 2023b, O’Brien, 2024a; O’Brien, 2024b), psychology is still philosophically off with their diagnostic categories and confusing to consumers because of the way the system has made sense of what we do in psychology and what diagnosing implies. This is the choice point of defining who is insane and who is not, who is well and who is not, and who is less crazy and who is crazier. This is in essence the social and moral police that was obvious during the recent COVID vaccine debate. Observationally, there is a lack of advocacy for moral development because it is counter to their legal and ethical dependence on their system of either professional gatekeeping or “checks-and-balances”.
With trends in psychology being what they are, we have to be cautious of a corporatized or bureaucratic version of authoritarianism. If we don’t see our government as this already, we may be misinformed or are predicting the future. What psychology knows (if it knows anything) is that we are not just talking to you today, we are talking to every you you have ever been and every you you will ever become. What this means to us, is that clients believe that professionals already know the whole story because we have definitions for things that they cannot explain. However, psychological explanations for how the work works needs to be reviewed (O’Brien, 2024a; O’Brien, 2024b). As we can observe, the body keeping the score is where we/clients intrinsically get our answers from. In combination with outside sources, we tend to make better decisions when we have accurate information and the time and space to make an informed decision. An important question to ponder, what if different professions that need to earn their retirement are causing the disease they are running from? Back to MN. MN is governed by common agreement, consensus, practice, and what is “normal”, but trends in psychology are just as disastrous as guns. The trend of believing that the system “knows” what is right and wrong for the individual is the one we are addressing here.
Back to our example. In reality, if clients have insurance, they would like to use it because they are already paying for it and MN becomes obsolete and we have a population of people thinking that psychology fixes people and does not know common sense from critical thinking. We see this mostly due to a lack of resources in education, but why would the education department have to be addressing where the USA is in the world’s educational ranking.
On another level, people lean on their insurance to pay for services, but this does not ensure quality, compassionate, ethical, or moral care.
From our perspective, people are expecting moral care because of the lack of development in the population caused by having educational training instead of training people to be educated. This expectation is mostly due to the fact that providers have to toe the line of the law, ethics, insurance company policies and procedures, and the client’s common expectations of our profession. Clients still expect ethical and moral care, not just ethical or legal care (O’Brien, 2024a; O’Brien, 2024b). We cannot be moral in a broken system where professions who dominate exponentially are in charge because history has taught us that “absolute power corrupts absolutely”.
This is the Machiavellian way to say that we are dependent, living dissociated, and are “diseased”. The disease? Addiction. Has psychology accurately named this disease? No (O’Brien, 2023a). Why not, because they are too close to the problem that they have become. Even more to the point, they do not know what the disease of addiction is (HINT: dissociation-in-trauma)(O’Brien, 2023a). The fact that they benefit from the rewards system setup by our educational system to be trained to obey, comply, and not ask questions, is why things will not change; therefore, it is not possible for a professional to be and to provide moral care in this day and age for what clients are asking for. This is mostly because our business practices were not set by psychology; therefore, they should be reconsidered in the light of our challenging of the diagnostic criteria and categories that we are suggesting (O’Brien, 2023a).
Dare we say that what is “normal” should be based on “evidence-based practices”; but even there we have a lot of reservations (O’Brien, 2023b), due to the system’s track record (O’Brien, 2023b; O’Brien, 2024a; O’Brien, 2024b). However, what if the climate of “the norm” is unrealistic, fueled by someone else’s/professions needs, addiction, or when expectations are perfectionistic? Or if it is mass psychosis like Red Scars, McCarthyism, Kamikazes, Nazi Germany, COVID, or what is on TV this weekend, then how would we know? What if mass psychosis is the denial from their addictions that they are calling normal? What if the truth hurts and we avoid pain, do we gain the lesson or knowledge? When was the last time you heard the government apologize to its citizens for not doing their job?
Necessity suggests that a need higher than what is “normal” or average, should be given the necessary treatment or care for whatever ails them. Our Westernized “normal” has been identified as traumatized, dissociated, and addicted because they are all transdiagnostic (O’Brien, 2023a). So, if MN, the law, and insurance companies set the norm and our diagnostic categories AND they are off, then what is normal and average is being diagnosed and treated as normal (O’Brien, 2024a). Our clinical example from our lived experience as a trauma clinician for the past 10 years, developmental trauma is the main disorder that people are really coming in for and it is not a diagnosis (Van der Kolk, 2014). Nor do we believe that it should become one because then normal is being diagnosed again (O’Brien, 2024a). Also, by their standards and as a way of measuring functioning, if people maintain their job (often to keep their health insurance) that pays for their insurance, then medical necessity is questionable because the level of impact varies.
Solutions
Identifying the problem as the problem is the problem. Healers are the ones who can see through the professional game of who is calling who insane, who is punishing/paying who for their mistakes, or why there are “problems” in the first place. A fully developed adult working in a professional capacity would be able to see the difference. But this is based on their individual level of awareness and the intelligence of the common collective. Also, the ability to access critical thinking.
Critical thinking is based on critical feeling because it is what informs conscious awareness. From this, the unconscious feeling body expresses the unconscious needs and story. The unconscious is present in everything we do. What recovering your feelings and thinking does, allows you to know the “right way” for yourself. This leads you to your destiny. Therefore, since recovery can be measured and morally quantified, governmental actions, policies, and laws can be evaluated through the lens of pathology. These manifestations of societal needs can be “diagnosed” and “treatment” applied, but that cannot be morally applied because people have choice in how they live and how they die. The system cannot eradicate the problem because the problem is you labeling a problem as a problem – that can be addressed and treated, if you are ready. But they can never be healed because healing can only occur in taking action or a stand against freedom of choice. Hence, these are moral injuries that need healing and repair. Healing is painful once you realize what you are healing from. If society is avoiding spiritual and moral development, then society would be lacking in it and the professionals that make up that society would too. This is what we see, even from morally-based professions (O’Brien, 2024b). What kind of outcomes do you need to know if you are a developed, mature, civil, and moral society? If you have been through a process of recovery, how would you know?
Recovery provides us access to the wisdom to know the difference. Those who have it are the ones who revere it. This knowledge can be reduced down to the word: freedom. Freedom of choice, freedom of expression, and speech. The cost of freedom as well. Separation of church and state has been corrupted by corporate interests and religion has become conditional. Spirituality and morals are not. Spirituality is moral fortitude and that is why we suggest a legal case for Spiritual Exemption from systematic bureaucratic authoritarianism. This is what citizens now require from their government in the wake of medical and psychological professional industries who gaslighting their citizens to sell them their solutions and denounce others in the name of “just doing business” or “national interests”.
Spirituality and its source have been defined by our work (O’Brien, 2023a). God has been found and they are dead. If you believe death is final, then this is probably terrifying you deep inside. If you cannot feel it, you are dissociative or currently numb/neutral. A Healer is living dissociated and knows it because that would be co-consciousness. This is otherwise known as dual attention because their emotional unconscious body and living their lived experience are shared. People feeling the pain are the ones dealing with it. People who avoid it are addicted to not dealing with it. The spiritual “work” is figuring out which side you are on before you commit to any one side. This is what WHI help with.
What recovery research offers us is the opportunity to measure recovery and society’s stage of awareness and stage of change. Specifically, with our recovery research and methods, people can know if their person, professional, provider, potential mate/spouse, or profession is sane and right for you. You can know your future to the extent that you can write it today. As a part of our process, we can tell you who is conscious and who is not. We can tell you who is sick and who is not. With our approach we can treat and heal what is actually underlying humanities decay – or we can at least slow it down. As mental health is about maintaining regulation so symptoms of expression do not make up pathology. Pathology is due to the same reason why addictions persist and pursue. With recovery principles at the forefront of systematic oppression, we can see a brighter future emerging. Educating on Recovery is Re-Educating you on what is dysfunctional, disordered, disgraceful, and immoral. More importantly, we can confirm whether or not you are because we have the wisdom to know the difference.
The difference between healing and treating something is treating symptom management and healing is doing something about the reason why it happened in the first place. For us, seeing people for spiritual and moral injury brings to light the whole issue with psychology thinking that it knows something. The addiction to avoiding feeling your feelings or feeling them too much is causing enough damage that hopefully people will start to see the destructive patterns of their addictive ways like more storage buildings to house all of the stuff you bought from Amazon.
A Healer is preparing you to die honestly. That is their teaching. Their educational example is their life in servitude to others, who are their teachers. This is why WHI say that “our unconscious is our educator”. Healers are the ones helping people see what side of the fence you are on. Once identified, people start getting back to the new old “normal” by communally grounding and through the healing methods that you know or the ones that we educate (and reeducate) on are what we suggest. If you don’t want to make this change alone, then come and join us.
Healing is the process of returning home to ourselves, our truth, and our need to truly care for ourselves and others. A system that creates this absence for its own greed cannot stand for very long. To care for ourselves, is to care for others in balance. In this context, we can be living dissociated from the norm AND living dissociated in the norm and not know it because we do not always know where or what normal is? Imperfections, issues, problems, consequences, abuse, and trauma wake us to the possibilities of choice. In these states of consciousness, dissociation and addictions are the solutions to the problems caused by those who have problems with these solutions. Healers do not see these things as problems because nothing exists. This “should not” terrify the informed reader, but the uninformed will probably want to ask more questions to someone who gets it. Healers get it. If they know something you don’t, at least you know that. They cannot tell you because you already know. True Healers are educators who help people identify who gets it and who doesn’t. [Remember, the difference between ethics and morals is action (O’Brien, 2024a; O’Brien, 2024b)].
Healers speak truth to power because they know the difference. America has become what it created and has sold its disease to the world. Now it is time to sell our recovery solution. However, you can sell something that you do not have and that is the major issue. Our developing podcast “Healing America with Dr. Adam” will explore recovery solutions in more detail, but here are the questions that the audience would have to answer: If America was your new client, would you refer out? What if you couldn’t because you are Healer instead of a Therapist?
References
O’Brien, A. (2023a). Addiction as Trauma-Related Dissociation: A Phenomenological Investigation of the Addictive State. International University of Graduate Studies. (Dissertation). Retrieved at woundedhealersinstitute.org/courses/addiction-as-dissociation-model-course/
O’Brien, A. (2023b). Memory Reconsolidation in Psychedelics Therapy. In Path of the Wounded Healer: A Dissociative-Focused Phase Model for Normative and Pathological States of Consciousness: Training Manual and Guide. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/courses/addiction-as-dissociation-model-course/
O’Brien, A. (2023c). Path of the Wounded Healer: A Dissociative-Focused Phase Model for Normative and Pathological States of Consciousness: Training Manual and Guide. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/
O’Brien, A. (2024a). Healer and Healing: The re-education of the healer and healing professions as an advocation. Re-educational and Training Manual and Guide. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/
O’Brien, A. (2024b). Diagnostic Privilege: Meta-Critical Analysis. In Healer and Healing: The re-education of the healer and the healing profession as an advocation. Re-educational and Training Manual and Guide. Appendix 2. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/courses/addiction-as-dissociation-model-course/
O’Brien, A. (2024c). Meta-Critical Analysis: The “Science” of Pseudoscience. In Healer and Healing: The re-education of the healer and the healing profession as an advocation. Re- educational and Training Manual and Guide. Appendix 3. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/courses/addiction-as-dissociation-model-course/
O’Brien, A. (2024d). Moral-Ethics. In Healer and Healing: The re-education of the healer and healing professions as an advocation. Re-educational and Training Manual and Guide. Chapter 14. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/
O’Brien, A. (2024e). Path of the Wounded Healers for Thrivers: Perfectionism, Altruism, and Ambition Addictions; Re-education and training manual for Abusers, Activists, Batterers, Bullies, Enablers, Killers, Narcissists, Offenders, Parents, Perpetrators, and Warriors. Re-Education and Training Manual and Guide. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/
