Introduction

One of the authors, Dr Matthew Draper, worked as a mental health professional in correctional settings and currently works as a clinical director of an addictions rehabilitation outpatient center (rehab), in which he daily treats those bound up in these two processes. In his field, one of the major links between those formerly incarcerated and those suffering from addiction is mental illness (Smith et al, 2017), and it seems that mental illness keeps many patients ‘stuck’ between rehab and incarceration. Upon close examination, it is not mental illness itself, or addiction itself, that perpetuates the cycle between rehab and incarceration, or even their comorbidity. Rather, it is a lack of adequate and affordable treatment and the way vested financial interests serve as a barrier to treatment for the poor and middle class. For example, Dr Draper submitted an assessment and treatment plan to an insurance company with the diagnosis of borderline personality disorder and opioid dependence (severe) for a patient recently released from jail. The insurance company denied the claim, leaving Draper to decide whether to treat the patient pro-bono. His peers at other facilities advised him to change the diagnosis to ‘mood disorder’ rather than a personality disorder. Insurance companies prefer mood disorders diagnoses because medication and brief psychotherapy seem to readily ameliorate them, whereas personality disorders (like borderline personality disorder) are not as readily treated with medication, require long-term intensive psychotherapy, and intensive training for the psychotherapist, which is far more expensive (Kersting, 2004). Practitioners’ commonly shared wisdom says that insurance companies tacitly ‘required’ diagnoses that fell under Axis I (clinical disorders—including mood disorders) of the DSM-IV-TR for the treatment to qualify for payment. Likewise, the unwritten understanding was that disorders formerly falling under ‘Axis II’ (i.e. personality disorders and intellectual disability) were, at best, questionable for third-party payment. It is not clear that the new structure of the DSM 5 has ameliorated this dynamic (Frances, 2012).

Curious, Draper inquired among colleagues, who told him that such deliberate misdiagnoses were very common, and they justified the practice as ‘necessary’ to provide at least some treatment to those suffering. Instead of borderline personality disorder, they suggested a diagnosis of bipolar disorder. Simultaneously, a patient must receive treatment for the diagnosis, including appropriate medications and psychotherapy, or the insurance companies deny the claims.