We are all perforce political animals; what happens in political life affects us daily and never more so in a climate of post financial crash frugality and an increasing reliance upon mega business to drive the American economy. For most of my life, I as a psychiatrist and psychoanalyst, have tried to avoid public political stances largely out of the value I place on analytic neutrality and the way in which such public stances could negatively impact my work with patients of different political persuasions.
This brief note is a break from that tradition. The last time I felt impelled to make such a commentary was a time when Congress was busy trying to prevent the use of so-called antipsychotics, and major tranquilizers in nursing home populations. In doing so, it was responding to a pleasant myth: e.g. that the use of such agents was perpetrated by uncaring, unempathic coldhearted doctors and staff upon helpless “victims”. It is always so nice when the situation can be neatly divided into good versus bad, the abuser versus the abused. Of course this view was as dangerous as it was ill-conceived. No one will argue that such medicines were given in ways that were not optimal or not given with enough care. This was most notable in the state hospital populations where such administration produced, over many years, significant tardive dyskinesia. On the other hand, I think no one who ever spent any time in nursing homes and who has seen the effects of significant Alzheimer’s related agitation and dysphoria could doubt the essential value of these agents over any other pharmacologic choice. I am grateful that my voice at that time was helpful in forestalling that dangerous legislative trend.
Now, is another time when action is required. Unfortunately, our “enemy” is an entity far more powerful; an enemy which perhaps exerts more control over our government than any other: the health insurance industry. Each of us must be aware of an increasing trend in insurance company practices of late to demand “peer review” as a method to beat down our therapeutic interventions to once a week treatment. This is not a blip on the curve; this is a concerted effort on the part of the insurance companies to make once-a-week psychotherapy the standard for all mental health care.
A recent article in the New York Times, entitled “LACKING RULES, INSURERS BALK AT PAYING FOR INTENSIVE PSYCHIATRIC CARE” spells out insurers aims in this regard. Already I would, as a psychoanalyst and a dynamic psychotherapist, “balk” at having anybody label a two or three session a week psychotherapy “intensive” psychiatric care. The concern is especially heightened in the setting of the Affordable Care Act being rolled out as it is likely that the federal government will be even less likely to intervene in an effort to establish safeguards for psychiatric care while they need the cooperation of insurance companies to institute this larger health initiative.
Recently I had one such “peer review” myself and in the aftermath of that review, which was predetermined in its outcome, I was given an explanation for the negative determination. In it, United Behavioral Health states that it is their policy “the use of multiple weekly therapy sessions typically is limited to acute exacerbations of illness, or in the context of a clinically urgent situation.” They went on to say that since my patient had a good job and was not acutely suicidal, once a week treatment is sufficient.
Before the typical counterattack by insurers and critics of our field is raised, namely that seeing a patient frequently is “a luxury” or is done for the financial benefit of the practitioner, I would make the following comments: my financial life, along with many in my field, has been adversely affected significantly by my decision to study psychoanalysis and to obtain training in intensive dynamic psychotherapy. I and countless others, have undergone long and extremely expensive educational endeavors because it takes great training and skill to do what we do and because, in my judgment, we have learned that this process is in fact the best way to address mental anguish and the dreadful repetitions of neurotic conflict that are inevitable without their elucidation. Further, it is not the practitioners of this modality who have principally suffered as a result of insurance decisions. Much larger sacrifices are made by patients who struggle to see us more frequently and who face the daunting reality that often more than 50% of their fee must be paid by themselves anyway. Insurers play with the numbers of so-called “prevailing rates” in the community to drive fees to arbitrary low levels and then with deductibles and paying only percentage of the remaining fee leave the patient to bear the bulk of treatment costs. From clinical experience of my colleagues, I have learned that patients are quite ready to accept significant financial burdens to be in treatment and often take second jobs or work overtime in order to have this important therapeutic experience.
Why are multiple sessions so important? The short answer is transference.
Therapeutically, whether or not there is unanimity on all aspects theory, those trained in analytic psychotherapy and in psychoanalysis are united in appreciating the fundamental power of analysis of transference which can only occur in the setting of a significant emotionally meaningful relationship. There can be no investigation of the conflicted past and no possibility of real mutagenesis without transference and its clear appearance in connection with the therapist. Further there is no question that multiple sessions, when feasible and tolerated by the patient, offer the strongest opportunity for the emergence of powerful transference trends which can be both apperceive intellectually and emotionally apprehended by the patient in a meaningful way.
To interfere with this process, or to limit it so drastically to once a week treatment is nothing less than forcing us as doctors to treat with watered down penicillin enough to offer the illusion of care. The insurance companies would authorize just enough to keep people extent but not enough to get them fully well.
It is worth pointing out that good treatment doesn’t simply result in one individual patient feeling better or living a better life. What we, as psychotherapists do, is like throwing a stone in the pond; the ripples of increased self-understanding extend through the patient far out into other peoples’ lives. Marriages go better, child rearing is improved, the ability to fulfill one’s dream and to work successfully with others in the workplace all are dramatically affected. It has been clearly demonstrated that good dynamic psychotherapy provides all kinds of benefits to the surround and to the social matrix as a whole.
Unfortunately, I see no one in the political or social field with the muscle, conviction, dedication or knowledge to resist this potential plowing under of our field and our therapeutic power to assist our distressed clients. And whereas universal health coverage is a fine idea, efforts to balance the books and reap financial reward on the backs of our clients by defunding coverage to treatments of more than once weekly is inhuman and constitutes a retreat from what we have learned in treating mental illness for over 100 years.
I would urge all friends of dynamic psychotherapy and psychoanalysis to write to their respective congressmen and to pressure legislative leaders on this important matter. I would also wonder if a social media campaign could be initiated to express our intense objection to this dangerous accelerating trend.