Jung At Heart Archive July 2007

Albert Ellis

Albert Ellis died Tuesday. He is widely considered one of the most influential and important voices in psychotherapy. As the father of cognitive-behavioral therapy, via his Rational Emotive therapy, his influence on the field is unquestionable. No one who reads here would be surprised that I am not a big fan of Ellis. Nevertheless, whenever one of the pioneers and giants in the field dies, it is worth noting.

Jul 26, 2007 9:15 AM

Any lingering doubts...

Thanks to CP&P for pointing to this, reported on Health Care Renewal:

The main pediatrics teaching hospital for the University of Medicine and Dentistry of New Jersey (UMDNJ) - Robert Wood Johnson Medical School is the Bristol-Myers Squibb Children's Hospital, named, of course, for Bristol-Myers Squibb, the large pharmaceutical company.. The hospital was apparently well supported by grants from the the Bristol Myers Squibb Foundation. 

The hospital opened in 2001. As best as I can tell from a Lexis-Nexis search, there was not the slightest controversy about naming a hospital for a large pharmaceutical company. Obviously, doctors and faculty at the hospital may choose to use Bristol Myers Squibb products, and to perform research, consult, or give talks for the company. Yet there was no public discussion about whether having the hospital named for the drug company produced even the appearance of an institutional conflict of interest.

 How in heaven's name can there not be even a thought given about the conflicts involved in naming hospitals and similar institutions (the same post mentions a furor aroused when the "University of Iowa proposed naming their new school of public health after a local for-profit insurance company in exchange for a substantial gift from the company's associated foundation" ). When a donor has an interest in products used by an institution or has a vested financial interest in their billing practices, then how can there not be conflict? How can the institution not be influenced in their decision making, even if unconsciously, to curry continuing favor from the "benefactor"?

Anyone doubting that health care is increasingly owned by drug companies and insurance companies borders on delusional, I believe.

Jul 26, 2007 8:35 AM

Whither psychotherapy?

For the last 20 years I have been watching what has been happening to psychotherapy, starting with the blessing that wasn't, third party payments, continuing to the present with the dominance of managed care and drug companies in setting policy. And what is happening runs quite counter to what is popularly believed about the field and its practitioners.

Psychotherapy Networker this month contains a number of articles about this very issue. And Lynn Grodzki spells out what too few outside the field understand:

"...last year, Psychotherapy Finances, a newsletter for behavioral health providers, released an industrywide survey of those in private practice and confirmed my observations. After 20 years of relative income stability, the financial picture for psychotherapists it described was dismal. With managed care on the rise, senior professionals surveyed, such as social workers, reported an inflation-adjusted 22-percent decline in overall income since 2000. Those who depended on indemnity insurance or self-pay clients reported problems keeping their caseloads full. A combination of factors led to the decline, but I'm convinced private practice stands at a crossroads of viability today...

According to the survey, the average licensed counselor, social worker, or marriage and family therapist in full-time private practice is earning a "salary" or net profit—income minus hefty practice expenses—of only $30,000 a year. The main reason for the drop in income is that managed-care fees for individual sessions, which account for 43 percent of the average practitioner's income, haven't risen for a decade, languishing at around $75 at the high end and $60 at the low end for a 50-minute session.

It's not that there isn't enough money: according to Plunkett Research, a company that specializes in health care market analysis, health spending in the U.S. is at about 16 percent of the gross domestic product, and growing. But the money funnels primarily through managed care delivery systems, which are disinclined to promote mental health. John Klein, editor of Psychotherapy Finances, notes that 15 years ago, the health care consultants he talked to found that 10 percent of all insurance dollars went to pay for mental health services. "Today, the figure I hear from the consultants is closer to 1.5 percent," he says, sounding discouraged."

The problem too seldom acknowledged is two-fold: first, insurance companies seduced the everyone by promising coverage which in turn created for many if not most therapists a serious dependency upon them as the only way to get paid at all. It has been an abusive relationship from the start, with the controlling partner, the insurance companies, creating ever changing rules and hoops to jump through, lowering payments and punishing any who dared to complain. So, too many therapists cower and watch their practices disappearing because they believe they cannot survive without being on managed care panels and playing the submissive game with them.

The second problem is that there are at least 5 categories of professionals who practice as psychotherapists but instead of speaking in a single voice, as psychotherapists, each group fights to guard its own little piece of the turf as the territory as whole gets whittled away bit by bit. The way the system is structured, with different payment schedules for each discipline, fragmentation is reinforced because joining together might result in everyone getting less.

The only solution I can see is for us to get out of the whole game. Which means dropping the medical model and turning to looking at psychotherapy as a kind of personal education rather than a medical treatment. The ICD-9  and CPT codes for individual psychotherapy* is called "medical psychotherapy", which I suppose is different from non-medical psychotherapy. But to tell the truth, having read very widely in the psychotherapy literature and having participated in workshops and seminars on all kinds of psychotherapy issues and techniques, I have never seen this term used outside of the ICD-9 and certain psychiatric circles -- because it claims psychotherapy turf for psychiatrists, not because they have special therapy skills but only because their training is in medicine rather than psychology or social work. 

There is no point in debating about "brain illness" or any of the rest of it because what we do no longer fits, if indeed it ever did, under the medical model. There is no point in arguing with insurers about the legitimacy of therapy other than CBT done short term. That train left the station a long time ago. 

Instead of focusing on how we can help with symptoms, we need to make it known, through what we write, talks we give, courses we teach, how therapy can broaden life, making available a wider array of choices and greater freedom in making them. How it helps people develop tools for dealing better with friendships, marriage, children, colleagues. It isn't about curing or healing. It's about making lives better, richer, more meaningful. We need to look at a wider variety of ways to offer our services, including online. But most of all, we have to extricate ourselves from the abusive relationship with managed care and be willing to leave behind our role as the bastard children of medicine.


* these codes are used on health insurance claim forms to describe the services rendered.

Jul 17, 2007 1:08 PM

Kindred spirits

Recently I said that sometimes I feel like buggy whip makers must have felt when automobiles began to be dominant because I am becoming more distant from the mainstream in mental health. So it is always heartening to find another voice articulately expressing some of my own concerns and reservations about this field. And I found one today: Candid Psychiatrist, whose blog seems to be more a collection of cogent essays than a traditional blog but well worth the effort to read. One excerpt, from her article, "Psychiatry's Own Inconvenient Truth"

One area of presumed scientific progress has been psychiatry, where the biological model of psychiatric disease has become dominant over the past three decades.  Prescribing medications has largely supplanted any serious exploration of psychodynamic issues, and relatively few psychiatrists now practice psychotherapy at all.  In large part I think this has been a favorable development—there are more and better medications nowadays, and the expertise of psychiatrists in the prescription and management of psychoactive medications is of premium value in the medical marketplace.  Besides, I think other disciplines do at least as good a job of psychotherapy as psychiatrists do, and at less cost as well.
 
But the biological model has demonstrated particular weakness when applied to the disorder known as depression.  Millions of patients have experienced significant benefit from antidepressant medications, and even dramatic improvement in a significant portion of cases.  However, the prospective benefits of antidepressants have been greatly oversold by a psychiatric establishment that seems intent on promoting the biological conception of depression as a matter of faith, rather than science. 
 
Many of us robotically prescribe serial medication trials in the face of unrelenting depression, even when we ourselves have no real expectation of seeing significant clinical improvement.  We participate in this fruitless ritual rather than adequately considering and/or confronting the non-biological factors that are often contributing to these medication-resistant cases.  And we justify our own circumscribed mindset with faith-based statements like “You have a chemical imbalance”, or “You will have to take this medication for the rest of your life.”  We have fallen into an intellectual rut in our conception of depression, having ourselves become dependent on the idea of medications as a convenient, if somewhat unreliable, therapeutic mainstay.      
 
But simply wishing something were true is not a justification for suspending our doubt, and for failing to reevaluate our belief system in the face of an unimpressive record of clinical success.  There is a mechanism for applying skeptical thought to this sort of problem, and that is the scientific method.  I think it’s a good time to rigorously reexamine the assumptions upon which most of our treatment of depression relies.

Well worth reading if you want to find another voice skeptical of the current state of affairs.

Jul 9, 2007 12:38 PM

© Cheryl Fuller, 2007. All  rights reserved.