Jung At Heart

I was talking with someone yesterday about the changes in mental health care since we became therapists some 35 years ago. We decided we are glad to be in the last part of our careers and not starting because we feel like a dying breed. I keep wondering why people are so willing to buy into the whole "better things for better living through chenistry" thing that permeates mental health care today and why they aren't more curious about themselves. 

Yesterday CP&P to an article on the NY Tiimes  on the emerging symbiosis between psychiatrists and pharmaceutical companies. As the Times reports,

"As states begin to require that drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty...

The number most likely represents a small fraction of drug makers’ total marketing expenditures to doctors since it does not include the costs of free drug samples or the salaries of sales representatives and their staff members. According to their income statements, drug makers generally spend twice as much to market drugs as they do to research them."

Granted that nothing like all psychiatrists receive money from drug companies, but I don't think either that they can safely argue that they are not heavily influenced by the many goodies available to them from reps, in addition to the co-option of so-called opinion leaders in the field. Mental health policy is not being independently formed with the the best interests of the patients now; it is about money and who gets it. And it is money -- the skyrocketing costs to Medicaid that is leading to states investigating where drug company payments are going,

Is it even possible any longer to completely clean house?

I think I am flattered to have been included for discussion in Shrink Rap's latest podcast following the interesting exchange Roy and I had about brain illness vs the worried well. Listening to it this morning, I wished I could have been there to participate in the discussion and clarify a couple of small points. So I will do that here.

I do believe that all humans are wounded, varying in degree and type of wound, but we are all wounded. My first professor in abnormal psychology put it this way -- from the moment of conception we are bombarded by influences of all kinds, both noxious and helpful and as adults we are who we are at least in part de to the effects of these influences. Some of us will be more scarred than others, but none of us will be unmarked by the experiences of our lives. So wounded per se is the normal state, not a state of ill-health. 

Now, the extent to which our wounds make our lives complicated and/or difficult is where therapy enters in. Problems in living are what bring most people that I have seen into therapy -- the desire to experience life in a different way is the motivator. There is no procedure or pill or technique I can apply that will close the wound. Whether or not healing is the appropriate description for becoming conscious of something that is an integral part of us, an unerasable part of our history, is something I balk at a bit. I can become more conscious of the ways I have internalized people and issues in my life. Becoming more conscious of them increases the array of possible responses I have available to me, so I can choose differently and thus find myself not in the old familiar ruts but in very different relationship to myself and those around me. That is what I believe therapy does for people and indeed is what I have experienced in my own therapy. I cannot be what I might have been had I not had the mother I had or the experiences in life I have had -- I am indelibly marked by them. But I can be freer in how I live my life and perceive my possibilities through the process of examining my thoughts, behaviors, history, dreams, reactions. That is what talk therapy as I know and do it is about.

So, in my mind, wounded does not equate to ill. And, as I have said before, I see those in hospital, who are acutely psychotic, hallucinating, disabled by their illness as suffering from something different from what I see in the run of my practice. 

And, Roy, I do not accept third party payment. My patients self-pay and I offer a sliding scale for fees, something I can do because I do not accept insurance. I do not assign ICD-9 or DSM IV diagnoses. 

I also have some thoughts on the Newsweek article Roy mentioned but I will get to that tomorrow.

I spent my first 2 years in college as a physics major so when I went off to grad school in clinical psych and one of my professors went on and on about psychology as a science, I disagreed. I knew science and I knew clinical psychology was no science. That bit of boldness earned a verbal slap from him in which he told me that I lacked identity as a psychologist.

There have been many times since that day some 38 years ago when I have been well aware that psychologists as a group are not my crowd, despite the fact that all three of my degrees are in that very field. This was brought home again for me in recent days as I have read about the role some psychologists have played in the development of the torture techniques employed in the so-called war on terrorism. Salon has two good pieces about this issue. I was upset a couple of years ago when the APA task force decided that it was ethical for psychologists to advise the military and other agencies to assist in developing these techniques and grateful that I was not a member. 

Sickening. Sickening that it was not seen to be unethical on the face of the whole thing.

A couple of weeks ago, I posted a thought I had in reference to a post by Roy of Shrink Rap had made about health insurance coverage for mental illness. We had an exchange in the comments of my post that started out a bit testy but ended well. I have a some additional thoughts from that exchange I want to add today.

Roy and I discovered, as I thought from reading him over several months, that we see very different patient populations. Patients who are in hospital, who are acutely psychotic, hallucinating, disabled by their illness do indeed seem to be suffering from a brain illness, from something having gone awry in the brain. And I have no problem ceding that they are best cared for by psychiatrists and that indeed, they should have parity in insurance coverage, as with any chronic illness.

But these are not the people that I see in my practice nor that most therapists see. Health insurance rarely, for example, covers marital therapy for the simple reason that problems in a marriage are not mental illness. Makes sense to me. It also makes sense to me that the woman wrestling with the impact of her abusive parent on her in her adult life, the man who wants to change his life but doesn't know where to start, the woman who wants a husband and family and cannot understand why she hasn't found that -- well, I don't see that as mental illness either or brain illness either. In fact, I really do not believe that such problems should be covered by health insurance.

When a therapist sees someone like I described above and agrees to accept payment from health insurance, both therapist and patient are agreeing to the assignment of a psychiatric diagnosis and thus tacitly accepting that these problems in living are in fact symptomatic of mental illness. I opted out of accepting insurance when I realized that in my mind continuing to assign diagnoses to people who were not ill was unethical. It allowed me, as it has those therapists who continue to do so, to charge higher fees, but it was also putting me in the position of colluding with something I didn't believe in. 

I watched what happened when outpatient therapy became a mandated benefit in my state. I watched as fees rose rather sharply. Where a therapist might have charged $50/hr before insurance, now it was possible to receive $80 or $90 or more without increasing the out of pocket expense for the patient. Then i watched as the system struck back, imposing managed care guidelines and insisting therapists join panels of providers and changing which diagnoses they would cover. And most therapists stayed in that system because they no longer believed that they could survive outside it and because the income possible with it was and is seductive. And now the insurance companies, hand in hand with their friends the pharmaceutical companies, run the whole system. The camel poked its head into the psychotherapy tent 20 years ago; now the tent is his.

Well, what to say? Phil got his and then everything just goes on. The ending led lots of people, me included, to think at first that the cable went out and my son to call with "WTF??!!", also not an uncommon response. I am not sure if I like what Chase did or not and I know that is because I, again like most people, like to know what happens, to have the ends tied up a bit more neatly. 

In a terrific review of the final episode, Matt Zoller Seitz says:

Don't you love it when a television show or movie stimulates lots of discussion? This last episode of The Sopranos has certainly done that this week with a great deal of discussion to be found in all kinds of places about the ethical lapses of both Melfi and Kupferberg. CNN has an article reporting on reactions of a number of psychoanalysts in New York to the episode.

I have been asked by several people if in fact when therapists get together they talk about patients as the characters did in the dinner party scene. I must first say that I can't imagine going to a dinner party where all the guests were therapists -- my social circle doesn't work like that. And on those occasions when I am with a close friend who is also a therapist, it is true we may talk about our work, but only in broad terms, never revealing names of patients -- that is simply taboo. The one exception is in clinical supervision and even there I have rarely found it necessary to reveal the identity of the patient. So what happened at the dinner party is too far out of the norm to even begin to be considered acceptable or common.

"Why did Kupferberg commit such a sin? He didn't think Melfi should be treating Tony, whom he considered a manipulative psychopath. Be that as it may, his disclosure was "a very egregious ethical violation," said Dr. Jan Van Schaik, chair of the Ethics Committee at the Wisconsin Psychoanalytic Institute." -- CNN

I also have reservations about whether or not Tony fits the diagnosis of sociopath. First, within his subculture, his behavior is normal. We can certainly say that the subculture lies outside the acceptable norms of mainstream culture but that does not make any member of it a sociopath, in the DSM IV sense. Tony also shows affect, has significant relationships with people he cares about and seems to have at least some insight into his own behavior.

At some point Melfi described him as alexithymic, that is someone who is unable to talk about feelings due to a lack of emotional awareness. Tony's "panic attacks" appear to be what happens to him when he experiences emotions he is unable to talk about or express, so he faints. Emotions arise first in the body, after all.

Would Tony benefit from continuing in therapy? I don't know. His family relationships likely would improve as indeed his marriage has. But therapy would never turn Tony into an upstanding normal law abiding citizen as he does not see his life in the Mafia as a problem to be worked through.