Psychoanalytic Therapy as Health Care

Effectiveness and Economics in the 21st Century

Harriette Kaley, Morris N. Eagle, David L. Wolitzky, Harriette Kaley, Morris N. Eagle, David L. Wolitzky

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781317713746
• Topic: Psicología
• Subtopic: Salud mental en psicología

In Psychoanalytic Therapy as Health Care, a timely and trenchant consideration of the clash of values between managed care and psychoanalysis, contributors elaborate a thoughtful defense of the therapeutic necessity and social importance of contemporary psychoanalytic and psychodynamic approaches in the provision of mental health care.

Part I begins with the question of where psychoanalytic treatments now stand in relation to health care; contributors offer explanations of the current state of affairs and consider possible directions of future developments. Part II looks directly at the conundrums that have resulted from the attempt to integrate psychotherapy and managed care, with contributors examining the ethical and legal dimensions of confidentiality, privacy, and reporting to third parties. Part III opens to wider consideration of the experiences of psychoanalysts under health care systems throughout the world. Finally, Part IV demonstrates the relevance of contemporary psychoanalytic approaches to a variety of contemporary patient populations, with contributors focusing on the applicability of analytically oriented treatment to AIDS patients, seriously disturbed young adults, and inner-city clinic patients.

Collectively, the contributors to Psychoanalytic Therapy as Health Care convincingly refute the claim that psychoanalytically informed therapy is an esoteric treatment suited only to the "worried well." Drawing on a wide range of clinical and empirical evidence, they forcefully argue that contemporary psychoanalytic approaches are applicable to seriously distressed persons in a variety of treatment contexts. Failure to include such long-term therapies within health care delivery systems, they conclude, will deprive many patients of help they need - and help from which they can benefit in enduring ways that far transcend the limited treatment goals of managed care.

PART I

Psychoanalysis and Health Care: Present Problems and Future Prospects

ONE

Psychoanalysis in the Political Arena

The Reality Principle

BRYANT L. WELCH

THE LAWSUIT

In 1985 psychologists took what seemed at the time a very radical approach to the problem psychologists were having obtaining psychoanalytic training. They filed a class action antitrust suit against the American Psychoanalytic Association, the International Psychoanalytic Association, and two of their component institutes.

Psychologists did not take these steps precipitously. In 1983, psychologists felt that at long last the American Psychoanalytic Association was going to change its policy barring psychologists from training in their institutes, from hiring their teachers to set up their own institute, and from admission to the International Psychoanalytic Association.

Unfortunately, in late 1983 the Medical Director of the American Psychiatric Association addressed the American Psychoanalytic Association and strongly cautioned them not to admit psychologists, but, instead, to move closer to their “medical roots.” And, in May of 1984, the American Psychoanalytic Association Board of Directors voted to table all proposals to train psychologists.

In the summer of 1984, in the newsletter of the American Psychoanalytic Association, the newly elected president, Ed Joseph, expressed relief that the proposals had been defeated and that during his tenure institutional attention could be directed to other areas. For those psychologists who had been following this issue for 15 years, not only was defeat of the proposals disheartening, but it seemed to them very unlikely that, barring a more radical intervention, psychologists would be able to obtain psychoanalytic training.

While the lawsuit effort was arduous for all, there is little dispute now, even within the American Psychoanalytic Association, that training psychologists has had a wonderful and rejuvenating impact on psychoanalysis in this country. And psychoanalysis is now one of the fastest growing areas of interest within the American Psychological Association, something one would not have imagined just a few decades ago.

The lawsuit’s challenge to the long-standing autocratic structure of the American Psychoanalytic Association has at least arguably had a positive impact within the American Psychoanalytic Association. One can now see hope for a reduction in the American’s rigidity, as a number of younger analysts realize that one can politically challenge its rules and procedures just as they can with any organization. That one may have a problem with authority does not mean that one has an “authority problem.” Indeed, the change has had a salutary effect on freedom of thought within the American Psychoanalytic Association.

It is true that in the early days after the lawsuit many members of the American Psychoanalytic Association responded with a defensive historical revisionism—claiming “We were going to do it anyway.” They overlooked the voluminous documents and public statements that were very much to the contrary, not to mention the direct statements made to the lawsuit organizers in presuit meetings between the two groups.

But it is noteworthy that, just a few years later, as psychologists and medical analysts began a perilous reformation period in the nation’s health care system, psychology’s closest ally was the American Psychoanalytic Association. As both groups confronted the multiple issues that the crisis had raised for them, the analytic community appreciated more fully that, in fighting over psychoanalytic training opportunities, psychologists were testifying to its importance, a value shared by analytically oriented psychologists and psychiatrists but not by many other large segments of society.

It became increasingly important for Division 39 psychologist/psychoanalysts and the American Psychoanalytic Association to articulate their shared values, which often were lost in the health care debate. Psycho-therapy is one of the few therapeutic sanctuaries that we provide in our culture. It is founded on a deeply held belief in the importance of the subjective realm of human experience and human emotion. And it inherently depends on a close and intimate relationship that can unfold only over sufficient time and with a degree of intensity sufficient to allow meaningful events to take place.

In 1992, the American Psychoanalytic Association took what were, for it, radical steps—it hired its own lobbying firm and began to participate in the political dialogue in Washington. Psychologist lobbyists were in regular contact with them, and, combined, they added energy geared toward securing a place for intensive psychotherapy and psychoanalysis in the health care reform.

THE HEALTH CARE SYSTEM

While the psychoanalytic community was waging its legal civil war, other major changes were confronting the overall health care system. Costs were escalating exponentially. The percentage of our Gross National Product spent on health care rose from 6% to 15%, and health care became a major political issue in this country. Simply put, we suffered from a system of health care in which patient and provider decided how much of the insurance company’s money they wanted to spend. Not surprisingly, their decisions were inflationary. And so we shifted to a system where a fourth private party was given both the money and the power to determine how much of the money to spend on patients and how much to retain for their own corporate profits. (They would like to retain a lot in corporate profits!) This new system became known as managed health care.

By the mid-1990s, the Wall Street Journal reported that the CEO of one of the largest managed care companies made a salary of ten million dollars, money that could probably have provided inoculations for most of the nation’s children who were not inoculated at the time.

Not surprisingly, long-term psychotherapy was extremely vulnerable in this new system. Therapy’s inherent subjectivity, people’s fear of and antipathy toward the subjective realm, and the prejudice that exists against mental illness all contributed to the problem and made it very difficult for people to protest when their psychotherapy benefits were removed.

AMERICAN PSYCHOLOGICAL ASSOCIATION PRACTICE DIRECTORATE

Managed care was clearly a political problem that was going to require a massive federal and state lobbying effort. And yet, when psychologists looked to their national trade organization, they found an organization that had been established by research academics, had very little to do with advocacy, and had even less to do with advocacy on behalf of psychoanalytic practitioners. Thus, in 1985, spurred by an insurgent group of young practitioners drawn largely from state psychological associations, the APA established a special tax on its practitioners to raise the three million dollars annually needed to establish an advocacy structure that could begin to tackle the problems that these young psychologists anticipated were going to confront psychology in the not too distant future.

In building the structure, psychologists had to focus on a number of areas. First psychology’s scope-of-practice issues, under assault by medical interests, were fought at the state level. Psychologists’ state political structures were extraordinarily primitive and ill equipped to meet the major tasks that lay ahead. At the federal level, our health care system appeared to be spiraling out of control and deteriorating so rapidly with managed care that eventually it seemed likely to collapse, forcing the federal government to intervene with some type of quasi-national health insurance system. The United States was one of just two countries that did not have a national health insurance system. (The other was South Africa.)

In response, psychologists did two things. First, they built an infrastructure. Substantial resources were spent building state associations and helping them hire professional staff and equipment. At the federal level, psychologists set up a grass roots network so that psychologists would be able to contact elected officials in their home district. They established a database of information about the value of psychotherapy and psychological services in general. They set up an aggressive political action committee so that psychologists could make contributions to candidates’ campaigns and form relationships with elected officials who would support them in legislative chambers. Psychologists set up a public relations arm to advocate their issues in public forums, and they developed a cadre of lobbyists to make their case on Capitol Hill.

The second thing psychologists did while building the infrastructure was to shape emerging legislation to have an impact on inevitable health care reform legislation. When Senator Edward Kennedy (D-MA) and Congressman Henry Waxman (D-CA) proposed the first national health insurance plan, it contained no mention of mental health and no mention of psychology. Psychologists responded aggressively to the proposed legislation and were successful in having both psychology and other mental health care included, albeit with a very limited outpatient benefit.

Psychologists also looked at the Medicare program. Many were predicting that Medicare would be the logical vehicle to extend for national health insurance. Clearly, if psychological treatment were not included in Medicare soon, psychologists would not be eligible for participation in that program in the future, and jockeying for position at a time of expansion to national health insurance would be even more problematic.

HEALTH CARE REFORM

The managed care marketplace continued to deteriorate. We had the worst of all possible worlds: a health care system under which costs of care were escalating dramatically and the number of people not covered by health insurance was also growing rapidly. In his first presidential campaign, President Clinton made health care a major campaign issue, and psychologists knew that with his election would come a major push toward national health insurance. Several questions, of course, then arose. What role would psychoanalysis and psychotherapy play? What could psychologists do to influence the outcome?

One immediate problem that had to be overcome by psychology’s leadership was the attitude many of their colleagues had about participation in the political process. Psychologists’ traditional passive political postures can be easily fit into personality profiles.

Deniers

Some simply denied that there was any problem. “Health care reform. What’s that?” At one Division 39 meeting, a psychologist in the audience raised her hand and said to the speaker, “You seem to be saying that this health care reform issue is something that could affect my practice.” The denier!

Narcissists

The narcissist responds to political tension in many ways: “It won’t affect me because I’m special,” or “Yes, but that’s politics and politics is dirty. I’m above that.” As Plato said over 2,000 years ago, “The price that wise people pay for not participating in politics is to be governed by the decisions of unwise people.”

Infantiles

The third group is the “blatantly infantile.” These are the people who look at the health care climate and, in effect, say, “This isn’t right,” their tone suggesting they have just implemented an action plan.

Escapists

The fourth group—soon to be an extinct species—is the “escapist.” “I don’t like health care reform. I think I’ll fight to get out of it. Then I can survive and prosper.” In short, the position suggests that psychologists can simply step “outside” the reimbursement system and do well by their patients and themselves.

That is true for some. But for most psychologists the simple fact is that, if the federal government is going to pour 80 to 100 billion dollars into mental health care, but nothing for intensive psychotherapy or psychoanalysis, psychoanalysis, psychotherapy, patients, and most psychologists will suffer drastically. One can talk about stepping outside the system all they want. Certainly, there are “Gold Coasts” in this country where a few people will maintain practices with the wealthy and the elite. But for most people on a very practical basis it is not a viable option. In reimbursement circles, it was never hard to “get out” of the system. Everybody would let you out. There was no enemy to be met on that battleground. The real battleground was over two issues: benefits structure and managed care.

As for the legislative struggle itself, it was very clear that psychologists wanted to make certain that they had the right to participate in the system. Thanks to the Medicare battle, inclusion of psychologists was not controversial, nor has psychology’s scope of practice been threatened in any proposed new systems. The controversy was all in the two areas of benefits and managed care.

The health care battle that ensued was remarkable. The psychologists’ case was very simple: we can afford good mental health care if we do not waste mental health resources. The areas in which mental health resources were being wasted were inpatient adolescent care and inpatient alcohol and substance abuse. Watch the hospital door carefully, but recognize that it is very cost effective to let people gain access to intensive outpatient treatment. The psychologists also pointed out that the then-current managed care systems’ allocation of up to 20 visits for psychotherapy was not sufficient for people who are multiple trauma victims or who have serious personality disorders or severe chronic depression.

Unfortunately, White House staff included one person who espoused a very antipsychotherapy viewpoint and another with an exclusively biological psychiatric perspective. This skew produced a bill with unlimited inpatient care, an unlimited drug benefit at 80% reimbursement, and 30 outpatient visits reimbursed at 50% coverage.

Of course, a major struggle ensued. Thanks to long-time psychologist advocates Senator Inouye (D-HI) and Congressman Ted Strickland (D-OH), psychologists received audiences with Hillary Clinton and with various staff for the Administration’s health care reform initiative. Thus, before a more objective tribunal, psychologists were able to present their case for a better outpatient benefit.

One might think that all mental health professionals would be delighted if a better outpatient benefit was obtained. This was not the case. Overlooking the fact that it was private-sector hospitalizations that had deflected money from the states and dominated and misled by the private psychiatric hospitals and later by the duplicitous managed care companies, a vociferous minority of the community argued that outpatient care would block access to treatment for the seriously mentally ill.

As a result of the split in the mental health community, psychologists obtained more limited improvement in the outpatient benefits with the Clinton administration than they would have otherwise. Therefore, they went to the Hill with two objectives: one was to remove from the bill the limits on outpatient care, and the other was to explain the managed care problem to Congress.

By this time psychologists had been through a number of battles. Medicare and other advocacy struggles had seasoned them in the political arena. The psychologists had formed ongoing relationships with key people who would be influential in the health care debate and who psychologists felt would be sympathetic to mental health. The psychologists hired full-time field organizers to go to the states and help organize for political activity. In one week alone, the psychologists sent out 350,000 pieces of mail, including letters to all the members of the American Psychological Association asking them to write and phone their elected officials. The psychologists also sent 35,000 telegrams on critical issues. The psychologists brought in conservative actuaries who said that the benefit model psychologists developed would work and made actuarial sense for health care systems.

Although the overall health refor...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Editors’ Introduction
• Part I Psychoanalysis and Health Care: Present Problems and Future Prospects
• Part II Legal Issues: Privacy and Confidentiality
• Part III International Perspectives
• Part IV Current Issues and Special Populations
• Part V Epilogue
• Index