Saturday, May 10, 2008

The Psychoanalysis of Oliver Sacks

First, a couple of plugs:

Since we're still talking about the Shrink Rappers' trip to APA, I'd like to steer you to Peter Kramer's piece on what psychiatrists actually do at big psychiatric conventions.

Nothing to do with APA, but we received a nice note from a psychiatrist, and he has a site for quickly looking up DSM-IV-TR codes. Unlike Roy, I actually can't remember all the codes, so check out :

Okay, so Oliver Sacks. I heard him speak just briefly at APA at the Convocation of Fellows. He talked about musical hallucinations, and as he gave his talk, he mentioned that he's been in twice-a-week psychotherapy with a psychoanalyst for 42 years. That's a lot of decades of therapy. Roy's comment: "Kinda weird." Here's what else I know about Dr. Sacks -- I heard him talk on an NPR show a few weeks ago. He was born in England in 1933. His parents were physicians and, more specifically, his mother was a surgeon. When he was a boy, he said on the NPR show, his mother would bring home fetal body parts for him to dissect. His brother does not think he should talk about this. Dinah's comment: "Kinda weird." I'll say it tongue-in-cheek, but this alone might cause one to need decades of psychoanalysis.

Before I say any more, let me add a disclaimer. I've heard part of an NPR's Fresh Air (Listen Here) -- oh, he has a Great NPR Voice. I've read
The Man Who Mistook His Wife for A Hat. I've heard him speak for roughly 15 minutes at APA. I think I saw the movie Awakenings with Robin Williams. I've never met Dr. Sacks, I've never e-mailed him, I have no knowledge of his life beyond what I've heard him say in public. This post borrows from him, but I have no idea why Dr. Sacks has spent decades in therapy, and please don't take my fantasies as reality.

I don't know if Dr. Sacks suffers from a mental illness. Perhaps he does, and perhaps that alone warrants all these years of treatment. But maybe he doesn't; so, now we can digress into my fantasies. Dr. Sacks lives in New York City, a place where many of the worlds' psychoanalysts practice, a place where the practice remains alive, and where therapy is still accepted (or was when I was a med student there) as a means to gain self-awareness and maximize one's ability to live life to the fullest. It's not necessarily about curing illness; it's sometimes about a vaguer, more self-actualizing goal, one that may be an on-going process and one without a specified end.

To divert a bit, I once had a supervisor who volunteered to me that he'd had decades of therapy. Unlike Oliver Sacks, he wasn't a stranger, and I didn't have to speculate: I asked why. He told me his therapist served as a surrogate father, helped him to process his work, and that after he finished analysis, he wanted to continue to see him weekly rather than just bumping into him from time to time.

Personally, I believe that psychotherapy is a personal endeavor--- if it's helpful to you, do you need to justify it? Of course not, but in ways, society asks us to do this. It's expensive, it's regulated, there are not enough psychiatrists to provide care to the mentally ill, so is it right that someone who is not in active distress should take up the precious time of physicians who might be better used elsewhere? I'm told that there are only a handful of psychiatrists in Afghanistan -- perhaps we should ship these psychoanalysts there to help the chronically mentally ill Afghanistan citizens.

Okay, so the question gets even more complicated: should the long-term analysand without a mental illness pass the bill along to her insurance company? This again gets foggy -- I see patients who've rapidly recovered from a Major Depressive Episode -- if they continue to come for appointments, should the bill be passed along to the insurance company even if the patient has no active symptoms of depression at the time of the visit? Not every patient walks into every appointment in distress, and some people go up and down. I imagine ( I don't know) that over the course of 42 years, Dr. Sacks has good weeks and bad weeks, whether or not he has a psychiatric disorder.

There are many who feel that with limited resources, our society should not pay for therapy for people who don't have mental illness; subjective distress is something you should pay for on your own, and self-awareness is the same. Socrates told us that the unexamined life is not worth living; he didn't tell us who should pay to examine it.


Midwife with a Knife said...

I think that the childhood dissection of human fetuses is why Oliver Sacks needs therapy... either that or him having a mom weird enough to bring him fetuses home to dissect....

As far as the "who pays for therapy?" question, the thing that makes it so tricky is the fine line between "mere" distress and "real illness". If the line were obvious, it would be easy to say that insurance should pay for therapy as long as someone has symptoms from a mental illness and then maybe some sort of "maintenance" period afterwards.

But... someone can be desperately unhappy and not be mentally ill. If therapy can help, it's easy to say that insurance should pay for therapy. But what if they're desperately unhappy and a Nintendo Wii would help (likely cheaper than therapy)... or what if they're unhappy and a vacation would really help? Or what if they're a burnt out (is that a psychiatric condition?) firefighter, police officer, paramedic....? Hm... Should their insurance give them some paid time off as well as therapy? I don't think that my insurance company is responsible for my happiness, however, I do appreciate that over the past year they've paid a good amount out more than I've paid in.

Then again, when getting a job, I usually chose the more expensive insurance with more doctor choices and more mental health coverage.

Dr. Pink Freud said...

Based on my experience, I'd venture the "average" person seeking Tx. for emotional distress (let's assume depression or anxiety) is looking for symptomatic relief and, by the time he/she presents, isn't remotely concerned with gaining insight. Further, with the emphasis now placed on "evidence-based" medicine and Tx., the days of long, drawn-out introspective meandering is simply something for which insurance will likely not pay. CBT, baby; eight sessions or less. Pretty soon therapy will be abbreviated to one session: meet the patient and state clearly, “Got an issue, take a tissue.” Be this as is may, “preventitive medicine” is all the rage (as it should be), and who knows, research may show that insight-oriented psychotherapy may provide some innoculating effect with respect to garden-variety depression and anxiety. As for billable diagnoses, God bless the DSM for being vague. If one feels the patient is benefiting from Tx., even in the absence of symptoms, we have the Dx. du Jour NOS (in partial remission)? Isn’t documenting continued improvement justification enough for continuation of Tx.? Blurry distinction, but what’s ethical and what’s allowable can skirt that fine line.

Anonymous said...

I'll bite.
I had a number of years of psychotherapy as part of treatment for major depression. To tell the truth I do not believe it had anything to do with my recovery. I totally credit the right combination of drugs and lifestyle changes. It was never clear to me what treatment was all about. The P doc was looking for "monsters under the bed" and there simply weren't any. Having said that I do think talking to someone can be useful. Religious people sometimes call it a spiritual director. I know my brother, a lawyer, actually pays our dad to listen to him talk about difficult cases. He says talking about them helps him get it outside his head where he can look at the cases more objectively and make better decisions. He has some pretty hairy cases with very nasty unethical people, and he is very conscientious about ethical behavior. I suppose if Dr Sacks had a person he could trust, who could not be called to give evidence, he might not use a psychotherapist. Twice a day does seem like a lot of "navel gazing" but he is a very creative guy so . . . It would be nice to have someone to talk to that you don't feel like you are imposing on.

Anonymous said...

Not all analysts are docs so, shipping them to Afghanistan--probably not worth it. Does Woody Allen ever have to justify his habit? He is probably still in analysis, not that it has helped him creatively much. I think everyone assumes he pays for it himself though. I doubt the types of people who treat the types of people who are in analysis for 40 years would be of much use to most other people. Can't put my finger on it, just a feeling I get.

ClinkShrink said...

This may be the best post you've ever written. It's definitely your best-written post.

As for shipping docs to Afghanistan, one of the things we talked about at the geek lunch you missed at APA was the use of telepsychiatry by the military. So I guess you could say they already are paying to ship docs overseas.

Anonymous said...

Psychotherapy is supposed to be maintenance treatment for a long-term illness, or sometimes is acute treatment for specific symptoms (eg, phobias.) It's not for lifelong introspection in people with no illness, IMO. I think there needs to be a diagnosis for insurance to pay for therapy. In cases where someone doesn't have a mental illness but subjective distress (eg grief) is interfering a lot with their life, that's "adjustment disorder," right? And therefore billable. If someone's distress isn't problematic enough to fall under adjustment disorder, then insurance shouldn't pay for it. As was pointed out, insurance won't pay for someone to take a vacation, even though it probably will help their mental health.

However when someone has a dx of a long-term, relapsing and remitting type of illness, I think therapy should be covered by insurance even when the person is not acutely ill. I have an episodic illness (bipolar) & I personally find therapy helpful ONLY when I am NOT acutely ill (and it helps me remain well longer), and of almost no value when I am.

Roy said...

Sounds like the same old double-standard. Health insurance should pay for your doctor's visit when you have vague physical symptoms, such as "fatigue", or "minor" symptoms, such as a headache, or dry skin, or a pimple. But if you have vague or minor mental symptoms (not attached to a "disorder") then they should not pay?

What's up with that? Ultimately, insurance will pay for whatever it says it will pay for in the actual legally written policy. If someone has an "Anxiety Disorder NOS" (that could be pretty much anything), and if the policy pays for any code in the DSM, then it should cover it. However, most policies have a "medical necessity" clause, stating that the proposed treatment much be "medically necessary", which is also defined in the insurance contract. That is where the whole "evidence-based" movement started from, as a way to either get coverage for a particular treatment or deny coverage for a particular treatment.

We still have a long way to go.

Anonymous said...

I highly doubt that Oliver Sacks has continued psychoanalysis for 42 years because he "needs" therapy, though having dead fetuses brought home by one's Mom is positively gruesome. I would think he continues for personal growth and because he LIKES thinking that deeply about his emotional and relational life.

Re: Woody Allen: Who knows if he even would have been ABLE to be as productive as he has been without therapy.

My own psychiatrist has been doing 50 minute sessions of talking therapy for 42+ years. My life has changed dramatically as a result of seeing him. In the last 17 months I left my husband of 30 years, am in the midst of a career change (after 23 years in the old), started playing piano again, and made numerous other concrete changes plus I have gained a lot of insight into my life and my emotional makeup.

I LIKE seeing my psychiatrist. I feel that we have incredible meeting of minds and emotions. Our sessions are philosophical, intellectual, emotional. We "click" REALLY well. I ALWAYS leave with things to think about. Our discussions go beyond my life (and his) to include discussions of books, movies, theater, art, music. He regularly suggests movies for me to watch and books for me to read (which I always follow up on). My contact with him has enriched my life beyond measure. I can imagine seeing him for as long as he is available to see me (he's 66 years old so who know when he will cease practicing). I can't imagine a time when I would not get a lot out of our sessions.

I imagine in reading all your responses that the idea that psychotherapy can be immensely useful and enriching is foreign and a bit unbelievable to doctors who have been trained to write prescriptions and make a practice of seeing patients for 5-15 minutes for med checks. I feel that the field of psychiatry has taken a huge backwards step in switching so emphatically away from psychotherapy and towards medications. I'd think it might be both professionally and personally rewarding for a psychiatrist to TRY psychotherapy twice a week for a year with an old-school psychiatrist. It probably would be life changing.

stephanie said...

As a patient diagnosed with the "worst case of Complex PTSD" in my large, American city, I'd like to speak for those of us for whom therapy is life-saving, not optional. My hat is off to psychoanalysts everywhere. As a patient recovering from serious illness, I count many of Houston's finest among my doctors. But the one who really came through never ever touched me, but correctly diagnosed my problem and cured me with the spoken word. In the process, he saved my children, too. I salute the spoken word. As for insurance? The good ones don't accept it.

Fat Doctor said...

OK, I don't have anything useful to add to this discussion. Just wanted to say, "Good God, woman, you are a great writer." Thanks.

Anonymous said...

Would Woody have been as productive? Well who can really say? I guess maybe Mia.

Gerbil said...

I once asked my very astute mother (well before I did my stint in managed care, and certainly before grad school; I was probably about 16) how insurance companies make their money. As my family is genetically blessed with all kinds of chronic health problems, I also knew that our insurance paid out a lot more for my parents' and my care than they got from us in premiums. My mother explained that for the vast majority of people, insurance is something you buy just in case.

So, if Oliver Sacks wants to go to analysis twice a week for 42 years, and his insurance is willing to pay for all or part of it, why shouldn't he take them up on it? After all, he (or his spouse, or if he's lucky, his employer) is paying premiums in order to access that coverage.

Anonymous said...

I think it's not so much of a double standard (as roy described above) as an apples and oranges comparison. Insurance may cover a doctor's visit for fatigue or dry skin, because those are legitimate symptoms that may signal a problem. So the person with these symptoms is evaluated and it is determined whether he needs ongoing treatment. Let's say this person did not have anything wrong with him, but wanted to keep coming to the doctor for his dry skin because he liked the moisturizing lotion they used in the office. Insurance might balk at covering that, with good reason.

If someone has vague mental health symptoms, it is reasonable to say that insurance should cover an initial evaluation. But if nothing is wrong, they should have no obligation to continue endless coverage so this person can have someone to chat with.

Dr. Pink Freud said...

With all this chatter about the "subjectivity" of a patient's distress, let's not forget that subjective distress is to a large extent what psychiatry is all about. We have no definitive measure (in the sense of an objective laboratory test) for depression, or for, say, pain, an arguably subjective experience. Insurance companies still pay (to varying degrees) for medications and Txs associated with pain disorders. Psychiatric D/Os are no less real, nor is the associated impairment. For me, it keeps coming back to prophylactic Tx. Is it not cheaper long-term to Tx. the depression or anxiety with the intent of preventing its return?

Anonymous said...

I don't want insurance to pay for a patient/client to have years of therapy. I'm glad they are putting limits on the # of sessions a person can have. For some people their whole lives revolve around therapy and that is just reinforcing pathology, in my opinion.

Battle Weary said...

I was going to make some inane comment about how I think if my insurance is willing to pay for me to see my GP because I have no energy or motivation, and then pay for endless tests to find out what is causing it...then I damn well think they should pay my psychiatrist and/or therapist if I recognize that it's probably depression and chose to see them instead. Then I read the last anonymous comment.

I don't believe therapy is reinforcing pathology! ^ years ago my GP suggested therapy and I waded in. At the time I was on medical leave from a horrible, dead-end job (medical billing...sorry Docs, but I will NEVER be responsible for a doctor's money again! EVERYTHING is the biller's fault! I still can't wrap my head around how exactly a local HMO going bankrupt is MY fault; but I digress). The medical leave was for a surgery that it is possible I did not actually need...apparently, all those weird, painful "female issues" *could* be related to sexual abuse and not have been a current medical issue...although there was severe endometriosis, I was actively suicidal with a plan and the means; the only thing stopping me was the fact that I didn't know who would care for my two, sweet kitties afterwards. During this time I wasn't doing much of anything except gaining weight from the over-eating combined with inactivity, sleeping, planning my own death, and wondering why I still had the same pain that the surgery was supposed to take care of, and now I had pain from the surgery itself on top of that. Fast forward 6 years and here I am, not always happy, but still alive and not contemplating suicide. I am graduating from our local Communitiy college in 11 days with an AA and dean's highest honors, in Aug I start at a 4 year university as a junior with a double major in Sociology and pre-nursing, and am already planning my entry into the Master's Nursing program at that school. I think this is a huge improvment and any reasonable person would probably agree.

Therapy is a big part of my life, but my life revolves around school...not therapy. Therapy makes my having a life possible...quite literally. My insurance pays for therapy... paying out of pocket is not possible for me. Without insurance (and mental health coverage as part of my insurance policy) I most certainly would be dead by now.

Anonymous said...

Okay so I read an interview that Sacks did a few years back. He never seemed to find the dissections he did with his mother disturbing but he did find her cold and distant. He had a terrible time in boarding school; he was sent there at a young age during the war, and bear in mind this was a place that caused his brother to suffer a "psychotic breakdown". Sacks claims that he began analysis after his freaky experiences with uppers and that he was on a destructive path at the time. Okay. He has been seeing the same analyst since 1966 every Tuesday and Friday and calls him Dr S and is called Dr Sacks by him. He doesn't know what he would do without this relationship. This is in fact his only relationship really. He never married, lived with anyone, says he is no good with relationships. Of course there are people who are no good with relationships. Obviously therapy for longer than I have been on earth has not made him good at relationships, just really attached to his shrink. So I have to ask if perhaps this person about whom he says he knows nothing about but who knows everythig about him, by virtue of being there for him, and expecting in return only a fee paid by, let's not dwell on that, has hindered and not helped the guy get better at relationships. He said that at one time he regretted not having a family but that has passed. I guess it would. I am worried what he will do when the shrink passes.Perhaps he never set getting better at relationships as a goal.Perhpas he sets no goals and lets life take its course.Okay, he has accomoplished plenty.
Issues, issues, yes the guy has issues, which does not mean he is not brilliant. Still,1966-2008 twice a week, same shrink. This is his relationship??!!!!! They have outlived the average marriage.Is that a healthy goal or outcome? I think that therapy is a place people go to be heard. That is very nice but shouldn't the goal be to take it out into real life at some point? Not arguing for short term CBT. Just asking.

Anonymous said...

So maybe Oliver Sacks would have never written a book or would have committed suicide without psychotherapy. It's impossible to know if his life could have been BETTER without it or without it being so protracted. Other people DO have outside relationships while in psychotherapy and I don't consider Oliver Sacks to be proof that a relationship with a psychotherapist impeds forming other relationships.

Battle Weary your comments resonated with me. My psychiatrist has spurred me to get much more involved in life and to change my life. When I contemplated suicide, I decided I did not want to cause him the anguish that I imagined a shrink might feel if his patient killed herself. He's not only kept me living but he's made life WORTH living for me. I have more outside relationships now than before I started seeing him, not less.

I don't think anyone starts with a psychiatrist for no good reason though they might continue beyond the bare minimum necessary. In my own case I started with my psychiatrist following a psychotic breakdown and a month on a psychiatric ward (involuntary). When I was first released my current psychiatrist was booked so I started with a "10 minutes plus meds" guy. My short term memory was impaired plus my emotions were totally flatlined. I felt like a robot (a brain with no feelings). In contrast, the long, slow talking approach has paid HUGE dividends for me. My life is WAY WAY WAY better than when managed on meds. It does not really matter to me if I am "hooked" on seeing my shrink. None of our time is wasted. I continue to grow. So what if I get better than the minimal level needed to survive?

Regarding who pays: I pay for my own sessions, twice a week, $180 per 50 minute session, and it's worth it.

Anonymous said...

With regard to using up precious psychological resources and taking them away the the "really" needy...prevention truly is the best medicine. If one's goal is to self-actualize and maximize themselves to whatever degree then I say full steam ahead.

Anonymous said...

A patient doesn't get endless physical therapy appointments just because the patient says it's helpful. They are cut off after a certain point. If they're no longer improving, then Medicare stops paying. We can't just expect insurance or the government to give a patient as many psychotherapy appointments as they want. What about the patient who wants therapy 2 times a week for 40 years, should insurance just eat it? What about if I say it's helpful for me to have therapy 4 times a week in 2 hour blocks? Insurance should just say okay whatever you think helps you? I think it's more than fair for insurance to expect some ROI, and there absolutely needs to be a limit to it. I found psychotherapy helpful and I am by no means anti-therapy. But, it shouldn't just be a bottomless pit. If a patient wants to pay for endless therapy appointments for years and years then that's their business, but I don't think insurance or the government should be expected to pick up that tab.