I know what it’s like, as a psychiatrist, to feel that your patient’s safety depends on your availability to provide emotional support. However, I also know from experience that patients usually survive our vacations, unavoidable short-notice absences and cellphone failures without actually falling apart. Certain patients feel very vulnerable, needy and worried about abandonment, but they feel that way long before we start treatment and, usually, those feelings don’t change in response to treatment. Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be.If weekly therapy does, indeed, have only a limited potential to heal and protect, then our patients must be stronger than they, and we, think they are. We know that depression and anxiety routinely distort our ability to think realistically by making us see nothing but our faults, failures and worst-case scenarios. When we’re sure that things will fall apart if weekly treatment isn’t readily available, we may well be accepting and stoking this distortion and, inadvertently, helping our patients believe that they are as weak and helpless as they feel.
Depression and anxiety, Bennett explains, can make some people feel like they can never be strong. He goes on to advice:
My advice to my colleague was to make a list of the patient’s strengths and encourage her to review what she had learned from the tough experiences that she had endured and survived. It would be normal for her to fear the worst from the coming transition in treatment, but this was also an opportunity for her to see through the negative distortion caused by that fear, review her resources and prepare plans for managing whatever worst case scenarios she could imagine. My colleague could assure her, of course, that emergency care was available. But he could also express confidence in her ability to use what she had learned in their work together to survive and thrive, in spite of her doubts and fears — and of his.
Where, oh where, to begin. To contain my urge to rant and ramble, I'll hold my analysis to a few bullet points:
- Obviously, Bennett may be right that therapy may foster dependence. The therapist may be financially motivated to patients coming frequently, and there are patients who could be seen less often then they are.
- So how do we determine how often a patient should come? The therapist & patient in this case say weekly; the insurance company says monthly. Why 12 appointments? Why not 11 or 13? Or 17? Or 9?
- What is the goal here? Is it to find that absolute minimum number of appointments that the patient can tolerate without another serious suicide attempt (as this patient had)? Without hospitalization? With medication? Without a recurrence of symptoms? (Which Symptoms?)
- Is dependence bad? What if one hour a week of "dependence" and any accidental psychotherapeutic work that happens to happen along with that dependence comes with the the trade-off is able to live life more fully and productively?
- "Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be." Excuse me??? Oddly enough, it seems to me that the therapeutic relationship is often quite helpful.
- Might I add that very few patients continue for an extended period in weekly psychotherapy -- it's expensive (even with insurance there are deductibles and co-pays), and time consuming. There is some automatic self-selection here that leaves the most vulnerable and distressed of people who even want this.
- Okay, so what do we think about someone from an insurance company who has never met a patient, and generally hasn't reviewed their history and medical record, should determine how much treatment they need? Oh wait, managed care has been around for a while. Now whose idea was that?
You do not want my thoughts, because being polite and considerate to people who are just out to profit from making decisions how to manage cost, not care, are beyond corrupt and contemptible to be respectful to as a person in the trenches.
Again, the silence from the APA on matters like this is beyond deafening, it is equally as contemptible as managed care organizations have colluded with the likes of the APA to be silent and complicit.
And you know it, Dinah, but, being in a fraternity means you have to just suck it up and go with the flow of your "brothers and sisters". Steven Sharfstein's unspoken campaign slogan when he ran to be APA President back in 1995 when he lost to Harold Eist was heard as "managed care is here to stay, deal with it", and how he has run Sheppard Pratt to be completely cooperative with insurers, and how Sharfstein is still a leader at the APA, well...? Hey, he lost in 1995 52 to 48%, so almost half of psychiatrists 20 years ago accepted that attitude, eh?!
Just remember this from a colleague who truly believes that psychotherapy is the mainstay of mental health care, continued majority silence from colleagues only reinforces my belief that a sizeable percentage of psychiatrists are truly whores and cowards. Not directed to you, but, next time in that room of a lot of colleagues, look around and think if I am so off the mark in my attitude...
Joel Hassman, MD
Thank you for this important and thoughtful post.
I am a Canadian psychiatrist, and I have felt happily free to offer time generously to my patients, without very many constraints and monitoring from insurers, government agencies, etc. But in Canada there is more and more pressure to offer brief, more superficial psychiatric care.
I do understand the need to "use time well" in order to care for the greatest number of patients. But I am troubled by an approach to psychiatric care which is narrowly preoccupied with symptom score monitoring, "efficiency," and other elements of medical reductionism. Furthermore, I believe that as this type of thinking becomes more prevalent, a selection bias could occur within psychiatry, in which those who could tolerate this style (i.e. highly medicalized, reductionistic, mechanistic, "efficient," engineering-style practice) would become more prevalent. Those devoted to caring for patients in a more devoted, long-term manner might ever more be seen as eccentric or old-fashioned.
Psychiatric care is different from parenting and from friendship in a variety of ways, but by way of analogy I think that it would be absurd for a parent to "ration" time with children, or cut off parental care to the children if certain symptom score criteria or insurance company regulations were met. Similarly, decisions about time spent in other relationships should not only be made based on monitoring symptom questionnaires!
It is true that thought and discussion should be given to tapering or stopping therapy for any patient, but I believe that it is highly ethical and "right" to not be dogmatic about this, and to accept that many patients desire and need long-term followup.
I can't imagine ever " insisting " on any frame for a therapy relationship -- or for any other type of relationship, for that matter -- that the other person did not clearly wish.
I fully agree that insisting on weekly sessions (or in some cases, several times per week!) should be considered wasteful and inappropriate, unless the person who is coming to these sessions experiences them as beneficial, and freely chooses to continue.
The criteria by which shorter frames of therapy are often supported in research rarely consider chronic, refractory, or complex disorders, rarely consider comorbidities (such as so-called "axis II" problems), and rarely have very long-term follow-up. The research that is evolving with such cases clearly does support longer-term frames of therapy. In my own practice I have often seen people with serious chronic problems, who have languished for years, often with repeated superficial courses of short-term therapy (each of which leading to symptom improvement at the time, but often not persisting), who are deeply grateful to see someone who will see them regularly over the longer term as needed. When things are going better, the sessions taper down to monthly or even every three months, but the point is there is an open invitation to have help as needed. Part of the motivation for this, as well, is simply based upon compassionate respect for the patient and the relationship, not merely respect for symptom score changes or other measures of "progress" which for some chronically suffering patients do not change a lot. In many areas of medicine, such as in geriatrics, oncology, cardiology, and palliative care, the role of the physician can be more one of connection, support, simple kindness, relief of simple problems of the day, etc. without necessarily being able to offer "cure".
A strict focus on symptom-score reductionism would make this type of open practice more difficult to offer, and I believe it would lead to a more impersonal, mechanistic style of therapy culture, which in the long term would be very harmful to patients.
I don't think insurance should cover endless therapy just because a therapist and patient say it's helping. I would have defended the first therapist I saw because I was knee deep in it and could not look at it objectively. Despite the fact that he was destroying me financially, crippling me emotionally, and I was continuing to deteriorate under his care I dutifully went to my weekly therapy appointments. I could not see what was happening at the time. It actually took people who cared about me intervening to get me out of that situation. Insurance should not have been expected to cover that.
I think insurance should be able to ask for evidence that therapy is helping the patient. I think that's reasonable. My concerns about endless therapy is that it may rob the patient of ever reaching out to other people for assistance. If the therapist is there for the patient week after week after week where is the incentive to turn to other people? Where is the incentive to make friends if you are always there for them?
Maybe insurance should allow more than 12 visits a year, but I definitely do support a limit on it.
With regard to scheduling sessions and length of treatment, two things seem particularly relevant to me; In the therapy the focus should be on getting better, period, and, that focus should extend beyond the discussion. Talking is good for insight and a therapeutic relationship is good for healing the soul. But shifting what we do day to day, including perhaps developing some soul healing relationships outside the therapy office, will wrench most of us out of a holding pattern of dependency on a professional.
Some people will benefit from long term therapy, some from intermediate term, some from short term. Some benefit best from periodic therapy over the life span. Depends on the person and the illness involved. A review of progress should be done from time to time - if not in session with the psychiatric or therapeutic provider, at least on one's own. If one is in weekly therapy for a great length of time without significant improvement, it's time to look at what's going on there.
We need to remember that psychiatrists and psychotherapists are not gods, they are humans with their own needs and motivations. They may have a lot of knowledge and perhaps a lot of empathy but no one actually knows what's going on inside someone else's head and heart. So while their guidance can be very valuable it can also be fallible. Usually it's a combination of both, even with the best of them. We ourselves are responsible for accepting what's helpful and rejecting what's not.
We should also remember that medical insurance, while beneficial, does not entitle us to endless expenditure. Insurance companies do have the ultimate goal of maximizing their own profits while spreading the cost of our treatment among our fellow citizens. It's a terrific blessing to be able to focus just on getting better but at some point we also have to accept the realities that this is how it works.
If I had my way, there would be no profit from treatment of medical or mental health problems. I can't imagine how to create such a system but, in any case, that's not the world we live in now.
While I think the tone of this piece is condescending and lacking in sensitivity, the author does have a point. A major goal of therapy should be to develop outside supports, but this isn't as simple as one may think. People often present in therapy with no one in their life that they feel they can talk to; Others really are alone. Helping someone develop relationships in a meaningful way can be incredibly difficult, bordering on next to impossible. Therapy can become a paid friendship of sorts, one that the therapist often underestimates. With that friendship may come a dependence, understandably. The question is, what does a therapist or psychiatrist do to help the patient through this. A client with crippling social anxiety or abandonment issues may be helped in the moment, but not after the therapeutic relationship ends. I could even say that many people end up worse than they were before starting treatment. So maybe the insurance companies have a point. Once q month indefinitely or even every other month is reasonable it the patient feels the need for check - ins, and I doubt insurance or the clinician would see a problem with that. It keeps the relationship in perspective yet allows the client to still feel safe. Anything more than that on a long term basis (meaning after a year or two) may be a red flag that treatment is not working.
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