Dilemmas of cash-based practice

cashI write in response to a recent post on KevinMD and the comments that followed. A primary care physician named Ashley Maltz discussed advantages and disadvantages of a cash-based practice. I appreciate her evenhanded tone: she prefers this model yet expressed concern for patients who can’t use it. In the comments section, several physicians extolled the virtues of cash-pay, but patients were mixed. It’s attractive for those who can afford it, while it worries, and maybe angers, those who can’t.

I enjoy the personal and patient benefits of a mostly cash-pay psychiatric practice (I also see some patients under Medicare). I like running my own small business, keeping clinically useful paper charts as opposed to a ponderous EHR, and protecting my patients’ privacy.  Billing is simple enough that I do it myself. There is also an argument for keeping the relationship dyadic, i.e., 2-person, in psychotherapy. Third party payers can complicate the therapeutic relationship in a domain where clarity is paramount.  Most of my private practice colleagues likewise avoid insurance panels.  It’s become the norm in my field.

Yet we’re all painfully aware that most of the seriously mentally ill can’t come to our offices.  They are relegated to county clinics, training settings, and to the rare private practitioner who still accepts public insurance.  Like Dr. Maltz, I’m saddened that

those on Medicaid or disability programs cannot be seen for cash by medical providers for medical care. Most of these people do not have the financial means to seek alternative types of care. Thus, they are seen in large community clinics with overworked providers and limited resources.

Some critics of cash-based psychiatric practice exaggerate, painting a picture of high-society shrinks getting rich off the worried well.  They point to real or imagined $400/hr psychiatrists calming the Silicon Valley nouveau riche. Others like Allen Frances M.D. provide a more balanced critique, noting that individual psychiatrists gravitate toward more functional patients, but that we are only a small part of a very large puzzle.  It appears that as a society we prefer not to pay for treatment of the seriously disturbed, but only for the jails and prisons they occupy after committing minor property and lifestyle crimes due to their condition.

Our situation in psychiatry is a harbinger for primary care.  There’s no denying the advantages of cash-based practice; it serves both doctors and patients very well.  Yet cash-based primary care practices, like psychiatric practices, exclude many patients who can’t afford them. They can’t comprehensively serve the primary care or psychiatric needs of a population.  Even more obviously, almost no one can pay out of pocket for more elaborate medical care, such as major surgery or a lengthy ICU stay.

There’s a basic tension between health care as a private transaction and health care as a public good. Regarding the former, we can show our compassion by offering some free or low-fee care, or by treating some publicly insured patients under Medicare or Medicaid. This way we avoid elitism and do our part for the less fortunate. However, we must recognize that no matter how charitable we are as individual physicians, many more are in need of our services than our charity can accommodate. The private transaction model of medical care cannot save sick people from dying in the street. Universal access to health services is needed.

While taxpayer-funded Medicare and Medicaid cover many patients who cannot otherwise afford care, our current backstop is EMTALA, the 1986 federal law requiring hospital Emergency Departments to evaluate and treat emergencies regardless of ability to pay. According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care now goes uncompensated, costing hospital systems tens of billions annually. Much of this cost is shifted to paying patients, inflating medical bills for everyone else. One way or another, society (i.e., we) pay to keep our fellow Americans alive and relatively well. It would be far more economical, not to mention humane, to offer universal access earlier, before health problems progress to emergencies — just as it would be to treat the seriously mentally ill before they need to be imprisoned.

It’s no surprise that many patients who are otherwise sympathetic to the plight of demoralized, burned-out doctors draw the line at a cash-based care model that excludes them. In order to ally with these patients, those of us with cash-based practices should at minimum acknowledge the need for a two-tier model, public and private. Better yet, we need to think hard about who provides services in the universal-access public tier. Should this be all of us at some point in our careers, i.e., a type of “doctor draft” or public service requirement? Should these services be ceded to PAs and NPs? Or can we “let the market decide”, such that these services are provided by physicians who aren’t sharp, ambitious, or economically secure enough to hang a shingle — or for whatever reason prefer not to?  These hard questions must be answered if we’re to be intellectually honest and admit that the physician’s role in society is more than entrepreneur.

Image courtesy of sheelamohan at FreeDigitalPhotos.net

Choose your actions, not your feelings

flowers1Again and again in therapy I find myself emphasizing the distinction between feeling an emotion and acting on it. Many patients, and non-patients too, take undue responsibility for their emotions, as though feelings were volitional behaviors, the result of a choice.  Often there is a stated or implied should: “I should feel this, not that.”  Note how commonly people blame themselves for feeling, or not feeling, a certain emotion:

“I should be more grateful after all she’s done for me.”

“It’s wrong of me to get angry at other drivers, they’re just trying to get home too.”

“It’s silly to mourn the death of my dog.  He was just a pet.”

When feelings are viewed this way, we hold ourselves to an impossible standard.  We expect to control what is essentially not ours to control.  If we prefer chocolate ice cream to strawberry, no act of will or rational choice can convince us otherwise.  When someone or something strikes us as irritating or funny or repulsive, these reactions arise unbidden.   We do not choose to feel depressed, and cannot opt to feel happy.  Sexual attraction to one type of person, and not another, occurs whether we like it or not.  It’s true that we can gradually temper negative emotions, particularly global ones such as depression and anxiety, by willfully altering our thinking — cognitive behavioral therapy (CBT) is based on this idea — and even more reliably by choosing situations and relationships that promote feelings we want.  But on a moment-to-moment basis, feelings come and go of their own accord.

The mistaken belief that one can and should be in control of felt emotions leads to unwarranted moral condemnation, a sense that having certain feelings is the mark of a bad person.  Self-condemnation of this sort is tragic and can last a lifetime.  By the same token, it is unhelpful to criticize or overanalyze the feelings of another, e.g., one’s spouse or child.  He or she didn’t choose those feelings, and may not know why they arose.  Calling on another to account logically for feelings often has an aggressive edge; it banks on the fallacy that emotions are rational and controllable when they are not.  Analysis of emotions is quite valuable — if done in the spirit of curiosity, not criticism.

Curiosity is the healthy response to a new awareness, including awareness of a previously unrecognized emotion.  It is a new piece of self-knowledge.  Emotions arise in the limbic system, the non-verbal, more primitive brain centers we share with other animals, not from the neocortex, the seat of rational thought. The neocortex “notices” and is affected by activity in the limbic system. This is why we can’t always immediately name or identify an emotion when we feel it, and why strong feelings can temporarily flood or short-circuit rational thought.

Actions are different.  Unlike emotions, they are, or should be, essentially under our control.  (Just as willful application of CBT can influence emotions, behavior driven by strong emotion sometimes feels compulsory, e.g., crying when feeling sad.  However, both of these are exceptions that prove the rule: feelings aren’t chosen, behaviors are.)  Anger or sadness or lust do not, in themselves, compel anyone to do anything.  Our ability and responsibility to exercise choice occurs when deciding to act, not at the point of having the feeling.

Our actions have real consequences for ourselves and others.  They can get us fired or arrested or divorced.  They can hurt our loved ones and coworkers.  This is why it is so crucial to differentiate behavior from internal feelings and emotional states.  Yet many fail to make this distinction, and suppress or deny feelings, often imperfectly, out of fear of the consequences resulting from acting on that feeling.  According to traditional psychoanalytic theory, unconscious effort to avoid awareness of these “dangerous” feelings results in anxiety and other symptoms.  Much of the value of psychoanalysis and analytically based psychotherapy is experiencing emotions in a safe setting, by separating this experiencing from adverse behavior and its consequences.  (When this separation fails to occur, the technical term is “acting out” if the adverse behavior occurs outside the therapy session, and the lesser-used “acting in” if it occurs within the therapy itself.)

Distinguishing feelings and actions is part of the “special sauce” of psychoanalysis and dynamic psychotherapy.  As with free association, transference, the relative anonymity of the therapist, and other aspects of dynamic work, I believe nothing is gained by keeping patients in the dark about the process.  When a patient speaks of emotions as though they were volitional actions, or fails to separate feelings from behavior, I point it out in the hope it leads to insight and greater self-knowledge.


Oneupmanship is the art or practice of successively outdoing a rival, staying one step ahead by ​proving superiority.  It is straightforward competition, whether playful in tone, as in friends verbally sparring, or deadly serious.  Presidential candidate Donald Trump employs oneupmanship incessantly, pointing out that he is richer, more successful, and more popular than his rivals and detractors.  While his tactics are debatable, their intent is clear.

The converse is in need of a parallel term, and the obvious choice is onedownmanship (or onedownsmanship, with an “s” in the middle).  This neologism appears sporadically in recent decades, including in a 1972 ad for an economy car, as an approach to conducting interviews in school consultations (Ingraham, 2000), and to describe faking outrage and injury in sports.  These uses coalesce around the concept of gaining advantage by appearing weak, victimized, dim, or inferior.  Unlike oneupmanship, it’s a tricky ploy, a surprise attack of sorts.

Onedownmanship is common, though it often goes unrecognized.  Anyone who elevates a job decision to avoid making it oneself (“well, you’re the boss”) employs a version of it.  As a medical intern, I was often asked to draw blood from the most difficult veins because I was “the doctor” — even though the nurses had far more experience drawing blood than I did.  Any argument that starts with, “If you’re so smart [or experienced, skilled, etc] …” turns the superiority of one’s opponent against him.  The Japanese martial art aikido relies on a form of onedownmanship, conceding that the attacker’s power is superior, yet ultimately and surprisingly neutralizing it.  TV detective “Columbo” solved cases by feigning ignorance.  Humblebragging is a new twist on onedownmanship.

Moving from these overt and often conscious examples, we enter a larger realm where onedownmanship may be partly or fully unconscious.  Controlling others through weakness is a typical dynamic in alcoholism, where others are manipulated into codependency, and in dysfunctional families where an anxious or easily hurt person causes others to “walk on eggshells.”  As I once wrote, sometimes a bull wanders into a china shop; other times the bull is minding its own business when someone builds a china shop around it.

Those who claim special entitlement by dint of physical or mental disability may be employing onedownmanship, although this highlights the trickiness of the concept: we may hurtfully “blame the victim” if we even entertain the possibility — and be unfairly manipulated if we don’t.  The same holds at the larger societal level, where claims to special consideration based on one’s status as member of an ethnic minority or another historically disadvantaged group is cause for endless and heated political debate.  A backlash deriding the “culture of victimhood” now stands in opposition to such claims.

Onedownmanship presents its targets with a dilemma.  Ignore or discredit overt weakness and inferiority, and one risks being a thoughtless boor, hitting a victim when he’s down.  This is its paradoxical power.  As in the converse case of oneupmanship, onedownmanship is therefore often challenged by like means, creating a rivalry between two sides in the same stance.  In the latter case a “race to the bottom” may occur, with each side claiming more disadvantage, weakness, and/or victimization than the other, e.g., “my minority group is more victimized than your minority group.”

Contests either up or down are normally bounded by healthy narcissism, i.e., self-pride.  That is, the heights of self-promotion (oneupmanship) as well as the depths of self-denigration (onedownmanship) are limited by the shame accompanying either extreme.  Pathological narcissism — which can appear either as excessive self-pride or none at all — erases these limits, allowing shameless oneupmanship or onedownmanship to proceed to the point of absurdity.

“Brain disease”: the anti-psychiatrists respond

I don’t avoid reading opinions strongly critical of psychiatry. They help sharpen my reasoning skills. It’s always possible they might alter my views in some way.  And like most everyone, I consider myself openminded and receptive to criticism. However, after years of reading Thomas Szasz, Robert Whitaker, and the screeds of the less articulate, after perusing the leaflets and poster displays of the protesters at APA conferences, I’ve heard most of the arguments by now. I rarely engage with such harsh critics. As I’ve written elsewhere, there has to be a shared foundation, some agreed-upon axioms, for a dialog to take place. Otherwise it’s just a shouting match.

My own views are pretty stable at this point. I’m critical of many aspects of psychiatry: I blog about sloppy thinking in the field, the limitations of DSM nosology, the overuse of pharmaceuticals. I teach psychiatry residents to think psychologically and how to practice ethically. But unlike anti-psychiatrists, I don’t consider psychiatry a hoax or an evil injustice. If I did, I’d find another career. And while it isn’t hard to cite cases of psychiatric mismanagement, it’s a good deal easier to cite cases of psychiatric benefit. We help people far more than we harm them. Truth be told, I’m proud to be a psychiatrist.  If I wasn’t, I’d do something else.

Philip Hickey PhD is a retired psychologist who blogs on behaviorism and mental health. His articles are reposted on Mad in America, a popular website created by Whitaker that is highly critical of psychiatry. Dr. Hickey wrote a lengthy critique of my December 12 post on whether psychiatric disorders are brain diseases. I considered replying in the comments section on MIA, but the anti-psychiatric echo chamber there assures it would fall on deaf ears. So instead I’ll follow up here.

In composing my last post I was more concerned about slamming luminaries in my field than worrying about how anti-psychiatrists might react. The piece, after all, is critical of language by prominent psychiatrists. Consequently, I granted that schizophrenia and several other named disorders look primarily biological in nature, even though this hasn’t been proven. Dr. Hickey agrees with me on first impressions, which was all I was claiming. However, he then goes to great lengths to refute this rather trivial bone I threw to the biological psychiatrists.  I could now respond to each objection point by point — schizophrenia does affect a diverse array of mental functions, not merely the few in the DSM criteria; neuroanatomical changes go well beyond mere “brain shrinkage”.  But why bother?  I’m not here to argue for the biological foundations of schizophrenia.  Indeed, doing so too well weakens the main point of my prior post.  Note the insidious dynamic: confronted by someone so “anti” I’m called upon to be more “pro,” even though this serves neither of us.

I also predicted, without offering much in the way of argument, that a few severe psychiatric conditions will eventually be shown to have biological causes. Dr. Hickey vehemently disagrees, and holds that behaviorism and learning theory account for these conditions. That’s wildly implausible, but no matter. The truth is, no one really knows.

Dr. Hickey wanders into the weeds of DSM diagnosis and labeling, a topic I didn’t address at all, other than to use the common terms for psychiatric maladies.  I don’t object to cautious circumlocutions like “feelings and behaviors currently lumped under the controversial label ‘schizophrenia’.” It just takes longer to write. Whether schizophrenia is one disease or many (or not a disease at all), whether the DSM criteria are valid or way off-base, whether some of the features called schizophrenia are actually iatrogenic — none of this matters for my argument. The point remains that the clinical presentation we call schizophrenia looks like biological dysfunction even though its etiology remains unknown.

Dr. Hickey took pains to explain in great detail the limitations of reductionist thinking, how new properties emerge at higher levels of organization, and how it is a category error to refer, say, to psychology at a molecular level.  This is because I misspoke in trying to convey the reductionist viewpoint. I wrote that, in theory, “all psychopathology can be reduced to aberrant electrochemical events, i.e. brain disease.”  That’s not true; a learned phobia is a ready counterexample.  It’s particularly unfortunate that I made this mistake, as it confirms the worst fears of those who believe we psychiatrists are mired in primitive reductionism.  Actually, Dr. Hickey and I agree here.

Now having said that, although some psychopathology arises solely psychologically, it’s also common for genetics or biochemistry to underlie aberrant psychological functioning.  This is the case for the many known diseases such as brain tumors, neurosyphilis, and lead poisoning that were once wrongly thought to be purely psychological (or demonic).  There is no reason to assume that all such discoveries are behind us.  Rather than digging one’s heels into radical behaviorism, radical neurobiology, or radical something-else, isn’t it more honest simply to say we don’t know what the future will reveal?

I’ll end by noting that anti-psychiatrists object to any pathologizing of behavior as stigmatizing and dehumanizing.  Unfortunately, it’s inevitable, and not just by psychiatrists. Paranoid psychosis — a behavioral description, not a diagnosis — may result from drugs, sleep deprivation, brain tumors, or extreme stress. Whatever the cause it’s still an unpleasant, dysfunctional state that differs markedly from the usual way human minds work. We can choose new, less stigmatizing names for such states, but we will never give up describing ourselves and others in value-laden terms. The conditions we call mental illnesses — and it’s interesting to ponder what exactly counts — are usually miserable for the sufferers, and arouse pity and fear in observers. It’s not realistic to imagine we’ll ever carefully tiptoe past naming such states.

I thank Dr. Hickey for his close reading of my article, and for calling it interesting and thought-provoking, probably the highest praise a psychiatrist can ever expect from such a critic.  I note that he calls me a typical psychiatrist when he disagrees with me, atypical and rare when we agree.  I would respectfully suggest that I’m not that rare.  Most of the psychiatrists I know have no rigid orthodoxy, no ideological axe to grind.  Most see only voluntary patients who come for relief of distress — and end up feeling relieved.  All value psychotherapy whether or not they provide it themselves, and all add a healthy dose of common sense to their specialized training. Psychiatry has much to improve, but that will only happen when supporters and critics engage in dialog, not a shouting match.

Are psychiatric disorders brain diseases?

brainSome maladies that attract psychiatric attention are unequivocally brain diseases.  Huntington’s disease.  Brain tumors.  Lead poisoning.  However, these are not psychiatric diseases.  Huntington’s is a genetic abnormality diagnosed and treated by neurologists.  Brain tumors are managed by neurosurgeons and oncologists.  Lead toxicity is treated by internal medicine.  Indeed, a long list of medical and surgical diseases include psychiatric features: stroke, anoxic brain injury, meningitis, lupus, diabetic ketoacidosis, and febrile delirium to name a few.  One important job of the psychiatrist is to recognize such problems, treat the psychiatric manifestations when appropriate, and refer the case to one’s colleague — neurologist, internist, surgeon — for treatment of the underlying problem.

Of the conditions deemed inherently psychiatric, some seem rooted in biological brain dysfunction.  Schizophrenia, autism, bipolar disorder, and severe forms of obsessive compulsive disorder and melancholic depression are often cited.  It’s important to note that their apparently biological nature derives from natural history and clinical presentation, not from diagnostic tests, and not because we know their root causes.  Schizophrenia, for example, runs in families, usually appears at a characteristic age, severely affects a diverse array of mental functions, looks very similar across cultures, and brings with it reliable if non-specific neuroanatomical changes.  Even though schizophrenia cannot be diagnosed under the microscope or on brain imaging, it is plausible that a biological mechanism eventually will be found.  (The same type of reasoning applied to AIDS before the discovery of HIV, and to many other medical diseases.)  A similar argument can be made for other putatively biological psychiatric disorders.

Lately, however, some big names in psychiatry have taken a more ideological stance, declaring that psychiatric disorders in general are brain diseases — right now, no further proof needed.  Dr. Charles Nemeroff, widely published professor and chairman of psychiatry at the University of Miami Miller School of Medicine, writes:

In the past two decades, we have learned much about the causes of depression. We now know from brain imaging studies that depression, like Parkinson’s disease and stroke, is a brain disease.

Dr. Thomas Insel, recent director of the National Institute of Mental Health (NIMH) wrote:

Mental disorders are biological disorders involving brain circuits…

Psychiatrist and Nobel laureate Dr. Eric Kandel says:

All mental processes are brain processes, and therefore all disorders of mental functioning are biological diseases.

These claims by prominent psychiatrists agitate critics.  No biomarker for any psychiatric disorder has yet been identified. Genetic vulnerabilities have been discovered, but nothing resembling a smoking gun.  Functional brain imaging reveals biological correlates of mental impairment, not etiology, and no such imaging can diagnose a specific psychiatric condition.  Our best account for most mental disorders remains a complex interaction of innate vulnerability and environmental stress, the “diathesis-stress model”.  These psychiatric leaders know the research as well as anyone. How can they call psychiatric disorders brain diseases without scientific proof?

The brain mediates all mental activity, normal or not.  Consequently, any psychiatric intervention — or influential life experience — acts upon the brain.  This is not a new discovery.  A century ago, Sigmund Freud wrote “Project for a Scientific Psychology,” in which he proposed that ultimately the mind would be understood biologically.  No modern studies of brain tissue, no genetic testing, no advanced brain imaging were needed for the father of psychoanalysis to posit that mental activity arises from biology.  It is a philosophical position, monism as opposed to Cartesian dualism, not a scientific finding.  Note that Freud could then have made it a point to declare, as Drs. Insel and Kandel do now, that all mental disorders are biological diseases.  No additional science was required even a century ago.

He didn’t because there was nothing to gain.  The best treatments at the time were psychological, not biological.  There was no grant money at stake, no research agenda to support.  The status and livelihood of early psychoanalysts did not depend on their treatment being biological.

Psychiatric “brain disease” is neither an exaggeration nor a lie.  It does not require scientific proof — and brain imaging has neither strengthened nor weakened the case.  For as long as one is not a philosophical dualist, it is surely true.  In theory, all psychology can be reduced to electrochemical events in brain cells. All psychopathology can be reduced to aberrant electrochemical events, i.e., brain disease.

Without elucidating the causative mechanisms, however, this reductionism amounts to little more than political rhetoric.  Calling psychiatric disorders brain diseases serves no clinical or research purpose, it only serves political ends: bringing psychiatry into the fold as a “real” medical specialty, impressing Congress and other funding sources, perhaps allaying stigma.  As a tactic it smacks of insecurity and self-aggrandizement, wholly unbefitting a serious medical specialty.

Freud’s psychoanalysis acts on brain cells, and ultimately alters chemical bonds in those brain cells.  We could rename psychoanalysis and psychotherapy “verbal neuromodulation.”  But to what end?  A reductionistic account of this sort, festooned with pseudoscientific verbiage, has no practical significance.

Brain research is a young field.  It should be vigorously pursued for what will surely be learned.  If history is any guide, many conditions currently considered psychiatric will eventually be explained biologically — and ironically, they will no longer be psychiatric conditions, as was the case with Huntington’s disease, brain tumors, lead poisoning, and many other diseases that now belong to other medical specialties.

Stumping for psychiatry as clinical neurobiology will be justified when basic research in this area affects clinical practice. Until then, “brain disease” is only a philosophical technicality, a spin, to give our clinical work and the institution of psychiatry an air of scientific credibility.  Particularly in light of how diseases leave psychiatry once they are well understood, the field should embrace uncertainty, not preempt it with the premature use of brain disease language.

Image courtesy of dream designs at FreeDigitalPhotos.net


therapyAs we grow into adulthood, each of us develops a personal comfort zone located on the continuum between paranoia and gullibility.  A few of us are highly suspicious by nature, a few are unwitting dupes; most of us are in between.  Mental health professionals are no exception, and it shows in our work.  Is a request for tranquilizers or stimulants legitimate, or are we abetting a substance abuser? When told of horrific past abuse, do we believe every word, or do we allow for possible exaggeration or distortion?  Credulity and skepticism exist in dynamic balance: too much of either impairs clinical work.

Our pride animates these assessments.  On the one hand, we see ourselves as sensitive and caring.  Empathy seems to require believing people’s stories, to be “on their side.”  On the other hand, we feel vulnerable and ashamed when fooled (as we sometimes are), and safer and proud of ourselves when we don’t fall for it.  Fueled by pride, proponents defend various points on the credulity continuum.  Some psychiatrists declare that they never prescribe tranquilizers because doing so invites manipulation by drug-seeking patients.  Conversely, some equally proud therapists never question the meaning of their clients’ cancellations, because doing so “lacks empathy.”

Like most doctors, I’m a critical thinker by nature.  This is a nice way of saying my comfort zone lies slightly closer to paranoid than gullible.  The perverse logic of the Freudian unconscious thus comes naturally to me.  Patients who claim complete marital satisfaction may be in denial, or at least recalling selectively.  Impassioned pronouncements of adoration may be “reaction formation,” telegraphing the exact opposite.  Dramatic hatred or disgust may hide a fascination, even an attraction.  The trick here, lest we treat our prejudice and not the real person in front of us, is to entertain such possibilities without becoming too attached to them.  It’s also important to distinguish empathy from blind agreement, belief, or endorsement.  I can empathize with a delusional person’s fear and panic without endorsing the delusions themselves.

A funny thing happened to me the other day.  A mental health professional in a remote land emailed me, seeking online psychotherapy for himself.  I was flattered that this colleague searched the world over and chose me.  He sought exactly the type of psychotherapy I like to conduct.  If not for distance — which would ultimately be a deal-breaker in any case, as I consider online therapy a poor substitute for the in-person kind — it seemed almost too good to be true.  Thus, wary of falling prey to my own pride and narcissism, I immediately suspected a scam.   After all, if something looks too good to be true, it probably is.  I imagined this email went to many therapists, and that it was a con, like those Nigerian emails that promise great riches and are now an internet cliche.  This is precisely what con artists do so well: appeal to one’s greed or pride.  They hook you, then reel you in.  I wasn’t going to let that happen.

As a savvy internet user, I knew just what to do.  I found the person online, and wrote him directly via his website.  I included the bogus email I received, to let this far-flung colleague know I wasn’t about to be taken in, and also that his identity was likely stolen for nefarious purposes.  I was rather proud of myself.

It turned out the original email was legitimate.  Adding injury to insult, I also violated the privacy of my correspondent, who doesn’t read his own website email.  I had unwittingly turned an earnest request into an awkward encounter by being too incredulous and self-protective.  In rushing to defend my pride against an imaginary threat, that very pride distanced me from someone who sought my help, and even hurt him.  It was an important and humbling lesson.

I sometimes share with patients that there is no disproving paranoia; it’s the safer stance at any moment.  Why ever let your guard down? Unfortunately this safety, which is sometimes only illusory in the end, comes at significant cost: isolation, viewing others as threats, constant fight-or-flight tension.  Sometimes this is the best self-protection we can muster in the aftermath of emotional abuse or betrayal.  However, it’s not the best we can do as human beings.  A degree of credulity, in contrast, brings vulnerability.  We can be hurt, humiliated, and diminished.  But it also allows relatedness, connection, and love.

In order for dynamic therapy to lead to change, psychotherapists must get caught up in our patients’ dynamics.  Not too much, such that we lose perspective and act like everyone else in the patient’s life.  Nor too little, such that no genuine connection or relatedness occurs.  Both parties ideally permit themselves enough credulity to be drawn into emotional engagement, while maintaining enough skepticism (or “observing ego”) to note what is happening.  Ideally, that is, for we therapists are the more obliged to maintain a watchful eye, and must balance credulity and critical thinking more carefully.

Logical argument is unlikely to convince the paranoid to be more credulous, nor the gullible to be more skeptical.  Our comfort zones are established early and unconsciously, based on emotion not logic.  The emotional power of dynamic psychotherapy and psychoanalysis, as well as close, healthy relationships in everyday life, can nudge our comfort zone in a direction that serves us better — and serves our patients better, if we happen to be psychotherapists ourselves.  Meanwhile, reflecting on prideful attachment to a particular stance on this continuum may offer us perspective and more flexibility.

Image courtesy of Ambro at FreeDigitalPhotos.net

Hiring the one-armed surgeon

surgical_gloveTwo of the most commented posts on my blog are about charging patients for missed sessions and how psychotherapies end.  As there is no single correct approach to either of these, there’s plenty of room for practices legitimately to vary, and plenty of room for patients, i.e., most of my commenters, to express their likes and dislikes.  By my reading, many commenters assume that cancellation and termination policies mainly feed their therapists’ wallets; they tend to dismiss clinical rationales that are not obvious common sense.  I’m often drawn to defend the field and their therapists, and to point out that insight doesn’t always come painlessly.

Other times, though, I’m just dumbfounded (or the more hip term, gobsmacked).  One therapist reportedly starts sessions ten minutes late on a regular basis, and repeatedly cancels with less than a day’s notice for home furniture deliveries and the like.  Another conducted a therapy session “lying half dead on the couch. Her eyes were literally half closed – she was sick but didn’t call ahead of time to reschedule.” Yet another disappeared in mid-treatment and was later found to be practicing without a valid license.  Another psychotherapist left a voicemail at 6 pm to cancel a 7 pm appointment because her 6 pm cancelled and she wanted to go home.  And most recently, a patient wrote that her therapist revealed her own diagnosis of borderline personality disorder “with narcissistic overlay,” then went on to cancel the writer’s regular weekly therapy appointment, without advance discussion or notice, following an apparent misunderstanding.

It’s important to consider that these reports may be distorted.  That is the nature of transference.  For example, patients have accused me of “yelling” at them when I clearly had not; some are certain that I want them to end treatment when that isn’t true.  It’s possible that these therapeutic missteps are fantasies or exaggerations of the truth.  But I have no reason to think so.  The reported behavior sounds all too human.

Why do therapists — my colleagues — act like this?   We all have momentary lapses due to fatigue or personal crises.  These are unfortunate but usually rare and short-term.  A good therapist gets back on track quickly, acknowledges (and apologizes for) any hurt feelings, and repairs the damage done.  Sometimes a particular patient really “pushes our buttons,” i.e., stirs up strong countertransference, and we lose our composure as we are swept up in the patient’s narrative.  Ideally, these enactments are also brief, lasting only until we step back and gain perspective.  According to some schools of psychotherapy, they may even be helpful.  However, since countertransference can be partially or wholly unconscious, they may unfortunately go on much longer than ideal.  The therapist’s own therapy may mitigate, if not eliminate, these reactions.

Beyond this, however, some therapists seem impaired.  A psychotherapist who has little tolerance for strong emotion, who routinely engages in power struggles, who can’t stand rejection, who is excessively self-interested (or self-sacrificing!), or who has outsized needs for adoration or deference — well, that’s like hiring a one-armed surgeon.  (Not to denigrate any actual one-armed surgeons out there, but you have to admit it’s a disadvantage.)  Certainly in traditional dynamic psychotherapy, and to some extent in any professional helping relationship, our own personalities and social skills are part of what we offer.  We need to be healthy enough to “be there” for patients, and not add to their problems.  Surely it’s possible to pursue a career as a psychotherapist even if one suffers “borderline personality disorder with narcissistic overlay.” But it’s a significant handicap, much like the challenges facing a surgeon who is missing an arm.

Don’t get me wrong.  Overcoming such challenges is courageous and noble.  I’d have great respect for a one-armed surgeon if I ever met one.  I have similar respect for those who overcome debilitating psychiatric conditions to pursue their dreams.  But from the patient’s point of view, the idea is not to give the underdog a chance.  The idea is to get help.  Given the choice, most patients would not opt for a one-armed surgeon.  Most would not opt for a psychotherapist who acts in erratic or traumatizing ways.  The difference is that the surgeon’s impairment is obvious and the therapist’s is not.

There’s a cliche that mental health professionals (MHPs) enter the field to figure ourselves out, or to deal with our own inner demons.  Like most stereotypes, it contains a kernel of truth.  What’s important is the degree to which we’ve succeeded in gaining that insight and conquering those demons.  What’s even more important is how our personality affects our patients — however far we’ve traveled and whatever we’ve overcome.