Psychodynamically informed clinical work

In a world of diverse mental health treatments and treatment settings, psychoanalysis and psychodynamic psychotherapy have lost their former prominence.  Only a small fraction of patients have the time, money, and interest to engage in long-term, open-ended mental exploration — even if doing so would get to the root of their problems and lead to lasting improvement.  More commonly, emotional distress is dealt with in emergency departments, in crisis clinics, on the medical and surgical floors of hospitals, in short-stay psychiatric inpatient units, and in non-clinical settings such as schools and prisons.  These settings permit only limited assessment and clinical intervention.  Partly as a result, nearly all have embraced medication and cognitive behavioral techniques.  These treatments are seen as “evidence based” because they empirically decrease, as designed, the discrete signs and symptoms that make up psychiatric diagnostic criteria.  They are, in other words, very good for treating most psychiatric diagnoses.

Treating the person so diagnosed is another matter, though.  No two depressions, psychoses, or traumatic reactions are the same.  An individualized perspective recognizes the person behind the symptoms — and even the person behind the persona.  Knowing patients in depth may uncover why one gratefully accepts care while another resists; why one is consolable while another is not; why one prefers inpatient care while another opts for yoga and herbs.  Two patients may meet criteria for “major depressive disorder, recurrent, moderate,” yet look and act very differently from one another.  Attention to these differences is the strength of psychodynamic treatment, and exactly what is lost as we turn away from it.

Fortunately, psychodynamic understanding is not limited to dynamic psychotherapy per se.  Psychodynamics are everywhere if we look for them.  The way people handle stress, their typical defenses or coping strategies, distinguish one personality from another.   By acting on plausible hypotheses about another person’s conscious and unconscious motivations, we align our efforts to his or her emotional reality, feel more empathy, and help that person meet his or her true needs.

Psychodynamically informed clinical thinking starts with staying awake and paying attention.   It takes no formal training to appreciate that, faced with the same threat, one person laughs it off, another counter-punches, while still another retreats and concedes.  Observing and acting on these personality differences can improve one’s skills as a trial lawyer, a salesperson, or an elementary school teacher.   If attorneys, salespeople, and teachers can enhance their work in this way, surely mental health professionals, and clinicians in general, can as well.  How does the patient relate to the clinician and to treatment recommendations?  How much motivation is there to get well?  How fearful is the patient?  Is it fulfilling to work with this person, or is he or she antagonistic, self-sabotaging, or working at cross-purposes?

The next step is curiosity: why is the patient this way?   From childhood we hear and apply informal explanations for what motivates others.  Psychodynamic theory refines this natural inclination.  It offers principles based in the dynamic unconscious to explain and predict human behavior, and to recognize emotions the patient may not have articulated or even been conscious of.  A prescription can feel generous and caring to one patient, and a brush-off to another; knowing something about the personalities of these patients can guide effective treatment.  The agitated patient in the emergency room may be an assault risk, or just frightened.  Knowing the difference can mean calling Security versus having a calming conversation.  In any setting the clinician can still prescribe the same medications, order the same lab tests, or conduct (or refer the patient for) the same CBT, just with a deeper sense of what the patient seeks, and what is most apt to help.

The final, optional step is to share psychodynamic wonder with patients, i.e., to encourage their own curiosity about themselves.  This is where clinicians differ from attorneys and salespeople: besides providing a service, we also strive to help patients feel and stay well.  Dynamic insight may help a patient better understand herself or himself (“know thyself”), tie together apparently disparate symptoms, and lay out a path to emotional healing.  It doesn’t take a mental health professional with psychodynamic expertise to imbue this curiosity and self-reflection — although it may help.  Minimally, it takes a psychodynamically informed clinician who is willing and able, even when providing other types of assessment and treatment, to see the patient as an individual with unique emotional reactions, a characteristic way of dealing with stress, and a subtle depth of personality that is meaningful and important.  While this perspective would enhance any clinical practice, its absence in any area of clinical psychiatry or psychology is a particularly glaring omission.


Diagnosing Donald Trump

On January 31, 2017, the Psychology Today editorial staff published a well-balanced summary of the debate over whether to declare President Trump mentally ill. While the debate focuses on mental health professionals such as psychiatrists and psychologists who are credentialed to make such diagnoses, the question clearly goes further.  Public commentary following this and other articles expresses outrage — not only at the behaviors and policies of Trump himself, but also at any suggestion that diagnosis is off-limits as a form of political criticism.  We want to be able to call public figures crazy when we don’t like them.  We defend our right to do so.

Criticizing a person’s character, not the content of their arguments, was recognized by ancient Greek philosophers as a logical fallacy: argumentum ad hominem.  Yet the character of powerful politicians seems vitally important.  Does our president have integrity?  Is he trustworthy?  Will he stand by what he says?  There is no avoiding questions of character when global war could result from a leader’s imprudence, irritability, or petty revenge.

Our armamentarium of terms of disapproval is large.  Some are purely moral, terms like “bad” or “evil.”  Some highlight impaired intellect: “shortsighted,” “foolish,” “idiot.”  Some take aim at undue self-interest and self-aggrandizement: “selfish,” “cold-hearted,” “narcisssist.”  There is no clear distinction between putdowns that derive from psychological concepts and those that derive from religious morality and other roots.  It is as legitimate to criticize Trump as narcissistic as it is to say he’s too hot-headed (or inexperienced) to be President.  And it is equally legitimate to argue against these criticisms, if one happens to support him.

Using psychiatric diagnoses — not just psychologically derived adjectives — adds rhetorical weight to one’s critique, particularly, but not only, if the speaker is a mental health professional.  A diagnosis, e.g., Narcissistic Personality Disorder, connotes a carefully considered conclusion based on scientific research — far more than a mere personal opinion.  There is an implied consensus: unbiased experts would concur if they looked carefully at the data.

Critique-by-diagnosis also unfortunately capitalizes on prejudice against the mentally ill, tarring the target with a label that diminishes him and sets him apart from the rest of us.  Diagnosis would not serve as political disapproval if it primarily called forth pity and generosity.  It is offered as disqualification, hardly the thing mental health advocates would want associated with, say, a personality disorder.

The “Goldwater Rule” instructing psychiatrists not to diagnose public figures was promulgated by the American Psychiatric Association to protect its brand.  Psychiatric diagnosis was, and is, already fraught.  Some who are opposed to psychiatry reject diagnosis on principle, while many others fear its negative impacts.  The authority to pass judgment on the mental functioning of others is not to be taken lightly.  By analogy, society would not grant police officers the right to make arrests if they did so for political expediency or to express a strongly held personal opinion.

Little is gained by arguing that President Trump meets criteria for a DSM-5 psychiatric disorder.  Other terms of disapproval can be just as powerful, without the liability of adding to psychiatric stigma, dulling the tools of our trade, and popularizing the use of psychiatric terms to double for everyday personality descriptions.

It also makes no practical difference. Diagnosis is mainly for treatment, clearly not the point here, and Mr. Trump’s character is what it is.  (And lest we forget, many people like it.)  The public will continue to use terms like “liar” and “idiot” and even “narcissist” for disliked politicians.  As private citizens we mental health professionals may do so as well — with the added advantage that we’re more apt to use psychological terms accurately, and can sometimes extrapolate character style to predict future behavior.  But all this is different than diagnosis proper.  Diagnosis is a sharp instrument for helping patients, but only a blunt weapon in political discourse.

Reposted from

Christmas 2016, a fable

starry reindeerNo one recalled when Rudy joined the teamsters, it may have been several seasons back.  Awkward and quiet, he mostly kept to himself.  The other guys avoided Rudy.  No one ever asked him to join their casual poker games, no one ever invited him to hang out after work.  He wasn’t harassed exactly, but their barely hidden disdain was depressing background noise.  Every day or two he caught a hint of derisive laughter; he imagined himself the butt of a joke he hadn’t heard.  It was clear the gang didn’t like him, and Rudy was pretty sure he knew why.  It was purely an appearance thing.

You wouldn’t think it would matter much to a bunch of young bucks — and the occasional doe, like Vixen — hauling cargo.  But Rudy’s nose glowed flamboyantly red.  It drew attention wherever he went.  His coworkers, if they thought about it at all, assumed it was from drinking too much, although they also feared a communicable disease, an infection maybe.  In any case, they didn’t ask, and in his shame, Rudy didn’t tell.

The truth was that Rudy was transitioning.  Although he was raised in a traditional reindeer family, childhood tales of flight had fascinated him.  In school he took a special interest in winged creatures: birds, bats, and insects of all types.  He imagined soaring above the tundra, smoke wafting from tiny village chimneys below.  He wanted to be an entomologist, an expert in insects, winged ones specifically.  But his grades weren’t good enough for college.  So he contented himself with his butterfly net, and with catching fireflies in a glass jar on warm summer evenings.

He felt a special kinship with fireflies, the way they hovered in place, their flashing glow signaling to others through thin air.  Always shy, Rudy wished he too had a way to signal to others, to reach across the void, to connect.  The longer he gazed into his jar, the more yearning he felt: to fly, to hover with his mates, to glow with an organic light from within.

After graduating, Rudy joined the air-cargo team up north.  It was seasonal work but the pay wasn’t bad.  His boss was always in a jolly mood, and he didn’t feel quite so alone with his team.  Best of all, the job fulfilled his dreams of flight.  Still, he kept thinking about the fireflies: their peaceful, carefree lives, the way their souls literally lit up the space around them.  He wanted to be one.

It isn’t easy for a reindeer, even one running air cargo, to transition to firefly.  Wings were out of the question; he was no Pegasus.  Fortunately, with dedicated internet searching he found tips and suggestions.  There was even a small online community of quadrupeds with an interest in — some called it a fetish for — chemiluminescence.  Posting anonymously, Rudy was welcomed in.  For the first time, his preoccupation didn’t feel so weird.  He learned that a glowing nose could be achieved with practice (and without scary, expensive surgery).  And practice he did, day and night, until he glowed just like the fireflies of his childhood.  Except in red.

Only last winter did Rudy muster the courage to come out at work.  He wasn’t expecting a warm reception; after all, he wasn’t that popular to start with.  Yet the blunt ostracism of the others shocked him.  He was still the same Rudolph inside, glow or no glow.  He loved the air runs, but started to think about different work — leading nighttime tours of the tundra, maybe, or helping with the caribou migration.

Then one foggy evening before a big run, the boss came over.  While he rarely talked to Rudy directly, he had watched the painful shunning all along.  He asked Rudy to lead the run.  This was partly practical — Rudy’s glowing nose would cut through the foggy gloom — but also to let the others know the management didn’t approve of workplace discrimination and prejudice.  After all, the boss was one of the first in the region to employ elves, another historically disadvantaged group.

Rudy took great pride in leading the run, which by all accounts was completed under budget and ahead of schedule.  And the wisdom of the boss, it turned out, shined even brighter than Rudy’s nose.  For this single event turned the glowing nose from a shameful liability to an asset.  The other guys now accepted Rudy and even celebrated the diversity he brought to the team.  Instead of making jokes at Rudy’s expense, they joked instead that they’d all go down in history as the only air-cargo team led by a four-hooved firefly.  They laughed with him, not at him, and that made all the difference in the world.  Several confessed that they too had dreamed of flight when young.  A few were even curious to learn chemiluminescence themselves, although none ever went through with it.  Rudy led a number of other runs over the years, especially when fog or a moonless night called for extra light, and was happy ever after to be accepted by his coworkers.

The moral of this story: Inclusion and acceptance are aided by powerful role models.  When leaders, such as workplace managers, employers, and politicians, model humanitarian ideals, we are encouraged to rise to their level.  Conversely, when those in authority promote bigotry and hate, when they fan the flames of xenophobia and prejudice, it gives permission for those who look up to them to show their worst (s)elves.

Image courtesy of MR. LIGHTMAN at

Prescription drug abuse and the physician gatekeeper

guard-gateOpioid painkillers such as Vicodin (hydrocodone) and OxyContin (oxycodone) are crucial medical tools that are addictive and widely abused.  Tranquilizers and sleeping pills of the benzodiazepine class, e.g., Xanax (alprazolam), Ativan (lorazepam), and Klonopin (clonazepam), are safe and effective in limited, short-term use, but are often taken too freely, leading to drug tolerance and withdrawal risks.  Stimulants such as Ritalin (methylphenidate) and Adderall (amphetamine) ease the burden of ADHD, but are also widely used as college study aids as well as recreationally.  All of these medications are available only by prescription.  This means prescribers serve as gatekeepers, permitting access for medical needs and denying it otherwise.

This gatekeeping can be difficult.  Doctors are imperfect lie detectors and can be fooled with a plausible story.  Pain, anxiety, insomnia, and inattention are mostly invisible.  The internet offers quick lessons in how to fake a medical history.  Beyond the initial assessment, every physician has patients who repeatedly “lose” bottles of painkillers or tranquilizers and request more.  Secretly seeing multiple doctors to obtain the same drug remains fairly easy.  While a few doctors run illegal “pill mills” and flout the gatekeeper role, many more are simply too overworked to be vigilant with every patient.

None of us became physicians to fight the war on drugs.  On the contrary, most of us are uncomfortable doubting our patients’ honesty.  It’s stressful to worry about being too suspicious or too gullible, and it’s a waste of valuable time.

The possibility of tranquilizer abuse arose with a new patient of mine recently.  My concern led to multiple phone calls to pharmacies and to consulting California’s CURES database online.  I was convinced enough that something was amiss that I confronted my patient, who responded by calling me names, making vague threats, and leaving in a huff without paying for the appointment (and, of course, never coming back).  Although the reaction seemed confirmatory, in truth I’m still not certain my suspicions were correct.  Why did I put my patient and myself through such grief?  Because I wanted to “do no harm.”  Accepting the gatekeeper role requires scrutinizing and sometimes confronting the patient at the gate.

Let’s consider other drugs that are used both medically and recreationally — but unlike those mentioned above, do not involve a physician gatekeeper.

The best candidate may be cannabis.  Currently legal in 25 states, medical marijuana requires a doctor’s authorization but not a prescription that specifies dosage, frequency, duration of treatment, or route of administration.  By definition, a Schedule I drug like marijuana is not “FDA approved” for any medical use.  Yet cannabis is very much like the Schedule II drug Adderall: it has a few solid medical uses, a much larger set of dubious or controversial ones, and a vast sea of mostly illegal recreational use.  A lot of medical marijuana is used for relaxation or sleep, blurring the medical-recreational distinction in much the way Adderall does when used for studying.  Purely recreational use is legal in four states as of this writing.  Legalization is on the ballot this November in five additional states, including California where I practice.

I have never authorized medical marijuana, although several of my patients were approved by other physicians and use it regularly.  Once a patient tells me he or she uses marijuana, whether doctor-approved or (for now) illegally, I can act in my preferred role as advisor.  We can discuss risks and benefits, sativa versus indica, THC and CBD, all without me having to second-guess my patient’s story, make a paternalistic decision about whether to authorize access, or even cast judgment on the decision to use it.

In states where recreational cannabis is newly legal, it joins the three drugs already native to our cultural landscape.  Adults consume alcohol, caffeine, and nicotine with nary a prescription, gatekeeper, or hoop to jump through.  And although we rarely think about it, all three have medicinal effects.  Alcohol can reduce stress, aid sleep, and may promote health in a number of other ways.  Caffeine treats fatigue, migraine headaches, and possibly obesity.  Nicotine eases Parkinson’s disease and perhaps schizophrenia, and helps with weight loss.  While smoking rates are declining in the U.S., most Americans continue to use alcohol and caffeine often and for a complex mixture of reasons: taste, psychoactive effects, social custom, and sometimes for plainly medicinal purposes.  Widespread use also leads to addiction in a significant subset of the population: caffeine becomes necessary and not just optional, and we go to extraordinary efforts to manage alcoholism.  As tragic as this is, nearly everyone agrees that Prohibition was the greater evil.

I like that I’m an advisor, not a gatekeeper, for marijuana and the (other) legal vices.  I also reject the gatekeeper role for stimulants by telling callers I don’t treat ADHD.  This is trickier: my refusal to treat a legitimate psychiatric disorder is arguably too finicky.  It can be hard for an earnest sufferer to obtain a thorough evaluation and treatment, even if paradoxically it is all too easy for a drug abuser to tell a sob story and score a prescription.  Nonetheless, with stimulants as with medical marijuana, I’m uncomfortable making Solomonic distinctions where medical and non-medical uses lie so closely on a continuum.

In any event, I draw the line there.  I continue to prescribe tranquilizers and sleeping pills for my patients who seem to need them.  I may unwittingly abet substance abuse in some cases, but the alternative is to not prescribe any abusable medication, a stance that feels far too finicky.  After all, medication gatekeeping is the norm for many physicians.  Oncologists, surgeons, and ER doctors can’t tell patients they don’t treat pain.  Surgeon general Vivek Murthy sent a letter to every U.S. physician in August urging us to help fight the “opioid epidemic” by limiting dosages and durations of opioid prescriptions, and by substituting non-narcotic alternatives — in essence, by being better gatekeepers.

The only way to avoid doctor-as-gatekeeper entirely is to make all drugs available without a prescription.  The prospect of narcotics and amphetamines on the open market strikes most of us as extremely foolish, even though Prohibition and the failed war on drugs should give us pause. The other strategy is to embrace gatekeeping even more seriously, as Dr. Murthy advises.  Careful comprehensive evaluation, “start low and go slow” prescribing, close monitoring using a system like CURES, and strictly limiting refills should drive down prescription drug abuse.  Unfortunately, this takes more clinical time, one thing most physicians can’t spare, and a trading away of doctor-patient collaboration for something more wary and legalistic.  As usual, physicians are asked to erode the traditional doctor-patient relationship, and do more work, to keep the system afloat.  Meanwhile, patients suffer further small indignities and a colder encounter.

Alternatively, we could wait it out.  The line between medical treatment and personal enhancement or optimization gets fuzzier all the time.  Society may soon fail to distinguish treating an anxiety disorder and taking something to relax in the evening, or treating ADHD and simply maximizing one’s mental sharpness.  The medical-recreational divide already looks more like a continuum for marijuana and stimulants, and is essentially gone with respect to alcohol, caffeine, and nicotine.  If this trend continues, physicians may no longer be called upon to distinguish legitimate from illegitimate drug use.  Our focus as medication gatekeepers may shift from the purpose of the prescription to its safety, making us more like pharmacists than judges.

Is the DSM clinically useful?

DSM-5_CoverPrior to the release of DSM-5 in 2013, I referred at times to the pocket copy of DSM IV parked in my office bookcase.  The main reason was to enter the right diagnostic codes on insurance forms.  I also sometimes quoted DSM criteria to show a patient that ADHD can’t arise in adulthood, that daily mood swings are not characteristic of bipolar disorder, or that six months of sobriety is still “early” remission.  In other words, aside from fulfilling the documentation needs of third parties, I occasionally used DSM IV to disabuse a patient of a faulty self-diagnosis, and even more occasionally to ratify my own assessment in the eyes of my patient.  Rarely if ever did I consult the handbook to make a diagnosis.  By the time I reached for it, I already had a handle on what was going on.

DSM IV diagnostic codes were a subset of ICD-9-CM, a catalog by the World Health Organization of all diagnoses in medicine.  DSM-5 uses these codes as well, but also provides the newer ICD-10 codes now required for virtually all insurance claims and similar documentation.  While I could look up the ICD-10 codes I need in DSM-5, I haven’t bothered to buy a copy for the past three years.  That’s right: I don’t own DSM-5.  Instead I check a plain list of psychiatrically relevant ICD-10 codes and use the one for the diagnosis I have in mind.  For three years I haven’t felt the need to consult DSM-5 to make a diagnosis, nor even to score rhetorical points with patients (which was never a very good reason to begin with).

I’m aware of the major changes in the new edition.  I realize multi-axial diagnosis is obsolete and that many diagnoses were tweaked.  ADHD can appear by age 12 now, substance abuse and dependence have collapsed into substance use disorders, autism is now a spectrum, and the controversial bereavement exclusion no longer exists.  None of this makes a bit of difference in my daily work with patients.

One reason it doesn’t is that traditional dynamic psychotherapy has little use for diagnosis.  The former highlights each patient’s uniqueness, while the latter lumps patients into groups.  I can’t recall a single instance when I, or anyone I know, altered a psychodynamic therapy based not on the patient’s defensive style, relatedness, or stated goals, but on whether the patient met DSM criteria for a specific disorder.  Within the confines of this form of therapy, DSM diagnosis doesn’t affect treatment.  So let’s concede that dynamic psychotherapy is a special case and focus instead on treating the major disorders we used to call “Axis I.”  In this medical-model, usually pharmacologic realm, accurate diagnosis obviously guides treatment.  Here, at least, the DSM remains the indispensable “bible” or gold standard of psychiatric diagnosis, yes?  And by not owning one, I must be navigating without a compass?  Well, no, not really.

DSM III was useful to me in training, just as the newer fourth and fifth editions undoubtedly help more recent trainees.  These manuals help beginners learn the jargon, the checklist criteria that officially define a disorder, the recognized variants and qualifiers.  Diagnostic criteria help students and early-career professionals build internalized prototypes or templates of mental disorders that go well beyond a layperson’s vague impressions.  We learn that (major) depression is more than sadness: it has a minimum duration and associated neurovegetative signs.  We learn that bipolar disorder describes abnormal moods sustained over weeks or months, not moods that shift over an hour or a day.  We learn that panic and anxiety aren’t the same thing, and that obsessive compulsive disorder is more than a personality style.

But this is just a starting point.  After seeing many patients, our diagnostic prototypes take on lives of their own.  We gradually form our own mental models of common diagnoses, views that may differ from the DSM.  We decide the published criteria for a particular diagnosis are too wide or too narrow.  Certain features compel us to call someone clinically depressed even though he doesn’t quite meet criteria.  A patient who meets DSM criteria for schizophrenia strikes us as atypical, prompting diagnostic doubts and a more extensive medical work-up.  A patient with generalized anxiety disorder has unmistakable thematic triggers, unlike other GAD patients who do not.  For these and a thousand other reasons, we deviate from strict adherence to DSM categories.  We make exceptions.  We season our assessments with clinical experience.  A DSM based on expert consensus — as opposed to something more empirical, like a reproducible test — invites debate.  In the end, we privilege the nosology of our own experience over the official manual that approximates it.

DSM stands for “Diagnostic and Statistical Manual.”  The use of criterion-based diagnosis since the arrival of DSM III in 1980 improved inter-rater reliability.  Since then, clinicians around the world largely agree whether a particular patient “meets DSM criteria.”  This has been a boon for research, where homogeneity of study groups is crucial.  It says nothing, however, about validity, i.e., whether DSM categories accurately reflect how the real world is organized.  This thorny issue brought the American Psychiatric Association (APA) and the National Institute of Mental Health (NIMH) into conflict a couple years ago, when the NIMH announced it would replace DSM diagnostic categories in its research with finer-grained, more elemental categories.  The validity concern arises regularly in practice as well, whenever a clinician feels not all major depressive disorder is the same or should be treated that way, or that the DSM strikes the wrong balance in defining post traumatic stress disorder.

What, then, is the true utility of the DSM?  It establishes a common language for professional communication and research.  It offers the untrained and clinically inexperienced a starting point that approximates the clinical reasoning of experts who pick up on nuances missing from the DSM — and who, it must be said, sometimes disagree among themselves.  It gives the popular press something to write about.  It allows corporate MBAs to learn its terms and thus become “part of the health care team.” It serves as a glorified compendium of insurance codes.  For patients, psychiatry’s “diagnostic bible” can reassure, threaten, challenge, or support.  For psychiatrists, it can ratify or legitimize our assessments and opinions.  However, for clinicians with significant real-world experience, one thing the DSM doesn’t do is aid clinical practice.

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

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.