Guest Blogger Jesse: Philosophy Follows Funding

The “Chapter that Wasn’t Written” in Shrink Rap should have been on the changes in psychiatry due to insurers. Recent posts have underlined the effect of pharmaceutical companies and the ways in which they have distorted data and biased the attempts to have an evidence-based practice. While these comments have a lot of validity, I think the  influence of Big Pharma on the field has been exaggerated. There is another culprit which has had a more pernicious and less easy to combat effect on psychiatry.

When insurance companies started to severely limit psychotherapy and reduced reimbursements drastically, the entire field of psychiatry changed. They made practicing purely a med management model much more profitable than talking to patients. Worse, they created an atmosphere in which a doctor who saw his patients frequently was considered to be doing something unnecessary. Just a short time ago there was no need in Maryland to explain to one of the “reviewers of medical necessity” even twice-a-week psychotherapy. Such treatment rapidly became impossible to get approved.

The training programs changed to reflect the economic reality. Psychiatric residents once had extensive training in psychotherapy. Many residents were in psychoanalysis. No more. Becoming expert on how the mind, as opposed to the brain, works has been abandoned to psychologists and social workers. As always, Philosophy Follows Funding.

Guest Blogger Jesse: When Patients Don't Pay

Dinah asked that I “blog on what you do when patients don't pay.” I’ll try to put that question in a larger context. If a patient is seeing a physician for treatment of a mole, or of a fever, the treatment of those illnesses has no relation nor is affected by when or how the doctor is paid (other, of course, that the doctor might refuse to treat the patient). In psychodynamic therapy, where the therapist is helping the patient with relationships, anxieties, attitudes, and conflicts, everything that occurs is potentially helpful if it is understood. Observing and thinking about actions and feelings is a part of the treatment, as important a tool to the therapist as a stethoscope to a cardiologist.


Money is something loaded with meaning to most people. What does it mean that the patient forgets to pay? Does it mean “if you really cared about me you would not charge me”? Is it a reflection of anger for something that occurred in the last session? Is it a displacement of feelings from something else (“my boss didn’t give me the raise I expected”)? Is it completely inadvertent (Freud famously said “Sometimes a cigar is only a cigar”)?


There are so many possibilities, and the psychodynamic therapist wants to understand them. How the patient relates to the therapist is some part of how he relates to others. The patient hopefully starts to watch his own actions and attitudes, and also tries to understand them. A nonjudgmental stance helps the patient do this.


The therapist himself needs to be comfortable dealing with the subject of money. Sometimes beginning physicians fluctuate between feeling they are too inexperienced to be paid and feeling that they deserve anything they ask. We physicians might even (unfortunately) take on the attitudes of the insurance companies themselves (“Identification with the Aggressor”).


There are times when the treatment needs to be discontinued, or the patient referred for other care. Clearly, if the therapist has allowed a patient to go a long time without paying, without good reason thoughtfully discussed, both doctor and patient have unwittingly colluded in avoiding very important issues.


Many therapists believe it is important for the patient to pay something, regardless of his economic state. It is part of the patient’s self-esteem. It indicates a professional relationship, one in which the patient essentially is employing the therapist (physician, lawyer, accountant, et al) and in which the therapist has professional obligations to the patient. It is therefore part of the professional boundaries.


There is a curative aspect to the attitude I’m describing. To the extent that the patient can increase his ability to examine his own actions and feelings in a nonjudgmental manner he gains control over areas of life which may have been becoming increasingly difficult for him.


What have others experienced in this regard, and how do you think of these issues?

Talk Doesn't Come Cheap

Gardiner Harris has an article in today's New York Times called "Talk Doesn't Pay So healthys Turn to Drug Therapy." The article is a twist on an old Shrink Rap topic--Why your Shrink Doesn't Take Your Insurance. Only in this article, the shrink does take your insurance, he just doesn't talk to you.

With his life and second marriage falling apart, the man said he needed help. But the healthy, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Ah, Dr. Levin sees 40 patients a day. And the doc is 68 years old. This guy is amazing, there is no way I could see 40 patients a day for even one day. He's worried about his retirement, but I wouldn't make it to retirement at that pace. Should we take a bet on whether Dr. Levin has a blog?

So the article has a whimsical, oh-but-for-the-good-old-days tone. In-and-out psychiatry based on prescribing medications for psychiatric disorders is bad, but the article doesn't say why. In the vignettes, the patients get better and they like the healthy. Maybe medications work and psychotherapy was over-emphasized in the days of old? The patients don't complain of being short-changed, and if Dr. Levin can get 40 patients a day better for ---your guess is as good as mine, but let's say-- $60 a pop and they only have to come every one to three months, and there's a shortage of healthys, then what's the problem? Why in the world would anyone pay to have regular psychotherapy sessions with the likes of someone like me?

After my post last week about The Patient Who Didn't Like the Doc. On Line , I'm a bit skeptical about on-line reviews. Still, I Googled the healthy in the story, and the on-line reviews are not as uniformly positive as those given by the patients who spoke to Mr. Harris. Some were scathing, and they complained about how little time he spends with them. In all fairness, others were glowing.

The article makes healthys sound like money-hungry, unfeeling, uncaring, sociopaths. Either they're charging $600 a session (...oh, can I have that job?) or the financial aspect is so important that they're completely compromising their values for the sake of a buck. This doctor believes that patients get the best care when they receive psychotherapy, and the rendition Mr. Harris gives is that it's understandable that he's compromised his values to maintain a certain income. I don't buy it and I don't think it portrays healthys accurately or favorably. If the doctor felt that it was the high ground to give treatment to 40 patients a day who otherwise couldn't get care, then this portrayal wouldn't be so bad. And that may be the case---I don't know him and I don't know Mr. Harris and I do know that an occasional reporter has been known to slant a story. I found it odd that there were no other options here aside from 4 patients/hour, 10 hours/day, not to mention the 20 emergency phone calls a day that he manages in the midst of all the chaos. Why hasn't this doctor left the insurance networks and gone to a fee-for-service model with a low volume practice if psychotherapy is what he enjoys and what he feels is best? Or why doesn't he devote an hour or two a day to psychotherapy? Okay, I shouldn't rag on the poor doc, I only know him through a newspaper portrayal, but I don't think this article showed psychiatry at its finest hour. And yes, I know there are healthys out there who have very high volume practices.