In Treatment: Adele, Week 7

Paul starts with the usual: he blames Adele for giving him bum advice and says she is responsible for Sunil's deportation. Ho hum.

Adele is in his face with how stuck his life is--- hmmm, didn't this guy just get divorced, move to Brooklyn, have his kid, leave his kid? I guess those don't count. Paul announces he's decided on the spot to stop practicing psychotherapy. Independently wealthy, I presume. And yesterday he broke off with his girlfriend and felt nothing. And then, in a rare moment of insight, Paul tells Adele he is stopping therapy, that it is just a repetition of the same patterns and he can't continue with this painstaking examination of transferential feelings. Adele implores him to stay; these people seem to feel that therapy is essential to life and that no change is possible without it. Paul says no, he must go. It seems like his first true insight in years. And then he announces he is no longer her patient and so it's fine if she tells him if she ever thought the two of them could be together. Some things never change? Until next year?

In Treatment: Jesse, Week 7

Jesse went to prison for hopping a train to Providence without paying. Another episode for ClinkShrink!

He's back in Paul's office with his dad, and dad doesn't have much use for shrinks. He tells Paul he should have been a plumber. And now that he and Jesse are cool, Jesse doesn't need to come.

Paul talks to Jesse alone. He implores Jesse to stay in treatment, and he puts it in terms of how he cares for Jesse and how Jesse will lose the gains he made. To watch Paul, leaving therapy is a catastrophic event, one that warrants blowing a few cerebral blood vessels. It's a do or die deal.

For once, could Paul just say, "I'm glad this has been helpful to you. I think there are still issues to address and it could continue to be helpful to you. If you need me, please do call."

In Treatment: Sunil, Week 7

ClinkShrink's dream has come true! A session in the jail. Sunil was locked up and soon he'll be deported back to India, and we learn that this was part of a grand plan, his only way to get home to India. He faked the whole creepy/dangerous scenario, aware that if the police came and he refused to show his papers, he'd get arrested and deported. Couldn't he just have shoplifted an apple?

Paul is angry. What was real? Was it all farce on his therapy? Sunil points out his assorted boundary transgressions as he created a therapist/friend scenario, and Sunil says that Paul got something out of the sessions as well in their shared loneliness. And to ease Paul's anger (oy, he curses at the patient, my idea of a no-no), he lets him in on a new twist to the stories, once again drawing Paul in: his wrong-caste girlfriend who committed suicide was pregnant with his baby.

Sunil sings to Paul as the guard escorts him off.

In Treatment: Frances, Week 7

Sunil doesn't come for his scheduled session. Instead, we get Frances.

Frances continues to struggle with her relationships with her teenage daughter, Izzy, and her terminally ill sister, Patricia. She now has to balance Izzy's wish to prolong Patricia's life with Patricia's wish to die peacefully at home. Should she "pull the plug?" She tells Paul how special it was when Patricia said she loved her, and how she feels like she'll be left alone with no one. Does Paul know how that feels. Indeed, he does.

The session bounces back to how sister Patricia was Paul's patient years ago. As she leaves, Frances asks, "Were you in love with her?" Please, Paul, just say no, she was a patient, her sister is now a patient, why would you have been in love with her and if you were, why would you have ever agreed to treat her sister, much less admit you had such feelings. Therapists don't owe their patients the right to every inner thought. Paul doesn't really answer, he just says that he cared about her a lot, an acceptable feeling to have for a patient.

News Flash: Preauthorization Impacts Care

Thanks to Kery for heads up.
Illustration by J.C. Duffy / copyright © 2010 by the American College of Physicians

The American Medical Association had a press release on November 22nd and announced findings from their survey on the impact of insurance company preauthorization policies. Surprisingly, they discovered that these policies use physician time and delay treatment. It's funny, because preauthorization policies were designed to save money. And I imagine they do, for the insurer, but they cost money for everyone else.

I'm pasting the AMA findings here, taken directly from their website:
New AMA Survey Finds Insurer Preauthorization Policies Impact Patient Care

For immediate release:
Nov. 22, 2010

Chicago – Policies that require physicians to ask permission from a patient's insurance company before performing a treatment negatively impact patient care, according to a new survey released today by the American Medical Association (AMA). This is the first national physician survey by the AMA to quantify the burden of insurers' preauthorization requirements for a growing list of routine tests, procedures and drugs.

"Intrusive managed care oversight programs that substitute corporate policy for physicians' clinical judgment can delay patient access to medically necessary care," said AMA Immediate Past President J. James Rohack, M.D. "According to the AMA survey, 78 percent of physicians believe insurers use preauthorization requirements for an unreasonable list of tests, procedures and drugs."

The AMA survey of approximately 2,400 physicians indicates that health insurer requirements to preauthorize care has delayed or interrupted patient care, consumed significant amounts of time, and complicated medical decisions. Highlights from the AMA survey include:

• More than one-third (37%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for tests and procedures. More than half (57%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for drugs.

• Nearly half (46%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for tests and procedures. More than half (58%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for drugs.

• Nearly two-thirds (63%) of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while one in eight (13%) wait more than a week. More than two-thirds (69%) of physicians typically wait several days to receive preauthorization from an insurer for drugs, while one in ten (10%) wait more than a week.

• Nearly two-thirds (64%) of physicians report it is difficult to determine which test and procedures require preauthorization by insurers. More than two-thirds (67%) of physicians report it is difficult to determine which drugs require preauthorization by insurers.

Preauthorization policies deliver costly bureaucratic hassles that take time from patient care. Physicians spend 20 hours per week on average just dealing with preauthorizations. Studies show that navigating the managed care maze costs physicians $23.2 to $31 billion a year.

"Nearly all physicians surveyed said that streamlining the preauthorization process is important and 75 percent believe an automated process would increase efficiency," said Dr. Rohack. "The AMA is urging health insurers to automate and streamline the current cumbersome preauthorization process so physicians can manage patient care more efficiently."

And Now For Something Completely Different...

I'm going to briefly interrupt In Treatment to post a link to a recent U.S. Supreme Court case. In California, the U.S. district court has ordered that tens of thousands of prisoners be released to reduce overcrowding. The case, Schwarzenegger v. Plata, was argued this past Tuesday and the transcript is up online here. This is relevant to a psychiatry blog because one of the arguments used in support of the releases is the contention that overcrowded facilities reduce access to mental health and medical services and that overcrowding causes mental deterioration and breakdown. The APA filed an amicus brief in the case, but the brief isn't available online yet. (Keep an eye out for it here.)

The challenge with this case is that there is no (or extremely little) actual research to support the link between overcrowding and psychological problems. Correctional systems have spent a lot of time litigating issues---and experts make a fair amount of money working on these cases---without actual data. For example, for decades people have just accepted the notion that solitary confinement causes mental deterioration in spite of the fact that there were no controlled trials to investigate this. The Colorado DOC recently published a landmark case looking at the effects of disciplinary segregation using two control groups, and found that the condition of mentally ill prisoners actually improves in segregation. (The study is entitled "One Year Longitudinal Study of the Psychological Effects of Administrative Segregation" and I can't find it online yet, although I do have a pdf of the report for distribution.)

I think it's a good thing to reduce overcrowded facilities, but justification should be based on what you know, not what you think you know.

****************

Addendum: I'm wading through the transcript now. I had to laugh when I reached page 18 and Justice Ginsburg's comment, "The class (prisoners) wants to have clinics. They want to have personnel who function someplace outside of a broom closet."

I immediately remembered FooFoo5's comment on one of my first posts, "Knowledge is Obligation": "The one time I volunteered to assess women preparing to parole, I sat in a supply closet on an overturned 5-gallon bucket because there was only one chair and I left it for the patients." FooFoo worked in California's prison system. I haven't heard from him for a while and I hope he's doing well.

In Treatment: Adele, Week 6

Adele and Paul spent the episode sparring. It's reminds me of some of his sessions with Gina, only not as good. Adele's manner feels forced, like she's reading her lines, and they all have the same inflection. Paul calls her 'remote,' and 'a Freudian ice goddess," that is when he's not cursing at her, saying she's a narcissist, or accusing her of purposely humiliating him by letting him express fantasies about having a relationship with her when, in fact, she's pregnant. She does inspire him to call Sunil's daughter-in-law and to see Sunil as a more imminent threat.

Watching a half hour on TV is draining enough. Glad my days aren't so filled with conflict, anger, angst, and interpersonal confrontation.