Dr. Michael I. Bennett had a opinionator piece in the New York Times a few days ago that made my blood boil. In You Are Stronger Than You (And Your Therapist) Think, Bennett talks about a patient who has been in weekly psychotherapy for years until the insurance company decides that the patient does not need weekly sessions -- 12 sessions per year are approved. But the patient is not Bennett's patient, and he writes from the perspective of someone who has worked for an insurance companies.
I know what it’s like, as a psychiatrist, to feel that your patient’s safety depends on your availability to provide emotional support. However, I also know from experience that patients usually survive our vacations, unavoidable short-notice absences and cellphone failures without actually falling apart. Certain patients feel very vulnerable, needy and worried about abandonment, but they feel that way long before we start treatment and, usually, those feelings don’t change in response to treatment. Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be.If weekly therapy does, indeed, have only a limited potential to heal and protect, then our patients must be stronger than they, and we, think they are. We know that depression and anxiety routinely distort our ability to think realistically by making us see nothing but our faults, failures and worst-case scenarios. When we’re sure that things will fall apart if weekly treatment isn’t readily available, we may well be accepting and stoking this distortion and, inadvertently, helping our patients believe that they are as weak and helpless as they feel.
My advice to my colleague was to make a list of the patient’s strengths and encourage her to review what she had learned from the tough experiences that she had endured and survived. It would be normal for her to fear the worst from the coming transition in treatment, but this was also an opportunity for her to see through the negative distortion caused by that fear, review her resources and prepare plans for managing whatever worst case scenarios she could imagine. My colleague could assure her, of course, that emergency care was available. But he could also express confidence in her ability to use what she had learned in their work together to survive and thrive, in spite of her doubts and fears — and of his.
- Obviously, Bennett may be right that therapy may foster dependence. The therapist may be financially motivated to patients coming frequently, and there are patients who could be seen less often then they are.
- So how do we determine how often a patient should come? The therapist & patient in this case say weekly; the insurance company says monthly. Why 12 appointments? Why not 11 or 13? Or 17? Or 9?
- What is the goal here? Is it to find that absolute minimum number of appointments that the patient can tolerate without another serious suicide attempt (as this patient had)? Without hospitalization? With medication? Without a recurrence of symptoms? (Which Symptoms?)
- Is dependence bad? What if one hour a week of "dependence" and any accidental psychotherapeutic work that happens to happen along with that dependence comes with the the trade-off is able to live life more fully and productively?
- "Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be." Excuse me??? Oddly enough, it seems to me that the therapeutic relationship is often quite helpful.
- Might I add that very few patients continue for an extended period in weekly psychotherapy -- it's expensive (even with insurance there are deductibles and co-pays), and time consuming. There is some automatic self-selection here that leaves the most vulnerable and distressed of people who even want this.
- Okay, so what do we think about someone from an insurance company who has never met a patient, and generally hasn't reviewed their history and medical record, should determine how much treatment they need? Oh wait, managed care has been around for a while. Now whose idea was that?