An American Psychiatric Horror Story
Imagine you loved her. Maybe she was your daughter or sister, maybe a best friend or ex-lover. Maybe a wife. You knew all about the sexual abuse she suffered through as a child. A real horror story. You knew about the suicide attempt that almost took her life and the doctor who then saved her. She came back to life. The treatment kept the demons at bay. Sometimes she even slept through the night. You felt deep gratitude, and some hope.
And then you get a call. She was in a panic. Her insurance company was taking away her weekly psychotherapy. Some company functionary or committee had determined it was no longer medically necessary. The decisions she and her actual doctor made about insuring her well-being were irrelevant. Less care means more profit.
You then find out her psychiatrist was also in a panic. He did everything he could to appeal the decision. Clinical guidelines and basic research were clear; this was a mistake. He feared for her state of mind, for her very life. Nothing worked. A promising life was being put at risk.
So her psychiatrist reached out to another psychiatrist, an expert supervisor who had experience working for insurance companies. Surely, this expert would help to reverse a decision that was already making her suffer while significantly increasing her risk of suicide.
Instead, this so-called expert applauded the decision. He advised her doctor to have her write a list of her strengths so she would remember she had the strength to cope, even thrive, in response to the insurance company’s decision. And don’t worry about increased risk for self-harm. He could “assure her, of course, that emergency care was available.” Because, after all, as that so-called expert wrote, “the goal of treatment is not to make [patients] feel more secure or comforted.” Plus, he actually said, in defiance of everything we know about psychopathology and brain science, that her doctor’s vote of confidence, one he will cast by not treating her, will be enough for her to take all “she had learned in their work together to survive and thrive, in spite of her doubts and fears.” A paternalistic pat on the head was all she needed to go forth and win the battle with her demons.
No surprise but this is not really a horror story, at least not in the sense that horror stories are fictional. This is an actual case as described in a recent recent column in the “Couch” series of the NY Times by Michael I. Bennett, who is the so-called expert psychiatrist. All the quotes came from that article he wrote. He is also co-author of F––– Feelings: One Shrink’s Practical Advice for Managing All Life’s Impossible Problems.
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Before going on I need to come clean. I found this article maddening. It’s like someone told the residents of Flint, Michigan they should be grateful to drink lead-poisoned water because of the government provided mineral enhancements. The author, apparently functioning as a shill for the managed behavioral health care industry, insidiously distorted facts and played with logic to reach his desired conclusion: care rationed to maximize corporate profit is, in fact, good care, even better care. It’s a black is white and white is black piece of corporate propoganda. In language Dr. Bennett might appreciate, his article, the perspective it enshrines, and the industry it supports is complete and total bulls––– .
Here’s why. Lets follow the pretzel logic of his distortions:
He Fails to Understand the Basics of Psychotherapy
In order to say denying care is a good thing Bennett has to denigrate the value of the care provided. He wants readers to believe weekly psychotherapy, or whatever frequency and duration a patient and therapist determine is in the patient’s best interests, has “limited potential to heal and protect.” He concludes this because, as he writes, “Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be…”
That is such an absurd pretzel I have to resist the urge to turn on my caps lock. Of course treatment is NEVER as amazing as people wish it would be. That’s what makes them wishes and not plans. His is a meaningless statement because not gratifying wishes for transcendent change is not an outcome measure. It is an inevitability. But that’s the reason he says therapy has limited potential.
And I should point out, every (EVERY!) medical intervention has limits. Remember the old joke about the patient who gets an unequivocal yes after asking his surgeon if he’ll be able to play the piano after the life-saving operation only to say “that’s great, I can’t play now!” Well, according to Bennett that would be reason enough for an insurance company to deny coverage for the life-saving operation.
Furthermore, when patients are asked about their experience in therapy we learn that they typically report having “benefited very substantially from psychotherapy, that long-term treatment did considerably better than short-term treatment.” This now classic 20 year old study of psychotherapy effectiveness from Consumer Reports November 1995 also showed that “patients whose length of therapy or choice of therapist was limited by insurance or managed care did worse.”
So, “objectively,” Dr. Bennett really is full of it. “Objectively” there is ample evidence that a treatment relationship unimpeded by the profit imperatives of a care rationing company is a powerful healing practice, albeit limited like everything else on the planet. And, “objectively,” a healing treatment relationship is not hand holding or a mere personal growth experience. It helps someone develop and maintain the capacity to have their hand held. It gets at the very possibility of growth.
And this brings us to one of the big lies of managed behavioral health care: Let’s interfere as much as we can so we can make therapy as ineffective as possible and then we can stop covering it because it is not as effective as it should be.
He Infantalizes and Ignores Patients
His whole schtick is a “doctor knows best” refusal to value certain patients’ preferences. Which ones? Those who suffer from depression and anxiety. Because those problems result in cognitive distortions they “may never allow certain people to feel strong.” And because of this, their preferences should be ignored.
According to Dr. Bennett, because someone has a chronic problem they cannot be trusted to know what’s best for them, even in consultation with a clinician who actually knows them. Better to have a paternalistic doctor or committee who never meets the patient make the decision to terminate or sharply limit care. And in this way they will actually be helped to discover the distortions of their chronic condition and therefore improve. Knock someone out of their wheelchair so they can discover that all along they were able to walk. According to Dr. Bennett the insurance company knows best.
I hope you see ignoring patient preferences for treatment because they have the problem for which they are seeking treatment is circular nonsense, as well as being callous and even cruel. Plus, ignoring patient preference flies in the face of both the evidence-based clinical guidelines put out by American Psychiatric Association and the available research.
For example, a 2013 review in The Journal of Clinical Psychiatry described the exact opposite of the snake oil Dr. Bennett is selling: “a growing body of evidence suggests that providing patients with their preferred treatment is associated with better treatment retention and clinical outcome.” Letting people access the treatment they want is not mollycoddling those whose pathology prevents them from seeing how strong they really are. It is solid good practice. Consider two of the three summary “Clinical Points” from this review. These are the clinical take-homes specifically highlighted by the research cited (my emphasis added).
The first states: “Patient preference for the treatment of psychiatric disorders is a core component of evidence-based mental health care and has been shown to impact treatment retention and outcome.”
The second states: “Consideration of patient preference, along with treatment efficacy and clinical expertise, may be important to optimizing outcomes in clinical settings.”
In other words, deciding one needs ongoing treatment should be respected. It is a “core component of evidence-based mental health care“ and “important to optimizing outcomes.” But Dr. Bennett wants to ignore what people feel they need when an insurance company decides it’s time to ration care. He writes that this “need, no matter how intensely felt, does not mean that they are actually in danger.”
Except sometimes it does. Sometimes life leaves a mark on brains and minds and lives that require ongoing care. Patients and their healthcare providers should make that decision, not insurance companies.
He is Cavalier About Suffering
The first time I read this “Couch” article I was really put off by the cruelty. Let’s say Dr. Bennett is right (he’s not, but I want to show the cruelty of his position). Let’s agree this patient really is stronger than she thinks she is. That for her, weekly psychotherapy made her feel secure and comforted. Bennett has said “the goal of treatment is not to make [patients] feel more secure or comforted.” But why not?
We know security and comfort is associated with lots of positive outcomes, not the least of which is a marked reduction in the risk of suicide and self-harm. But even if not, have we so degraded our humanity as to remove security and comfort from what a treatment should provide. Are we now nothing but function, deadened vessels whose subjective experience has no role in treatment planning? Sure, people sometimes take feelings to be facts when they are not. But they are still feelings and feelings matter, suffering matters.
Imagine an operation, or a dental procedure, equally effective with or without the anesthesia. Think of how much money could be saved if we no longer use novocaine for that pesky tooth removal. After all, the outcome is the same. Don’t mind the pain. You only think you are not strong enough to bear it. So, make a list of all the times you survived pain you only thought was excruciating. See! This too will end. And this, apparently, is Dr. Bennett’s approach to psychotherapy. All function, no feeling.
He Confuses Psychotherapy and Self-Help
Dr. Bennett’s book F——— Feelings actually has a good message for the self-help world. He reminds his readers that life is hard. There are limits to growth and change. We all have to accept that which is inevitable and locked-in, be it mortality, the reality of our personal histories, the limitations of our talents and the limitation of those we know, work with, and sometimes love. The trick is to develop strategies to help reach realistic goals, to not let one’s feelings derail getting where you want to go. This is a useful contrast to the infinite self-improvement promised by the self-help industry. Unlimited potential is a myth. The real secret is that not everything is possible. We have to make the best of what we can’t change. And there is lots we can’t change.
But trumpeting unlimited potential is not the promise of psychotherapy. Good psychotherapy strives for, at best, better but never perfect. Sometimes the promise is less bad, finding better strategies for that which cannot be changed. And sometimes it is even comfort and security. Good psychotherapy offers an experience that can help you mourn what you may want but can’t have or achieve so you can then celebrate what is. And good psychotherapy takes seriously that feelings are not facts, just like Dr. Bennett. Except we also understand that feelings are feelings and deserve a level of respect missing both in Dr. Bennett’s article and in the work of others who shill for companies at war with psychotherapy. Grabbing profit by rationing care is not a treatment strategy anyone should respect.
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