A quote from a fine editorial by Dr. Glenn Treisman in American Psychiatry News (free subscription needed) about psychotherapy and the problems with government medical treatment.
We live in a time when a great emphasis has been placed on individual expression and self-discovery. Neil Young once sang that “We are what we feel.” In fact, to other people we are mostly what we do, and we experience other people through their behavior toward us. The emphasis placed on feelings can easily mislead vulnerable people into believing that all behavior is acceptable if driven by feelings. My patients on the addiction treatment unit say they can’t get out of bed, when what they really mean is that they don’t feel like getting out of bed, a difference that is critically important in rehabilitation of patients with addiction(s). In order to live in a world with maximal liberty, we need a system that helps vulnerable people handle maximal liberty. This is not an unreasonable expenditure given the cost of ignoring the problem. Crime, addiction, wasted lives and untold misery are the results of ignoring the “special needs” of people with a generous endowment of feelings who have not yet learned to cope with that endowment.
Psychotherapy has been shown to help patients with many types of problems (yes, evidence-based medicine), including the one this patient had. Yet, he had not been prescribed psychotherapy of the type I gave him. Instead, he had been convinced that he could not prevent his behaviors and needed to be medicated to tolerate the stresses of life. He was persuaded that he needed to be on disability so that he would not have to be uncomfortable at work. Oddly, this works against the very premise of self-expression and self-discovery. With psychotherapy, he was able to develop and put his talents to work.
What happened? The forces at work in public sector psychiatry place pressure on clinicians to provide the kind of care this patient received. The checklist diagnostic method of the Diagnostic and Statistical Manual of Mental Disorders allowed this patient to “make criteria” for all types of problems, depending on how he felt at each interview. Each checklist diagnosis generates an algorithm of treatments that leads to one drug trial after another. The psychiatrist sees the patient for a few minutes, and then a therapist sees the patient with a set of goals for the therapy based on the psychiatrist’s checklist diagnosis. Financial pressures push the staff to spend as little time as possible on patients who require more time and skill than the average. By giving a diagnosis like bipolar disorder, the psychiatrist narrows the focus of treatment, which becomes less expensive.
Moreover, the quality of public sector health care is now based on ratings by patients, and patient complaints generate aggravation. The easiest out is to allow patients to choose both their diagnosis and their treatments. This leads to satisfied customers on the surveys. Finally, disability leads to more used resources for both the patient and the treatment system; therefore, finding a diagnosis that might establish disability, with the attendant Medicare coverage and resources, is desirable for the patient and the clinician. Unfortunately, life continues to beat the patient up, and the real satisfactions of life that come from successful relationships, rewards for productivity and admiration from others remain elusive.
The term psychotherapy includes a broad range of practices, including the cognitive-behavioral and supportive forms I used with this patient. Unfortunately, we are seeing these therapies lumped together and delivered as if they are all the same. Expert diagnosis and treatment are needed for the most difficult patients. Surgical textbooks describe standard approaches to performing particular operations. Technically, people with modest medical education could be trained to do these procedures, but if the diagnosis is wrong or if something unexpected happens during the procedure, things will turn out badly. Surgeons spend years in training to ensure an accurate diagnosis and to prepare for unexpected problems during surgery. They need to be able to feel the difference between healthy and unhealthy tissue. The same standard needs to be applied to mental health. Mental health parity should mean not only parity of reimbursement for expert treatment, but also parity of health care quality for the patients.
