Living between three and seven

Despite my mostly psychodynamic approach to psychotherapy, I sometimes include cognitive interventions as well.  I think of this as choosing from a variety of tools to suit the moment.  Generally speaking, cognitive techniques (and psychiatric medications) aim for symptom relief, while psychodynamic work aims for structural personality change, with symptom improvement as a byproduct.  There's a time and place for each, their relative value varying from patient to patient.  The following is a cognitive framework I've introduced to a number of patients over the years.  Let me know if it's useful to you. Essentially it's a simple one to ten scale that highlights polarized thinking — "splitting" in dynamic lingo — and encourages modifying it through conscious effort.

Many patients who evidence polarized, black-and-white thinking — who devalue the bad and idealize the good — quickly catch on when I propose that their abject hopelessness and seething rage represent a "one" on a one to ten scale, whereas their over-the-top exuberance rates a "ten."  (Some take it further and claim their despair sinks to "negative 100" and positivity zooms up to "50" on that scale, but usually they'll agree to keep it manageable.)  The key intervention is then to point out that life is mostly lived between three and seven. Realistically speaking, bad experiences in life usually rate a "three" or "four," good experiences a "six" or "seven."  Anything more extreme is rare.  Feelings of "one" and "ten" are almost always exaggerations, polarized distortions that whipsaw the patient's feelings and interpersonal relationships.

The concreteness of speaking in numbers comes easily to most of us.  Once introduced to this scale, some patients spontaneously and enthusiastically rate their own feelings: a troubling encounter "felt like a 'one' but I know it was really a 'three'."  More often they relate an experience in unrealistically glowing terms, and I gently challenge their idealization by asking if it was truly a "ten" or more accurately a solid "seven" (and likewise with a "one" that upon reflection could be re-rated a "three.")  Some patients formerly prone to one-or-ten thinking soon begin sessions by telling me their day feels like a satisfying "six" or a disappointing "four".  Either way, I support this more nuanced assessment and discuss how they may nudge themselves up the scale.

Many patients, particularly those who take a degree of pleasure in the ups and downs of their emotional roller coaster, would never abide a monotonous life stuck at "five."  Where's the fun in that?  Fortunately, the point of the scale is not to aim for stagnation, nor to suggest that the midpoint is ideal.  The realities of life assure that some days will be better than others.  No cognitive trick will stop successes from feeling good and letdowns from feeling bad.  The question is how much.  Attaching numbers to feelings offers a little distance and perspective.  It's a gentle reminder that such emotional exaggeration may be a form of self-torture — and that an apparent "ten" is risky (and literally "too good to be true"), often crashing precipitously into a "one."  Most of the time it's far more comfortable, safe, and sustainable to "live between three and seven."

Of course, it wouldn't be psychodynamic therapy if we stopped there.  The numerical scale offers a useful language to describe unrealistic emotional extremes, and perhaps to help the patient mitigate them through conscious effort.  However, it can't account for the splitting itself, nor change the patient's propensity in any structural way.  For that, we turn to unconscious dynamics, and to a trustworthy, consistent therapeutic relationship that permits emotional nuance to gain a foothold. Rather than being seen as mutually exclusive — itself an unhealthy polarization — cognitive and psychodynamic approaches can complement one another.

Graphic courtesy of Danilo Rizzuti at FreeDigitalPhotos.net

My goal as a therapist: to make myself obsolete

Traditional psychodynamic therapy is often caricatured as endless, with a complacent therapist silently growing cobwebs, listening to a patient who never plans to leave.  This isn't completely unfounded: there are therapeutic advantages to losing track of time, "swimming in the material," and letting one's therapeutic focus be broad.  The patient's chief complaint, i.e., the ostensible reason for coming, often gives way to more troubling underlying conflicts and concerns that might never appear in more directed or time-limited work.  Highly defended material may be uncovered and worked through in the fullness of time.

All the same, and as many critics have pointed out, this is a cozy arrangement.  If the therapist is happy to have a paid hour, and the patient is gratified to pay for the undivided attention of a caring doctor, nothing need change.  Ever.  Many patients fear becoming emotionally dependent on their therapists, i.e., finding it too comfortable to stop.  And some therapists, being human, are not above maintaining a pleasant status quo.

Psychoanalysts and analytic psychotherapists anticipate this concern, and hold that a patient's dependency, like everything else, can be explored, understood, and overcome.  However, in highly non-directive therapy, i.e., with a mostly silent therapist, this can take a long time and be painful for the patient in the meantime.

My approach to dynamic work is more interactive.  While I believe transference and countertransference are highly useful tools, and that both manifest and latent content are important, I also strive to help paients in the here and now, whenever doing so doesn't interfere with long-term gains.

In this light, I often tell patients that I aim to make myself obsolete in their lives.  Saying this can quell dependency fears, but it's open-ended enough that I'm not promising how long (or briefly) we'll work together, nor that I guarantee they won't feel dependent along the way.  I can't promise these, because I don't know.  But I can give my word that I won't allow myself to get so comfortable with our arrangement that I forget why we're meeting at all.  It's a comforting statement that has the advantage of being true.  It feels good to have a patient not need me anymore, a little like the bittersweet feeling when a child goes off to college.  And in a way, hearing myself say so out loud helps me remember it.

The trade-off, a psychoanalyst might point out, is that I short-circuit any fantasies patients might harbor that I seek to trap them, that I want them to feel dependent.  Patients might gain more insight about themselves if I let such fantasies germinate, and then collaboratively explore them.  It's an important point to keep in mind, but on balance I usually feel this modest bit of support helps the therapeutic alliance much more than it forestalls exploration.

A successful psychotherapy is when a patient leaves with the satisfaction that she "got what she came for," and no longer needs, or even wants, to see a therapist.  And a successful psychotherapy practice is one where patients come (in need) and go (improved), the therapist becoming obsolete one patient at a time.

Do patients avoid psychiatrists for fear of legal holds?

Over on the Shrink Rap blog I got caught up in an off-topic debate.  The post was on why psychiatrists avoid insurance panels, something I've written about myself.  But the commentary wandered into exorbitant fees, inadequate mental health services for the poor, income disparity between psychiatrists and patients, a generation that expects something for nothing, and so on.  After a week, prompted by minor irritation with San Francisco's transit system the night before, I finally posted a comment.  I wrote that buses and taxicabs perform roughly the same service, but for many riders who can afford it, a cab is worth the extra money.  I acknowledged that the analogy to mental health care was flawed: bus and cab fares are both regulated, and psychiatric care is often more urgent and critical, and definitely more expensive, than an optional ride downtown.  Nonetheless, the comparison made the point that more affordable mental health services are inevitably "bus-like," and that there is a legitimate role for higher-cost "taxi-like" services for those willing and able to pay for them. It's important to realize that all analogies are flawed.  They only highlight certain similarities between two situations.  There will always be differences too, the salience of which are inevitably disputed by partisan debaters.  For this reason analogies illustrate far better than they convince.  One commenter noted that even "bus-like" mental health services are not always available.  A psychiatrist pointed out that many of us accept reduced fees or otherwise "come to some agreement" with cash-strapped patients in ways taxi drivers don't.  Then another commenter who frequently writes about forced psychiatric treatment argued that coercion never occurs with buses or cabs, rendering my analogy "shallow at best."

Going off-topic, I replied that forced treatment, e.g., being subjected to a 72-hour legal hold (the "5150" here in California), is uncommon in office psychiatry, and in any case didn't bear on the point I made.  I later added that a number of non-psychiatrists are also authorized to apply the 5150 in California, and in many instances would be far more likely to do so than a psychiatrist in a private office.  My interlocutor, and at least two others, pressed on: the mere possibility, however remote, of being placed on a legal hold is a threat that evokes fear in current and potential patients.  This fear keeps some who "truly need psychiatric intervention ... from even attempting to access 'help'."

I had already let it drop when our host asked everyone to return to the topic of insurance panels.  But it's a point that bears discussion, here if not there.  Do patients avoid office psychiatrists for fear of being placed on a legal hold?

I'm sure the answer is yes, at least sometimes.  In the first place, many patients do not know what triggers a 5150.  Movies, popular culture (such as the depicted t-shirt), and history itself prime the public to think a padded cell readily follows from a few ill-chosen words.  Often I've reassured patients that ideas or feelings, however destructive or horrific, never in themselves lead to involuntary commitment.  Patients are free to divulge fantasies of mass murder, elaborate suicide scenarios, gruesome torture, etc. without risk of being locked up.  Indeed, talking in confidence about disturbing ideas or feelings is a good way to defuse their emotional power.

But there's much more to this than simply not knowing the law.  In my experience a great many patients fail to distinguish feelings and actions.  They try unsuccessfully to control troubling feelings, and somehow equate this with uncontrolled behavior, a very different thing.  Yet the distinction is hugely important in life, and with regard to legal holds.  Feelings never justify a hold, whereas behavior, or its "probable" likelihood, does.  If this distinction is unclear, even feelings seem dangerous.

At a more subtle level, patients with hostile or self-destructive feelings often expect to be punished for them, or they unconsciously feel guilty, i.e., that they should be punished.  Indeed, people avoid psychotherapists of all types, imagining the therapist will condemn or humiliate them for the ugliness of their inner world.  Unconscious mixed feelings, i.e., simultaneously fearing and seeking a harsh response, are common as well.  A crucial part of dynamic psychotherapy is gradually trusting that the therapist won't fulfill this fantasy.  Seeing a psychiatrist evokes these usual fears of being judged and punished, heightened in some by the psychiatrist's power to diagnose and to initiate a legal hold — even if the risk of the latter is virtually zero.

I hasten to add that we psychiatrists don't make this any easier for ourselves or our patients when we are sloppy about applying legal holds.  Patients' fears of subjectivity and loose criteria are partly based in reality.  A casual "better safe than sorry" attitude may send the wrong message, trampling the treatment alliance and savaging trust.  Meticulous care in applying the 5150 is a "frame issue" as central to therapeutic success as any other treatment boundary.  As a profession we can never count on being afforded more trust than we have earned (and sadly, often less).

Of course, there are circumstances when we rightly apply a legal hold in the office.  A patient who believably voices, or behaviorally telegraphs, intent to die or to kill others should expect a trip to the psychiatric ER for further evaluation in a secure setting.  Conversely, there are presumably people intent on suicide or homicide who consciously avoid seeing psychiatrists who could thwart their plans, just as they avoid telling their family or the local police.  Such people, however, are not seeking psychiatric assistance to avoid dying or killing.  If they were, they would accept help, including inpatient treatment if needed.

I once had a patient who came to see me, he said, so I could convince him not to die.  If I failed, he would kill himself.  I quickly replied that I wouldn't play this game, although I was more than willing to talk with him about his suicidal feelings.  We met five or six times; he wasn't truly interested in overcoming suicidal feelings, and I wouldn't engage in the no-win challenge he set up.  He left — no hold applied — and months later I learned he was still very much alive.

Similarly, those who rail against the completely predictable response of psychiatrists to voiced threats of harm are enacting a "death by cop" scenario.  The paradigm is someone who brandishes a weapon in front of police, who then react the only way they can — and usually with great regret.  Fantasies of punitive authority, forcing the hand of those in power, and/or getting one's just desserts, are made real.  Patients who force their psychiatrists to take control of their behavior likewise sacrifice adult autonomy in order to enact a primitive unconscious fantasy.  Unlike most patients who are relieved to be protected from their own frightening impulses, these few harbor antagonisms that may feel more vital to them than life itself.

Third-party payment for psychotherapy: (2) Medical necessity

In my last post I outlined some complexities of third party payment for office psychiatry, and especially for psychotherapy.  As my example I used Medicare, the only third party payer I bill.  Some of the problems include complex billing (i.e., collecting from multiple parties), partial reimbursement, unrealistic documentation requirements, loss of patient confidentiality, and a misplaced emphasis on medication "evaluation and management" over psychotherapy.  There are also challenges specific to dynamic psychotherapy, such as obscuring the transference.  But I saved the most fundamental issue for this post: Does third party payment for psychotherapy make sense in general? This may seem a puzzling question, coming from me.  I not only value deeply what psychotherapy offers, I make my living from it.  Shouldn't it go without saying that psychotherapy should be paid for somehow, no matter where the money comes from?  My experience with public and private health insurers tells me otherwise.

"Medical necessity" is the linchpin, and frankly the problem.  The more a therapeutic encounter fits a medical model and is arguably "necessary" in that framework, the more readily it is covered by health insurance.  Psychotherapists of all stripes tiptoe uncomfortably around this issue.  Medication management fits the medical model very well, so psychiatrists who incorporate this into their psychotherapy sessions enjoy outsized reimbursement (or their patients do).  Talking about anything else, no matter how central to the patient's presentation, does not fit the medical model nearly as well.  Nonetheless, psychotherapists who offer a step-by-step approach aimed concretely at relief of symptoms emulate medical evaluation and treatment much more than those who employ open-ended, exploratory approaches to tackle dysfunctional family dynamics, chronic self-sabotage, and many other concerns for which people seek psychotherapy (and later report benefit; see Consumer Reports, November 1995, Mental health: Does therapy help? pp. 734-739, and this analysis of the Consumer Reports survey by Martin Seligman).  Note that the crucial variable for coverage is not what helps more, or relieves more agonizing misery.  It's what seems more "medical."

Using “medical necessity” as the criterion to treat human misery that often isn’t medical at all leads to much inconsistency and even cruelty.  As mentioned in my last post, insurers demand that I code my "procedure" (i.e., the session) depending on what we talked about.  If we spend the hour discussing medications, even if this focus can easily be understood as a symbolic, unconscious appeal by the patient for care-taking or some other emotional need, it's worth far more to the insurer than if we spend the same hour explicitly discussing the patient's experiences and reactions to actual caretakers.  (As added irony, the latter discussion can obviate the former in future sessions, a detail lost on insurers and most everyone else.)  Since private insurance partly reimburses many of my non-Medicare patients based on how their sessions are coded, an agitated, marginally employed, chronically suicidal patient with severe personality issues is reimbursed far less over time than a high-functioning, stably-employed patient with a medication obsession.  This makes no sense and is blatantly unfair.

The truth is, I'm the same expert — and put bluntly, worth the same amount of money — no matter what I'm discussing with the patient.  That is, as long as I have the integrity to focus on the patient's central issues, not to provide or bill for unneeded services, not to offer hand-waving in lieu of explanation, not to mindlessly prescribe medication after medication, not to casually chat and call it psychotherapy, and so forth.  In other words, I need to be a good doctor instead of a sloppy or unethical one.  I need to know when to be "medical" and when not to be.

Traditional dynamic psychotherapy fits the medical model especially poorly.  It is not primarily focused on symptom relief.  The treatment is not tailored to diagnostic categories.  It follows no step-by-step sequence.  Even expert practitioners often cannot estimate treatment duration.  After many decades of published studies the evidence base for treatment efficacy still triggers heated debates.  Arguing "medical necessity" for such treatment is at best unnatural, at worst contrived or even misleading.  (It's even more absurd to argue the medical necessity of one specific session in an ongoing treatment; to me, this is like asking whether the 10th note in a piano concerto is "musically necessary.")  Those of us who recognize the value of dynamic work and have seen patients change in important, fundamental ways are kept busy trying to pound this square peg into a round hole.  But CBT doesn't avoid this problem either: it's more like a square peg with rounded corners.

Faced with the struggle to show medical necessity, it's tempting to wonder whether psychotherapists should refuse to play this game.  However, opting out isn't easy.  Even if I chose not to be a Medicare provider — I admitted my mixed feelings about this last time — self-pay patients with private insurance would still seek maximal reimbursement for seeing me.  I can hardly blame them.  I see no way out of participating, at least indirectly, in this misapplied standard of medical necessity.

It's hard enough to assure that all Americans have access to basic health care.  Assuring that all have access to mental health care is one step harder, even when that care accrues only to the seriously mentally ill and fits the medical model very well.  It will be a very long time indeed before America deems it worthwhile to offer psychotherapy to the so-called worried well: those who have all their faculties but are miserable due to inner conflicts, self-defeating beliefs, or a traumatic past.  If that day ever comes, it will be when medical necessity is supplanted by a more fitting standard, one that judges mental distress and its treatment on their own merits, and not by borrowing legitimacy from medicine.

Third-party payment for psychotherapy: (1) "Do you take Medicare?"

From late 1996 to early 2007 I was medical director of a low-fee mental health clinic where psychiatry residents and psychology interns receive training.  Since the clinic accepted Medicare for payment, I did as well.  I signed on as a Medicare "preferred provider" and have remained on the panel ever since, even though I left the clinic for full-time private practice nearly seven years ago. I never joined private insurance panels for several reasons.  As an inveterate do-it-yourselfer, I've always handled my own billing and bookkeeping.  This is considerably harder when multiple health plans are billed, co-payments collected, and so on.  I like the straightforward way I provide a service, and the person receiving the service pays me directly.  Somehow it feels more honest than contracting with health plans to funnel referrals my way.  Private health plans also pay less than usual-and-customary fees and require doctors to share patients' private details with corporate reviewers to document "medical necessity."  Moreover, since dynamic psychotherapy has always been a big part of my practice — increasingly so over time — I'm sensitive to arguments that third-party payment complicates transference and countertransference, obscures acting-out around payment, and detrimentally takes payment out of the treatment frame.  Last but not least, as I'll discuss mainly in my next post, insurers base reimbursement on a medical model that fits poorly with dynamic work.

The upshot is that I have a cash-only (or "self pay") practice, with the exception of my Medicare patients.  Until this year, Medicare "allowed" 65% or so of my full fee.  (Medicare sets an allowed fee for a given service, and then pays 50-80% of that.  I can collect the rest, up to the allowed amount, from a secondary insurer or from the patient.  This works more or less automatically for secondary insurers, and rather awkwardly when I try to collect from patients.)  In 2013 the CPT codes for psychiatric office visits were revamped.  This made billing more complicated, and introduced odd, often illogical variations in Medicare and private insurance reimbursement — sometimes paying more than before, sometimes less.

As one of the few private-practice, office-based psychiatrists in San Francisco still on the Medicare panel, I've become a magnet for these patients.  A local medical center with which I have no affiliation used to refer several callers to me every week, until I sent a letter asking them to please not kill me with their kindness.  Medicare callers request to see me for medications only, even after I explain this is not the nature of my practice.  It's more tricky when patients claim to want therapy to get a foot in the door, and then once in my office and now my medico-legal responsibility, confess that they only wanted medication refills all along.  Some callers ask to be added to a non-existent waiting list, or to call me every month or two to see if I change my mind about accepting them as patients.  Clearly, the demand is there, the economic incentive is not.

Medicare and other third-party payers have a valid need to assure their money isn't wasted.  Sometimes my claims are rejected, as when I received a notice this week that one patient's diagnosis (Depression Not Otherwise Specified, 311) "is inconsistent with the procedures" I billed (three weekly sessions of moderate-complexity medication management, 99213, combined with 50-minute therapy sessions, 90836).  It's tempting to protest this, as there's absolutely nothing inconsistent about treating atypical depression with medication and psychotherapy.  I could take the time to marshal my arguments, compose a letter, and reveal personal details about my patient to present my case.  But it's far easier to resubmit the claim with a slightly upcoded diagnosis, e.g., Major Depression, recurrent, mild severity, 296.31, and get paid.  This uncomfortably clashes with my usual tendency to downcode slightly to protect my patient's confidentiality.  (Since pressures to upcode and downcode routinely distort the documentation of diagnoses in clinical practice, I'm skeptical of all research that uses these diagnoses to derive conclusions about psychiatric practices, disorder incidence, and the like.  Garbage in, garbage out.)

Upcoding and downcoding in such cases is not criminal mischief, but an attempt to fit traditional, mainstream psychiatry into a procrustean bed of medical-model diagnosis and procedure coding.  Public and private insurers alike sacrifice ecological validity for documentation that appears, but really isn't, "evidence based."  To take one example, as of this year we must code medication "evaluation and management" separately from the provision of psychotherapy, even if in practice these are done simultaneously and inseparably.  A 50-minute psychotherapy session (90836) that includes brief attention to medication (99212) is reimbursed at a much lower rate than the same 50-minute session with more time devoted to meds (99213 or 99214).  This makes little sense when in many cases the psychotherapy is far more clinically significant than the medications being discussed.  (You'll note that I think of the psychotherapy code first, but actually it is an add-on to the primary medication "E & M" code.)  If medications are not mentioned or evaluated at all, there is yet another code to use for psychotherapy (90834), with an "allowed fee" of $89 for 50 minutes, well below what any psychiatrist or psychologist actually charges.  If this isn't bewildering enough, some of my colleagues are now doing 52-minute sessions, an insignificant increase in duration that qualifies for a different code with much higher reimbursement.

Since cash-only practice excludes all but the affluent, I view my taking Medicare as a modest concession to avoid elitism.  I also support a single-payer health care system, also known as "Medicare for all," so participating in Medicare feels like practicing what I preach.  At the same time, it's easy to see why most of my office-based colleagues opt out of Medicare: lower pay for more paperwork, rules that don't make sense, and various factors that make dynamic psychotherapy harder to conduct and be paid for.  So far I still answer yes, albeit hesitantly, when asked whether I take Medicare.  In my next post I'll expand these ideas into private insurance for outpatient psychiatry, including whether dynamic psychotherapy resembles a medical intervention enough to fit a "medical necessity" model.