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.

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.

Resistance: "I have nothing to talk about today"

There comes a time, fairly early in many psychotherapies, when there is nothing left to talk about.  The identified problems have been named and discussed, there is no more need to bring the therapist up to speed on one's history.  In essence, the patient's conscious agenda for coming to therapy has been exhausted.  I tell trainees this often happens around session #7 — truly it's more variable than that — when the patient has voiced all his or her prepared topics, said everything already known or consciously felt about the issues, and offered all the background he or she believes is relevant.  The patient may then appeal to the therapist for guidance, not in any profound sense, but simply to suggest something to talk about, so they don't sit there in awkward silence. A dynamic therapist typically turns this back on the hapless patient:  "Say anything that comes to mind."  This challenge can bring therapy to a grinding halt — or trigger the start of genuine exploration.  For it is only when the patient speaks unrehearsed and without self-censorship, in the moment, that the two can observe the here-and-now workings of the patient's mind.  It has been mere preamble up to this point, groundwork at best and chit-chat at worst, not the real work of dynamic psychotherapy.  Speaking "without a script" allows topics to arise that are impolite, uncomfortable, and awkward, ideas the patient previously thought but chose not to say, feelings that had been brushed aside up to that point.  Some patients unfortunately cannot speak without a script; it is too scary and they are too defensive.  Dynamic therapy ends at that point, although emotional support and cognitive techniques may still prove very helpful.  But for those with the courage to look at themselves, their own defenses, resistance, and unconscious motivation, it's time to dive in and explore the unknown.

In a similar vein, patients at any stage of treatment sometimes arrive to a session with nothing to discuss that day.  They exude an uncharacteristic blandness or boredom, as if to signal: "Nothing to see here, just move along."  With a mildly apologetic tone they claim to have no burning issues, nothing especially vexing or troubling.  In fact, maybe it's time to talk about wrapping up treatment...

If this presentation stands in contrast to the patient's usual enthusiasm, I take it as a very good sign.  Something emotionally important is going on, and the patient's Unconscious is trying desperately to throw us off the trail.  In the language of dynamic therapy, this is resistance: unconscious effort to avoid painful or troubling material in therapy.  Some patients employ this sort of resistance constantly, and for this reason are either very challenging to treat, or they "vote with their feet" and leave treatment early in the process.  But when a new resistance stands in clear contrast to the patient's typical openness, it is easier for the therapist to recognize it, easier to point it out to the patient (who is more open to hearing about it), and easier to identify dynamics that may underlie it.

In my experience, these unusually boring or bland openings lead, more often than not, to the best sessions.  Because the patient is not consciously avoiding a troubling issue, and because I rarely know at first what motivates the patient's avoidance that day, it becomes a shared exploration where new discoveries and insights come to light.  For reasons I can't quite explain, the factors motivating such resistance are not deeply buried or inaccessible.  They usually become apparent to both of us well within the 50-minute hour.  "Making the unconscious conscious" (in Freud's famous words) leads the patient to new and unexpected insights — usually a delightful experience for us both — and also to clearing of the leaden resistance, which is no longer needed to keep the material out of consciousness.  Rather than heralding the end of the treatment, awkward silence at the start of an hour, like the awkwardness near the start of many a dynamic psychotherapy, points the way to important thoughts and feelings.  It turns out there is a lot to talk about.

Psychotherapy branding and marketing

I just read a mildly disturbing article in the New York Times called "What Brand Is Your Therapist?"   The author Lori Gottlieb was a full-time journalist who took six years to retrain as a psychotherapist — her website, but not the article, says she has a master's degree in clinical psychology.  Yet she found herself virtually unemployed after several months and in search of marketing consultants to attract clients.  The thrust of the article is that such marketing involves branding, i.e., defining a niche that promises quick, painless, easily grasped results, and then promoting oneself online and elsewhere using that brand. Gottlieb is clearly uncomfortable about the trade-offs inherent in branding and marketing psychotherapy services.  Traditional psychotherapy is often painstaking, uncomfortable, and lengthy, and thus hard to sell.  In contrast, one-time phone consultations and executive coaching are brief, feel-good interventions that lend themselves to snappy, positive catchphrases that sell better.  Such services may be "fast-food therapy — something that feels good but isn’t as good for you; something palatable without a lot of substance."  Moreover, she notes that many sales techniques clash with the tenets of traditional psychodynamic therapy.  Sharing personal details makes one more approachable and "human," at the cost of complicating and possibly precluding transference work.  Active use of social media such as Facebook and Twitter can attract potential clients and publicize one's "brand," but may also blur relationship boundaries essential for effective psychotherapy.  Gottlieb lays out the dilemmas well in her article, but her practice website illustrates the practical conclusion: Lots of "selling" of various services, few of which are recognizable as psychotherapy.

Of course, I am writing this on my psychiatry blog, which is linked to my own practice website.  I too have grappled with similar trade-offs.  I launched my website over five years ago, and started the blog about a year later.  Several months ago I heeded marketing advice I found online:  I re-wrote my website in the first-person and added photographs.  I expanded the sections on my hospital committee work and past research.  I included more practical information about my practice.

Like Gottlieb, I had mixed feelings about doing this.  On the one hand, helping potential patients make more informed choices sounds innocuous enough.  I want suffering people to be able to find me and to know what I can help with.  I want the process of engaging in psychotherapy to be as transparent as possible.  I explain what I do, and even list my fees on my website (most of my peers don't).

On the other hand, I'm concerned that branding and marketing commodifies a personal healing relationship.  It offers to treat psychological issues in little bite-sized pieces, misleadingly suggesting that therapy to resolve one's indecision about marrying, say, can be completely separate and distinct from therapy to deal with career indecision.  It conflates psychotherapy with counseling and coaching, all of which are useful but different things.  Mainly it risks dumbing down psychotherapy.  Psychotherapy is often complex if done carefully, and in my opinion it can't be conducted as well over the phone, by email, while sitting by the pool with Skype running on one's laptop, or in a guaranteed four-session package.

I haven't availed myself of the whole branding arsenal, since I strive to maintain a psychotherapy practice worthy of the name.  If I ever write a book, offer coaching services, or engage in public speaking, those activities will be clearly distinct from my role as a psychotherapy-oriented psychiatrist.  Moreover, patients and would-be patients seem to agree that informational websites are useful, but that too much branding and self-promotion by a psychotherapist is a turn-off.  That makes good sense, and encourages me to take another look at my own website — I may turn it down a little.  What do you think?