Psychoanalytic Therapy as Health Care: Effectiveness and Economics in the 21st Century (Book Review)
Author: Kaley, Harriette, Eagle, Morris N., & Wolitzky, David L. (Editors)
Publisher: Hillsdale, NJ: Analytic Press, 1999
Reviewed By: Elaine J. Belz, Summer 2001, pp. 59-61
On mornings when I ride the train to my office and to the analytic training program I attend in New York City I see an advertisement from a well known managed care company. The message is as follows: “Our providers are among the most highly trained clinicians in their specialty fields.” I think to myself: “I’m one of their providers. Are they referring to me? Are psychoanalysts the highly trained clinicians they are advertising to prospective customers?” Probably not. I begin to wonder about the choices I have made regarding my professional development. In particular, I question my decision to pursue both analytic training and to work with a managed care system. The editors of this highly readable book set out to examine these vexing questions and have conducted a serious and comprehensive review of the challenges facing psychoanalytic therapy in the present health care environment--an environment that has been dominated largely by the managed care industry.
Psychoanalytic Therapy as Health Care addresses some highly controversial issues in the practice field. Both economic and political perspectives are examined, and rather cogent arguments are presented as to why psychoanalysis cannot function properly within the prevailing health care system. The provocative subtitle, Effectiveness and Economics in the 21st Century, reminds us that, unless we are vigilant, the managed care marketplace, in its preoccupation with cost containment, is shaping the future of our profession. The editors have divided Psychoanalytic Therapy as Health Care into four, somewhat arbitrary sections, each of which considers different aspects of the issues currently facing the development and delivery of mental health services, particularly psychoanalytically-oriented treatment. Introductory comments by the editors emphasize that the contributing authors are concerned with all forms of psychoanalytically-informed treatment, not just psychoanalysis. They emphasize that psychoanalytic treatment has been under exceptional scrutiny by many in the managed care establishment, since it tends to be associated with increased length of time and is less concerned with the achievement of symptom reduction.
Part I focuses on the status of the current mental health care system and some possible directions for meaningful alternatives. In the chapter entitled “Why Psychoanalysis is not a Health Care Profession” Marvin Hyman argues how the medical model is fundamentally opposed to the principles of psychoanalysis. He describes how the medical patient, unlike the psychoanalytic patient, “consciously defines him or herself as not responsible for the condition that is presented,” and that medical treatment consists mainly of “the professional’s doing to and for the patient” (p. 89). Hyman’s comments are grounded in the traditional medical model, which privileges authority, pathology and biology. Stanley Moldawsky takes a slightly different view and characterizes psychoanalysis as alternative healthcare. He emphasizes the need to educate the public, our legislators and our patients in terms of how unconscious processes affect individual experience and what it takes to achieve improvement in one’s condition. He supports continued involvement in the health care system in order to influence change.
In Part II Psychoanalytic Therapy as Health Care the authors address what may be the most important legal and ethical challenges facing psychoanalytic therapy today--confidentiality, privacy and third party reporting. Russ Newman’s brief chapter on “Confidentiality and Privacy” outlines how reporting guidelines actually function less effectively in practice than in theory. David Sundelson discusses some interesting and controversial cases where reporting became a crucial issue. He asserts that psychologists must seek to restore the “confessional aspect” of psychotherapeutic treatment where it can be valued as a “space set aside by social and legal agreement for the essential work of psychic healing” (p.102).
The status of mental health care systems in other countries is reviewed in Part III with results that are enlightening, albeit sometimes disturbing. German analysts have been effectively involved in public health care debate and have made some real advances in advocating for the public to have access to a variety of psychological health care professionals. Canada’s system is viewed as both discriminatory and outdated in that only medical practitioners are funded by the national health care system.
Part IV is composed of articles specifically written for this book and covers special topics, such as working in diverse treatment settings and with special populations. Mark Blechner, for example, discusses the use of psychoanalysis with AIDS patients. Eric Plakun reports on the Austin Riggs Center in Massachusetts and on how this institution survived the arrival of managed care. He also emphasized how psychoanalytic treatment is particularly useful when working with more disturbed cases in an institutional system. Neil Altman’s chapter on clinical work in the inner city illustrates how a psychoanalytic orientation is essential to treatment of cases where race, culture and social class converge.
The book covers an eclectic array of topics and the overall impact of the collection of articles seem to be affected as a result. Some chapters take on a more philosophical tone and criticize the psychology profession for being too passive and apathetic about pressing issues. One chapter was derived from Dorothy Cantor’s keynote address to the New Jersey Psychological Association about the strategies that have been undertaken to address the conflicts between professional psychology and the managed care industry. Other chapters broadly surveyed political issues in other countries throughout the world, or described programmatic models that have been successfully implemented. No doubt it is difficult to integrate legal, political, philosophical and clinical issues all in one text.
It seems to me that there are some critical issues that need more thorough consideration in any discussion of psychoanalytic therapy and the healthcare industry in the United States. It is important to remember that, inasmuch the traditional model of healthcare as it has been practiced in many diverse settings throughout the country is being challenged by managed care, it is also true that there are significant opportunities for shaping a more responsive and effective healthcare model. Current trends in medical center healthcare, for example, emphasize the integration of biological, psychological and social factors affecting wellness and disease. Psychoanalytic principles are uniquely relevant and applicable to this type of integrated thinking. Physicians are being taught to take a more holistic view when they treat their patients. In the institution where I work medical doctors seek out consultations with psychoanalytically informed psychologists, not only to help them understand their patient’s behavior, but also to secure a more appropriate treatment. Recognition is being given to the complexity of emotional experience and its contribution to disease and poor health. Psychoanalytic treatment is fundamentally a meaning-making process and, as Eisold (2000) has noted, psychoanalytic therapists focus on identifying and exploring the gaps in what we think we know. Psychoanalytically informed treatment seeks to understand that which has been disavowed, forgotten, or dissociated. It consists of helping patients develop their “capacity to think about parts of their experience that have been disabled by anxiety and fear” (Eisold, 2000, p. 62).
What does the patient think his GI distress is telling him and how will his thinking about eating and elimination affect his motivation to change unhealthy behaviors? What does the AIDS patient or the cancer patient believe about why he contracted the disease? How does it influence his expectations and recovery? Between the physician and his patient’s disease is an individual who constructs a psychological experience of his body. Many refer to this as the behavioral aspects of healthcare. Analysts think of it as “the mutual interplay of the body-mind and mind-body” (Aron, 1996, p. 3).
Indeed, psychoanalysts are the experts--“the highly trained clinicians”--who have a substantial contribution to make in the conceptualization of what constitutes well being and what contributes to ill health. Within the profession we need to articulate how that knowledge can be incorporated into what is essentially an emerging healthcare system. As we achieve a sensibility about this, we also need to reach beyond our closed doors and collaborate with other disciplines, particularly medicine. How can we maintain the psychoanalytic frame and participate in collaborative multidisciplinary efforts? Plakun spoke about this when he reviewed the Austin Riggs Center reorganization. He suggested that the use of an interpretive focus in the analytic perspective “organizes, integrates and coordinates an otherwise chaotic set of problems” (p. 252-253). I am impressed and encouraged by the outreach I have observed on the part of the physicians I work with. To the extent that documentation of the effectiveness of psychoanalytic treatment is called for, we should seek to design research and evaluation projects that are multidisciplinary in nature.
In general, separate systems for mental health and medical care are being discarded and replaced with new, more integrated models. Current training in medicine, for example, emphasizes that physicians assume a more collaborative role with the patient. New Graduate Medical Education regulations instituted in 2001 require that physicians proactively involve other disciplines, such as psychology, to advance the health care of their patients. Thus, I think analysts can now be more than critics of an “evil” system who stand on the outside advocating for change. Psychoanalytically-informed theorists and practitioners can directly influence the way health care treatment is conceptualized and delivered.
Aron and Anderson’s (1996) edited volume entitled Relational Perspectives on the Body describes clinical interventions with individuals whose discomfort is somatically manifested. Psychoanalytically informed inquiry increases our understanding of how unconscious material, suspended just out of awareness, is signaled in bodily states and how emotional experience is registered and metabolized. We can provide valuable assistance to the medical community as it begins to shift away from viewing the body as a machine and articulate “a more plastic and complex ‘body’ where inside and outside fold around each other and distinctions like inside and outside are abstractions” (Harris, 1996, p. 61).
The editors of Psychoanalytic Therapy as Health Carehave concluded that at the heart of the matter is a fundamental clash of values between the health care professionals who are committed to the delivery of best possible care and the forces of cost containment stemming from the managed care industry. To my mind psychoanalytically-oriented therapy will remain an important treatment option in the evolving healthcare systems because it so thoroughly integrates the conception of an individual’s overall sense of well being and malaise. As noted by the editors, psychoanalytically oriented therapy should be considered a core discipline of all the therapies including cognitive, behavioral and brief therapies. There is every reason to believe that it can survive and should flourish in most treatment settings and health care systems. The more disturbing question is how to maintain psychoanalysis, itself, as a legitimate, appropriate and effective treatment approach. Perhaps, however, the issue has been construed as a false dichotomy between psychoanalytic therapy, on the one hand, and psychoanalysis, on the other. How can we determine where the former ends and the latter begins, and furthermore, why should we?
Finally, and perhaps most importantly, it remains for analytic clinicians to demonstrate that psychoanalytic treatment in all of it forms goes beyond the goal of eliminating the patient’s symptoms. It is particularly meaningful because it helps patients “reduce significantly their vulnerability to future psychopathology and impairment in adaptive functioning” (p. 277). As analysts our goal is to improve the quality of our patients’ experience as individuals who are fully alive human beings. Whether the insurance industry can afford to accept this as a reimbursable service remains to be seen. In any event, it clearly falls to mental health professionals to “broadcast that it is a small cost item critical to the care of many deeply suffering people” (Eist, cited in Kaley, Eagle & Wolitzky, p. 275).
Aron, L. (1996). The Clinical body and the reflexive mind. In L. Aron & Anderson, F. S. (Eds.),
Relational perspectives on the body. Hillsdale, NJ: Analytic Press. pp. 3-37.
Eisold, K. (2000). The rediscovery of the unknown: an inquiry into psychoanalytic praxis. Contemporary Psychoanalysis, 36, 57-75.
Harris, A. (1996). Psychic envelopes and sonorous baths. In L. Aron & Anderson, F. S (Eds.), Relational perspectives on the body. Hillsdale, NJ: Analytic Press. pp. 39-64.
Elaine Belz is a candidate in the Postdoctoral Program in Psychotherapy and Psychoanalysis at New York University, and is Assistant Director of Psychology Training at the Brooklyn Campus of the VA New York Harbor Healthcare System. She is a member of the Medical Center’s Primary Care Quality Improvement Team and has served on other steering committees, including the Sexual Trauma Advisory Team. Dr. Belz is President-elect of the Middlesex County Association of Psychologists. She maintains a psychotherapy practice in New York City and in South Plainfield, New Jersey where she treats adult and adolescent patients.
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