What if psychoanalysis were available in your internist's office?
SCOTTSDALE, ARIZ. -- That grumpy grimace is not the face of today's pscyhoanalysis, even if it is the mug of the man who "invented" the notion of using your words as keys to unlock you from your prison of tortuous memory. Whereas the neurologist Sigmund Freud's notion that mental disorder was the constant re-enactment of childhood discontents, today's psychotherapists have helped evolve the treatment modality away from memory as the enemy, and detachment from the patient as therapeutic, to it instead being a partnership between two people, one of whom just happens to have training in how to use words as excavation picks. But who has time for so much talk? Isn't it easier to pop the pill and get on with things?
As I reported recently, for much of the 20th century, psychoanalysis was the leading outpatient psychiatric therapy. Beginning in the late 1980s, its star began to fade with the rise of safer psychotropics, the outcomes of which are easier to quantify. It also takes less time to see results with drug therapy in the clinical setting, compared with the various forms of psychotherapies – some of which require three or more visits weekly. Here's what Robert Michels, MD, a Walsh McDermott University Professor of Medicine, and professor of psychiatry, at Cornell University, New York, told me recently at the annual meeting of the American College of Psychiatrists.
“There’s a great deal of discussion about whether psychoanalysis has an adequate evidence base. That’s a popular concept. It’s not so much about whether practitioners want to use it, but whether or not they can defend using it in their dialogues with insurance companies, government agencies, and other sources of support. My summary is that it has less adequate data supporting it [than pharmacologic interventions]. … There is, however, convincing evidence that all of these treatments, ranging from cognitive-behavioral therapy to [dialectical behavior therapy], to dynamic psychoanalysis, to mentalization-based treatment, do have an effect.”
I am noting an uptick in psychoanalytic activity in the zeitgeist, perhaps in part because we have such a mystifying political situation on our hands, and many such as psychoanalyst Steven Reisner are trying to make sense of the how and the why of the White House. I think it's also to do with the fact that older psychoanalysts are considering their legacies, as STAT contributor Carter Maness reported that some in the field are urging their colleagues to cooperate with data collection.
My own personal theory hinges on the concept of scarcity: Whereas the goal of pharmacotherapy is cure, the point of psychoanalysis is to derive meaning from neurosis, and ultimately, from life. In a world where every single material resource is finite, and the number of people vying for those resources continues to increase exponentially (consider that in less than 15 years, there will be 11 billion humans on this planet), the only resource left to which we have potentially unfettered access is our own minds.
When I see images of the brain, the many tangled spires of neurons look like roadways, however jumbled. Consider that all those internal information highways and byways are conveying information, including our thoughts, which when we pay attention to them, are revealed to us in words and pictures. Words tell stories. Stories are maps. Maps imply destination. And having a sense of destiny, however mundane, is what gets us out of bed. Meanwhile, on Capitol Hill where how to provide access to basic healthcare seems to muddle the minds of most of the elected officials marching around in their suits and ties, looking backward instead of forward, here's what the ACP's program chair Scott T. Aaronson, MD, director of clinical research at the Sheppard Pratt Health System in Baltimore, told me about the tension between providing what works in psychiatry vs. what healthcare plans will cover:
“I don’t think that psychoanalysis has ever been a great friend of insurance. I think we need to educate insurance companies on what psychotherapy means. Instead, we just sort of allow them to make rules. It’s been a one-way street that needs to change."
Yes, I agree. But, because there is no cash incentive for anyone other than the therapist to offer talk therapies, good luck with that. Data collection will help legitimize it, but until it can be charted as a revenue stream, you won't see much cash flowing towards it.
The real challenge for psychoanalysts is to get around the gatekeepers. Whether or not they want to admit it, a common complaint primary care physicians have about working with psychiatrists is that they are arrogant at worst, aloof at best. But if there could be a way to partner with primary care clinics to provide more talk therapies, I think the basis of support for keeping the field alive would grow. By making friends with the generalists, psychoanalysts can ensure their relevance. Not saying they aren't--just encouraging more to do so. There is an economic component to this: regardless of whatever happens with federal healthcare policies, we have entered the vale-based care era, where overall outcomes indicate how physicians are paid. Mental healthcare is finally becoming a well-established component of total health, which means however you provide it, it will eventually prove to have been worth the investment. In Mental Health Consult, my colleague, Lorenzo Norris, MD, a psychiatrist and the assistant dean of students at the George Washington University School of Medicine, and I worked with both policy, academic, and clinical leaders to explore how to provide effective psychiatric care in 15 minutes or less, which is what clinicians are forced evermore to do--GEICO-ize their services.
I understand that psychoanalysis is a highly refined, years-in-the-making skill, but it starts with something that every single physician should know how to do: listen. And then it builds off the second thing they should know how to do: ask the right question.
Although Dr. Michels made the point to me that the global medical education curriculum is tight, as there is only so much time to teach too many things, I do wonder if our medical schools are really so pressed for time that they can't help our future physicians learn how to have a good conversation.
Why should an insurance company--or anyone else--prevent a patient and his or her healthcare provider from having a meaningful conversation? In a world of shrinking resources, knowing we matter enough to be heard can go a long way to healing.