I was in terrible pain. There was a darkness in my soul and I didn’t know where it was coming from so I finally decided to see a psychotherapist. A friend suggested that maybe I was dealing with issues of aging—illness, abandonment, death and so forth—so I called a couple of agencies and looked on the Mental Health Association’s web site under “aging, elderly and geriatric,” and I found nothing. I heard “Oh, we don’t do that.” You get old and start feeling useless and unwanted, seek professional help, and discover that you really are unwanted. Ain’t it great to be an American?
So I stopped saying it was issues of old age and just started saying I was depressed. God knows, the system deals with that. I called people I knew and asked for help and/or referrals, then I called people and agencies I didn’t know and asked. What I found out was that money matters more than I do. I’d call, somebody would answer, we’d go through name, rank and serial number, then I’d be asked what insurance I have. I would answer “Medicare primary, Medicaid secondary,” and the call-taker would say, “Oh, we don’t accept that.”
The official government insurance is not accepted by mental health care practitioners. Ain’t that a bitch? What’s the point of having insurance if it won’t pay for treatment? A good psychiatrist charges about $150 a session. He is only allowed to bill Medicare $100—and Medicare only pays 50%. The doctor’s office practice is based on $150, but Medicare only pays $50, one-third his cost. For medical care, as opposed to psychiatric care, Medicare pays 80%. The rates are progressively lower as you go down the scale through psychologist and clinical social worker. Unlike Medicare, Medicaid only pays about $10 a session. It is, therefore, official government policy to drive us all to taking drugs: pills are cheaper than personal care.
One agency I called asked me what my insurance is before they asked me my name. You don’t want to go there. Psychotherapy is supposed to be about the person; the patient is supposed to come first. My social worker friend Dick Gottlieb tells the story of having gone to hear Bruno Bettlheim speak. Bettlheim, a secular Jew, was born in Vienna and incarcerated in a concentration camp before coming to America and gaining prominence in the compassionate care of children with emotional problems. In the question and answer period following his speech, a young psychiatrist asked “What should I do if my agency will only let me see a patient for six months?”
My social worker friend Dick Gottlieb tells the story of having gone to hear Bruno Bettelheim speak. Bettelheim, a secular Jew, was born in Vienna and incarcerated in a concentration camp before coming to America and gaining prominence in the compassionate care of children with emotional problems. In the question and answer period following his speech, a young psychiatrist asked “What should I do if my agency will only let me see a patient for six months?”
Bettelheim, in his deep Germanic tone, replied quietly, “Bullshit!”
The startled psychiatrist said, “Dr. Bettelheim, what if the patient needs more than six months treatment but my agency won’t let me provide it?”
Bettelheim again said “bullshit.” Across the room, another man rose and stated that he worked in the same agency and could attest to the accuracy of his colleague’s concern. Bettelheim, in a louder tone, said, “And to you I say bullshit, too.” The audience, made up of professionals in the field, started to murmur their discomfort. Bettelheim quieted them down, turned to the first questioner and said, “Tell me what you do on Sundays.”
“Ah,” stumbled the psychiatrist, “I spend the day with my family, we cook out on the grill . . .”
“You do not see patients?” asked Bettelheim.
“No,” replied the psychiatrist.
“Well, I’m not paid to work on Sundays,” was the reply.
Triumphantly, Bettelheim bellowed, “Ah-ha! It is not a question of agency limitations; it is a question of money. I’m not suggesting you work on Sundays for no compensation. I’m only suggesting that you be honest with yourself about it.”
What you and I need—what we want and what works—is therapy in which we are more important than the money. I’m not saying that mental health practitioners should work for free, but that we should be somewhat more important than the money. Last year I wanted to go to Dr. Peter Breggin’s Empathic Therapy Conference for care providers but was late registering. Ginger Breggin, the organization’s executive director, said that wasn’t a problem so then I asked if I could get an accommodation on the rate. She asked about my circumstances. I told her I was on Social Security Disability consequent to damage by psychiatrists and she said, “Oh, just come; come.” I was more important than the money.
If your therapist doesn’t think you are most important then don’t go there. They are now teaching university students “patient-centered” therapy: it’s not about what the therapist decides to give; it’s about what the patient needs to get. In short, you ask the patient where it hurts, and proceed from there. Does that seem obvious? It’s not the historical way of doing it. Traditionally, the doctor decided what was wrong with you and what treatment he should provide without reference to what you said was wrong and what you thought would help.
So this summer a young clinical social worker, in the time between graduating from university and passing her licensing exam, went to a big three-day “client-centered” conference. She was eagerly telling me about all she had learned when I asked her, “How many clients were there?”
She looked shocked and stuttered, “N-n-none.” Despite wordplay in which the therapist tells the patient that they are entering on a collaborative journey, we continue to teach that the patient is the least important element in psychotherapy.