So the efficacy debate doesn’t matter, but only in so far as it’s moot to the powers that be. For providers (therapists) of all traditions it can also be moot to one degree or another. Perhaps suspecting that evidence-based research is a ‘sham’ (as Jonathan Shedler puts it), therapists can diversify their approaches, be flexible, incorporate interventions that don’t fit prescribed models because control of the process from the top is… illusory? As stated earlier, depth therapy providers can at times aim their interventions at cognitions and not affect; CBT providers can aim their words at cognitions but hold knowledge of an intrapsychic defense structure. If a client or patient (I know. I use the terms interchangeably. Sorry) asks in a session, “Do you find me boring,” it’s not from the CBT workbook or ‘cookbook’ to demur upon gratifying curiosity while exploring the meaning of the question itself. The pedigree of that approach is clearly psychodynamic, counter to the social norm of saying “of course not!” (to spare rather than understand feelings), and is understood as an accepted technique by all but the most pedestrian members of my profession.
And there are countless other moments that call for an effort to understand rather than soothe. However, I think most providers, working variously upon a taut schedule and budget, become selective. Highly selective. In my book, Working Through Rehab, I opine that psychodynamic depth-therapy models are not so much prohibited as institutionally proscribed. In most mental health agencies, hospitals, especially, there’s no one listening in on a consistent basis, determining that interventions fit the principles of CBT versus alternative approaches. It’s more that the conditions imposed on providers and consumers lend themselves to CBT methods, and at least make more difficult a committed psychodynamic approach. On one level, these conditions include limited numbers of sessions authorized, reflecting expectations of linear treatment progress; frozen reimbursement rates for providers, which incline them to respond to rising costs with more patients, which in turn makes more difficult a depth approach with any given individual; in many but not all contexts, the requirement of copious documentation, intended to support interventions (rarely achieving this, actually), which also impinges upon providers’ tasks.
But let me give (finally?) a subtler illustration of how mental health systems (agencies, insurance providers) intrude upon a therapeutic process. In order to understand the following case anecdote, the reader must first understand something about the concept of transference, which pertains to unconscious thoughts and feelings, drawn from past relationships, which manifest in relationships between therapists and patients. Across theoretical orientations, transference is understood as an essential ingredient of a therapeutic episode (despite not being an evidence-based phenomenon); one that must be attended to by a therapist, otherwise therapy is undermined. This transpires via what James Masterson once termed transference acting out: a variation on transference wherein the patient acts out (unconsciously) old and pathological relationship patterns. Examples include missing appointments, arriving late, or not paying fees (or co-pays)—behaviors that constitute passive resistance to treatment, difficulties with authority, or responsibility-taking, that mirror broader problems in life. From the moment a trainee therapist first sits with a patient, he or she is told by a clinical supervisor that such behaviors ARE important; that they must be addressed directly, or else real therapy won’t occur.
So consider a patient who is acting out a resistance to therapy via missed sessions, late cancellations or lateness, versus talking about ambivalence to treatment openly, even consciously. In the extant system of managed care, a therapist can treat those behaviors as examples of transference acting out, but will have to do so on his or her own dime, so to speak. Meaning, they cannot charge the patient for missed appointments, or bill the insurance company for missed sessions (unless acting fraudulently), because technically no service is provided if there are no sessions. In the minds of administrators, nothing is happening when this occurs. So the patient is not held responsible for missed sessions, which in turn undermines efforts to explore the behavior’s meaning if and when the person does return to therapy. After all, why should they take seriously a behavior for which there is no consequence?
Why won’t third party payers observe the bedrock principles of psychotherapy? Because they only reimburse that which is observable; because transference is not an evidence-based phenomenon; because the administrators of our populist, utilitarian mental health system (third party payers, funding sources and insurance), utilize the rubric of “medical necessity”, authorizing services which are intended to reduce an observable syndrome of pathology, not “contain” the projections of a disordered intrapsychic structure, in part because they wouldn’t know what that last clause means. Insurance companies might mimic CBT practitioners by, as one supervisor of mine once put it, acting as if the unconscious doesn’t exist, but more importantly, they won’t pay for its unfolding process, whether they understand it or not. Assuming a provider relations official would engage me on this subject, he or she would likely suggest that a beneficiary who repeatedly misses sessions be fired; meaning, that their therapy be terminated. Beyond that, there would be little room for confronting acting out behavior, holding the patient responsible for resistant behavior while “holding” therapeutic space available—again, unless the provider is willing to foot the bill for missed sessions.
The following is not an overstatement: those within the psychoanalytic community argue that the implications of this kind of system-wide policy are profound. Recently, a patient I see via a public health contract missed back-to-back sessions. Days later he called to apologize, knowing I couldn’t bill for the missed sessions, and also knowing that I was contractually bound to not charge him. He offered to withdraw from therapy, expressing regret and feeling disentitled, and proclaiming that there were others more needy or deserving that could use my services. On the one hand, it seemed a craven gesture, this passive retreat. But it also seemed to reflect a rather sad and commonplace expectation: that failure will be ruthlessly punished, with no conversation necessary; that individuals are replaceable, or that conflicts are best dealt with swiftly; that is, until the next one arises, thus cycles perpetuate. I think there are few in our culture who would have called for a suspended sentence in the above instance, much less a protracted discussion, yet this is what I did, reeling this man back in with my interpretations of inner conflict while absorbing the cost of his absences. I’m not looking for applause, for there’s certainly a limit to how often I can do this if I want to make a living. But I am echoing the psychoanalysts’ utilitarian-balking complaint. Borrowing language from behaviorism (turnaround is fair play), they’d assert that extant policies of mental health systems reinforce a societal tendency towards splitting: of dualism, black and white, either/or, all-or-nothing (pick your synonym) thinking and being, wherein the lines are drawn between stay or go, profit and loss; the good and the bad, the evidenced-based and the not. The space for a longer, slower, more involved, subtler exchange between what Bion called the container and the contained is squeezed in our national apparatus of care—some say destroyed, leaving in its place a system beset with pathos. You can disagree if you like but remember, you won’t get paid for your time.