https://www.forewordreviews.com/reviews/venus-looks-down-on-a-prairie-vole/
2 stars…hmm. Maybe I’ll try a children’s story
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The ins and outs of porn
Nothing like a little innuendo to start a blog that is both serious and comic in nature, but if you’re waiting to read about best porn sites on the internet, you’ll be greatly disappointed, for this entry is about as anti-porn as it gets, ironically. This entry is all about the written word and the long narrative—things porn dispensed with almost from the get-go of its existence.
Reviews are available of my porn-on-the-periphery novel, Venus Looks Down On A Prairie Vole: mostly lukewarm responses from the likes of Kirkus and Clarion, who seem to regard my writing as competent, if unremarkable, but take issue with my central character, thinking him unlikeable, a drag upon a worthy cause. The only thing that’s surprising is their reticence. You’d think reviewers would spend a bit less time/print giving synopsis; a bit more time reviewing prose, plot or character development. Daniel Pierce, my protagonist, is indeed an unhappy guy, as the Clarion reviewer points out. He is perhaps arrogant as Kirkus observes. But I’d expected to read more about why reviewers think this, and beyond that, to wonder. It’s strange to me that while people in my profession are used to seeing beyond defenses into what’s inside another (in other words, observing that which is not expressed explicitly), readers expect conscious endeavor, and reject characters who won’t say what readers want them to. In writing Venus, I knew I’d annoy progressives with my teasing of feminist cliches, what I think are tired attacks upon porn. I’d expect disapproval from 12-step adherents, who may not care for my lampooning of drug treatment, or the casual misuse of recovery principles. Both these factions, plus old school paternalists—everyone—might resent my implied sympathy towards sex offenders. As Daniel observes towards the beginning, you the reader might not like what he’s about to share.
Of all these contentious themes, porn gets the spotlight today. It’s in your face, as Daniel comments. Here’s a sample from the text:
“You see, in sex, real sex, not porn sex, eyes are the thing; the personal center. I know because I don’t have great eyes or facial symmetry, which hasn’t helped my pursuit of sex—well, except when light flatters me, when no one is around to look. I wish it were different, not that I want more sex these days. I just wish I knew what makes a pair of eyes great. When I hear people say, “so and so has pretty eyes”, I always wonder what they’re referring to, because compliments tend to be unspecific. Is it the color, the shade, or size, or what my mom, my first gal, used to call “the shine” that dots the pupils? The women of porn stare into cameras seducing viewers with their eyes, big pupils and all, plus their dirtied personalities, looking undignified, yet ambiguously powerful; ambiguously not, I guess. They say—some say—that the women of porn are in it for the power, the sexual power, not the money. Are they? I don’t know, though if you ask me, no one’s coming out of porn looking or feeling their best. The real issue—the real offense to the egalitarian way—is the air of servitude, for what porn really does is arrest women into roles of pleasing. Don’t agree? Go watch some porn”
Actually, eyes are secondary. The penis is the star—the object, if you will—of porn, Daniel remarks, adding that they are in our faces, and “literally in women’s”. These are examples of his flippant, crude armchair views, and a portent of more earnest commentary later on in the story. Venus echoes an argument I first read in Martin Amis’ Money, written thirty five years ago when porn existed only in magazines or in seedy, downtown theaters—maybe videotapes. Money is a masterpiece of gritty, maverick literature. In it, a character (Amis himself, actually) says to John Self, the protagonist, that pornography objectifies women and men equally. Self, a debauched porn addict himself, jovially disagrees, saying that men don’t or wouldn’t mind being so objectified, especially for money (his stand-by argument about everything). Amis rebukes this assumption, claiming he and most men wouldn’t have sex for money, thus pointing out that all involved in porn are exploited. Lira, my women’s advocate/former prostitute in Venus, argues that whatever exploitation of men exists in porn is irrelevant, as men are the dominant consumers. Daniel retorts that if the consumer is the oppressor, then we are all oppressors in our consumer society, and that scapegoating sex for the problem of exploitation merely exposes western prurience.
This is not to say that he’s a fan of porn. In fact, he finds it cold, cynical and narcissistic, though he shamefacedly indulges on occasion when feeling disconnected. But like myself, he’s wary of the righteous; distrustful of zeitgeist opinion, well-marketed, sound-bitten ideas, and therefore has a soft spot for the demonized consumer. This leads him to work with sex addicts in his practice, and with some sex offenders, though he demurs on most cases mired in a legal process. Meanwhile, serendipity places him the company of Rick, ostensibly a chef whom Daniel meets when working shifts at a restaurant during his practice-shedding hiatus. Later, it turns out that Rick is a budding porn actor who goes by the name Kane Able, a typical double entendre slapped on for parody’s sake. So, too, are some scenarios that are common to porn’s semi-theater: the fireman or policeman skit-gimmicks, enacted with thin, tongue-in-cheek pretense, which play upon themes of heroism, damsels in distress and the pull for male sacrifice; abuse of authority, plus the chance to fashion dialogue replete with daft innuendo, silly plays upon words. As a result, Venus is filled with plays upon words, at times mimicking the artifices of porn; otherwise providing a kind of parallel script alongside the action.
Amidst all of this, Venus drops down into a serious contemplation of sex and gender politics. In its subtext it observes a shift in mores, from the castigation of female sexuality, to a back-handed latter-day quest for more freedom, but to what end? For men, the freedom train is heading in the opposite direction. Former license(s) is being revoked, yielding more punishments, weaker performance, and more anxiety, even as advertising media goads them to take the same old risks. Porn offers a kind of refuge to those who are not sure that sex, as in regular intimacy-enhancing, not-paid-for sex, is worth the effort or the risks. With respect to this problem, Daniel Pierce is an outsider: he’s too old to have known the ubiquity of porn prior to his marriage or to have experienced dating as the online shopping exercise it currently is. In a sense, he is safe from contaminated society, but still he is adrift, a closet romantic largely suppressing comment but now seizing a moment with an unlikely listener. Lira listens well enough, but like my reviewers, I think, doesn’t really connect with him. I realize that’s what Daniel Pierce’s story is about: a lament for what is missed.
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Tommy
No essay, just a link. Check it out…
http://cap.sagepub.com/content/22/1/94.abstract
and read the following blogs: “Ever since I was a young boy”, “Your mind must learn to roam”, “You didn’t hear it. You didn’t See it”, “Listening to you”
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About reviews, popularity
Ever get the feeling someone’s trying to tell you something by not telling you something? Psychotherapists (that identifier feels awkward for some reason) have to learn to interpret the unsaid, by thinking about non-verbal information: everything from muted sighs to averted glances at a hidden clock, to I’m-running-late text messages, belated vacation or business trip announcements; e-mail terminations. Relationships in some people’s lives end with tumbling regularity. Exchanges are transient. Promises are easily given, and more easily withdrawn or better yet, forgotten. If you wrote it down, good for you. Kudos for the documentation, signifying that something meaningful happened.
I don’t spend a lot of time documenting psychotherapy, largely because it makes for dull reading, the type of notes one is meant to write for nosy overseers. It makes for good stories however, not that I can lift them directly from my clients’ shares. Instead, it’s an exercise in grabbing at pieces, tossing them at a blank page, worrying later about the links. For my first four novels I’d picked sketchily from my clients’ backstories, preferring to represent moments, unidentifiable fragments of individuals’ lives, maintaining everyone’s confidentiality. Except mine, of course. It’s several years since my first effort, the much somethinged Living Without Blood, about somebody named Eric Metcalf and his friend Richard something else, coming together after years of gradual estrangement in order to…actually, I’ve forgotten what they did together. I loved LWB at its time of publication—2009. It was my first-born: a sloppy, muddled beginner trying to find its legs after a nine-month labor, but occasionally standing tall, inspired by a self-consciously prosy flow. Skip to 2012: the release of Crystal From The Hills, a picaresque adventure that I’d conceived as a 600-page novel, only to split the story in half, releasing its follow-up, The Situation, two years later. Crystal took three years to write, in sporadic bursts in between semesters of my post-graduate training program at the Masterson Institute. Written three times, suffered over like a still-birthed thesis, it was my best effort thus far I thought, and I was confident enough of its value to submit a manuscript for review, with Kirkus magazine, a reputed den of literary cognoscenti.
Kirkus didn’t like Crystal From The Hills, calling it “sprawling”, “meandering” (a reference to its many flashbacks, childhood background material to make John Bowlbyesque sense of my protagonist’s disturbance). I got my first real taste of a reviewer’s, and presumably an average reader’s distaste for disrupted narrative, impatience with detail. I learned that some might find my prose difficult to read, for it was “ponderous”, “stacking of clauses and syllables”; containing way too much minutia. Gee, had they ever read David Foster Wallace? There wasn’t much complaint (from Kirkus) about the plot as such, or about character development—rather a suggestion that readers prefer heroes to be heroes, or at least charming, as opposed to being self-absorbed underdogs, or as one reader put it, losers. Ironic, for the novel’s underlying theme was empathy, so I did indeed fail in my task. I absorbed the criticism graciously, I think, noting that for my modest investment I’d received more honest feedback in two paragraphs—indeed more feedback, period—than I’d received from most non-paid (friendly or not) readers over the previous three years. Seriously, outside of the odd sympathetic review posted on Amazon, my readers, which include one loving family member, plus a rough crossection of my friendship circle, have given me little interest over the years. Some of them don’t care for psychodrama, preferring sci-fi, fantasy, non-fiction, or pleasant yarns about dogs or foreign travelogues. I think some struggle with the opening pages of my books, are left sucking oxygen within minutes having regarded my prose as if it were like the text of vacuum cleaner manuals. Most think that theme is subordinate to plot, which I agree with to some extent, except that some just don’t register ideas, only action. And some just don’t read. Period.
Oh well.
The effort to engage strangers moved on. The Situation received a warmer review from Kirkus, as in lukewarm, with concessions that it contained less of its predecessor’s flaws, as in less background material, less “meandering” plot. This was a somewhat hollow non-criticism, as the novel was a sequel and therefore did not require much backstory. However, other elements, like theme, the relatively fast pace or crisp prose, plus what I thought were clever plot devices (For example, Crystal’s opening, “He’s dead”, regarding a referenced character named Weed, is mirrored by Weed’s opening line of Situation: “I’m alive”. Reaction from Kirkus: nothing). Clarion/Foreword reviews didn’t notice this and other plot tidbits either, but otherwise offered a glowing review of The Situation, giving me four stars out of five, and remarking that my text was “captivating”, my writing assured; the story humorous, adventurous and fast-paced: gratifying, if not quite redemptive of the story as a whole. Kirkus’ reticence continued to irk me. I held the impression that their reviewer was holding something back, thinking my novel worthwhile but not wanting to say so.
This idea was reinforced earlier this year by their latest (and likely the last I’ll solicit) review, for my new novel, Venus Looks Down On A Prairie Vole. I was cautiously optimistic this time, half thinking my third submission would be the charm, otherwise simply believing my latest novel is pretty damn good. Alas, it was not to be. Upon providing a typically competent synopsis of the plot and a begrudging recognition that I was “drawing attention to an important issue”, Kirkus then complained that my protagonist, the sarcastic, at times pathetic Daniel Pierce, is not likeable. No kidding. According to them, he is pompous, contrarian (like that word, actually), and anti-feminist—a problem, apparently. Actually, as a therapist he’s resolutely neutral: a Bionion depository, as he puts it, “lacking memory or desire” (a famous Wilfred Bion quote). Outside his office he’s not so much anti-feminist as anti that which co-opts platitudes for self-serving aims, which is why he might be unlikeable. I suppose that negativity is not likeable, which I further suppose depends upon point of view. Anyway, it should tell me something, this reaction: something I’ve known at least since high school: in this world, in nearly all endeavors, it’s not enough to be good. BTW: my novel is damn good! But here’s the thing: you have to be liked.
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Names matter, don’t matter
They do if you give them up. Daniel Pierce is a seasoned psychologist, presumably trained to maintain the confidentiality of his patients, or clients as he sometimes calls them. It’s the most important thing he does, he says, and he doesn’t do much. He gives the reader his name, plus that of some others, people who don’t require or deserve the privacy, but otherwise names are a problem. People’s names, place names: they don’t matter, or they are anonymous. My novel, Venus Looks Down On A Prairie Vole, places confidentiality at the center of a host of themes underpinning its plot: that of a jaded counselor taking an impromptu hiatus from his practice, but thwarted in that effort by a stalking ex-prostitute who wants information about a patient whom she says has sexually abused a child. BTW: this ‘thwarting’ was a main reason the novel was originally called Blocked. The blockages are all around: her blocking of his escapism; his blocking of her social intervention; the internal blocks that Daniel Pierce suffers from, that…well, maybe you get the idea.
Daniel is reluctant to give it up, this information she seeks, but he strings the woman along, hopeful of a diversion to juice up his drunken life; or perhaps he’s intrigued by a strange opportunity. See, he’s met numerous people over time who are similar to Lira, the seductress who takes him to a bar, then to her home, and then upon a ride-along through an alternative world-view, that of an activist. Like many unctuous members of society, she wants Daniel to violate his neutral position, the trust that one of his patients has placed in him, in the service of protecting society, and specifically children. But it doesn’t work like that, Daniel rebukes. In fact, he declares that such cavalier heroics will do more harm than good, impinging upon efforts to prevent child abuse rather than the reverse. He articulates, of course, something I believe: that if our profession is going to help understand child abuse, we have to give its perpetrators reason to speak to professionals. And I mean speak to us, not comply with us. That means maintaining privacy when hearing that which turns the stomach. As far as authorities are concerned, it means not naming names.
Daniel Pierce wasn’t always so inclined to protect devils in order to further understand them. One of his background jobs was that of a group home director—a man in charge of delinquent boys, who keep secrets as well as any therapist, and punish violations of confidentiality more severely than the board of behavioral sciences ever does. A passage depicting efforts to out the identity of a house assailant reveals Daniel as a kind of one-time policeman: a house heavy and dad, lecturing young criminal minds about the importance of standing by the innocent; about not protecting wrongdoers, by giving up their names to those in charge. Daniel’s youthful adversaries managed to disillusion him, by reminding that for many, loyalty is more important than justice; that protecting friends and other loved ones is more compelling than doing right. Now it’s sometime later and Daniel Pierce is not so sure about who is innocent and who isn’t; about who are the abusers, or the oppressed. This is partly because he feels like one of the oppressed, which is hardly surprising, topically speaking. His political leanings unclear, he could be a supporter of either Donald Trump or Bernie Sanders: marginalized, confused, and looking to blame either a subset of society or its entrenched institutions for the messy world he’s a tiny part of.
On balance, his biases are progressive, but above all he’s isolated, seeing hypocrisy, shallow rhetoric and contrived solutions on all sides of the grand social split. He’s alienated, fed up, and tired of social advocates in particular: bleating feminists on the left, blow-hard paternalists on the right. Grieving the loss of his one and only love of his life, and estranged from his son, his only child, he’s in collapse, sliding along a path towards a bottom out drinking experience until this one woman appears, like a seraphic breeze with a provocative mission. She says Derek Metcalf, Daniel’s patient, has committed a horrible crime, and that Daniel can and should help him to confess, if not report that event if it’s already occurred. Daniel is non-committal, neither agreeing nor disagreeing with Lira’s plan, or its premise, and privately holding that he doesn’t know much. Like many troubled drinkers, he doesn’t remember much. Actually, he doesn’t even remember (partly due to his alcoholism) ever seeing a patient named Derek Metcalf. The profile Lira gives him sounds a bit like a man named Andrew, who came to see him once, flitting in on a bicycle, discussing a sordid life of street drugs and prostitutes, appearing and later proving elusive, for he too is on the run, escaping from his life, operating incommunicado, living anonymously, having sex anonymously; explaining that his name, where he’s from, where and who he is at any time doesn’t matter. Only it matters.
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Introducing Venus
Time to fulfill a promise. Last year, about nine months ago now, I previewed a novel I had then nearly completed and which now has been available for about three months online. At the time it was called Blocked, not that names matter, and I wrote that I’d comment on the novel, its various themes and other elements, leading up to and beyond its publication. Alas, that didn’t happen. Sorry. I know you were waiting with baited breath. Anyway, I got distracted, like my protagonist Daniel Pierce often does; became sarcastic, as I still am, though he is less so. Among other things, my object relations explicating Tommy article got accepted for publication in an academic journal (I’m quite proud of that, in case you can’t tell), and random events occurred, concerning dogs, graphic novels, the politics of evidence-based psychotherapy: all happening with Bionic (as in Wilfred) meaning.
So the novel’s called Venus Looks Down On A Prairie Vole, which is a meaningful title, but you’d have to read the novel to learn fully its point. I know. What a typical, asshole-self-important author thing to write. Well, I’ll give a heads up on a couple of things, hopefully make this labor of my last two years interesting for you. Venus is a reference to women, which shouldn’t surprise. A prairie vole is a monogamous rodent. There. Figured it out yet? Oh well, let’s take it one step at a time, one day at a time, which should clue you into one theme of the story, at least. So, the first chapter (about five pages, I think), will introduce you to Daniel Pierce, a lonesome psychologist (actually, the reader doesn’t really learn his name and vocation until chapter two) who is talking to an insurance representative, seeking payment for a claim that’s gone awry, but also flirting somewhat. There’s some foreshadowing in this comic opening, but mostly I’m introducing a voice—one that’s flippant, like this blog entry—and a theme of subjugation to a system or machine. Daniel suffers and doesn’t “forgive” systems, but he latches onto individuals, like his clients, and also like the angelic-seeming, barely English speaking helper on the line. She’ll listen to him, he hopes. She might really listen. No one else does, he explains sourly.
There isn’t much to help a reader feel sorry for the self-pitying Daniel Pierce, but a troubled, flaky son, and a deceased wife give some cause early on. Later, as he becomes dogmatic, contrary, awkwardly humored, if self-deprecating, liking him might get even harder. But try, won’t you…he needs help. As to his crises, the reader first learns about Ryan, his early twenty something son: absconded from Daniel’s home after completing a stint in rehab and winning from him the reward of an inherited car—a bad move, Daniel concedes. You’ll learn that it’s one of many mistakes he is making in his life, though hereafter they will relate mostly to his working life: his poor boundaries, and at least questionable ethics. In the early pages, Daniel’s wife, Lisa, is introduced as “sleeping”—a figurative trick, for she is really gone. She and Ryan are spectral figures in this tale: oblique motivators, sources of regret, or in Lisa’s case, an overseer of sorts.
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Where’s the breast?
A comical question, no doubt. Somewhat crazy: inappropriate, eccentric. Welcome to the world of psychoanalysis, or more specifically, Kleinian or Bionian analysis. This is what a Bionion therapist might ask of a group making what he/she would call a ‘basic assumption’ of a dependent group (seeking a leader), and floundering in midst of unfulfilled expectation. Yesterday I attended a four hour presentation about the work of Wilfred Bion, whose name, like his copyrighted interventions, have dotted this blog over the last year or so. This essay follows the spirit of Bion, the seminar I attended on a sluggish Saturday morning: it will be inchoate, elusive in meaning; seemingly interchangeable at times with ideas that many working in or else consuming mental health systems will take for granted. A discussion of Bion’s ideas begins plainly enough, with references to having an ‘ordinary conversation’, the ‘subjective experience’ of the patient; a search for the ‘real’ experience. Yet there is a secret attached: a sense that understanding is something that is transiently captured but then hard to retain, as if the desired knowledge (if that’s the correct term) was not meant for us.
Having taught a class once on Bion I knew the bio: born into an aspiring gentry in India at the end of the 19th century, Wilfred went to boarding school at age 8 to one of those stiff, militant academies that Harry Potter has since immortalized; he faced peer cruelty, the incomprehensibility of adults…their occasional kindness. He recounts a story of a headmaster who rebuked him for a game in which a playfriend is harmed by a game involving a rope without a knot, tied around a neck. The game might have killed the boy, the headmaster admonished. The headmaster later spoke to an assembly of boys, sparing young Wilfred humiliation, but drawing attention to the dangers of exploratory play. Young Bion felt chastened but not shamed, and oddly understood. An incident with an initial meaning took on another meaning, and its evolution was understood and modified by what Bion would later term the ‘reverie’ of an adult.
World War I was a setback in many ways. Obliterating men, obliterating meaning, Bion never felt more foreign that when he fought on European soil as a tank commander, his responsibility that of determining enemy positions, orienting his comrades. Impossible, he decided, observing the chaos. Impossible also to take in the purpose and meaning of all that slaughter, though he noted the primitive attempts, the glorifications of Winston Churchill, for example, who wrote with seeming ecstasy about the sensuous whistle of bullets in the field. After a momentous campaign in Cambrai, France, Bion was offered a Victoria Cross medal for his bravery, but declined, and when interviewed by an admiring General, later reported: ‘I couldn’t think what to say’. So Bion’s development was one of estrangement from commonplace human aspirations: for power, status, or even belonging. An outsider, Bion contemplated trauma, dissociation, the breakdown of thinking, and links to emotion, and later brought to psychoanalysis an almost mystical view of the human mind.
To consider the types of scenarios wherein Bion’s ideas are relevant, a student should invest some time and read his seminal papers of the late fifties, early sixties: “Differentiation of psychotic and non-psychotic personalities”, “Attacks on linking”, “A theory of thinking”, in which Bion asserted that many patients in psychotherapy communicate via a primitive defense known as projective identification (a defense first explicated by Melanie Klein), inserting into another’s mind a disturbed experience, which is then to be either ‘contained’ or not, metabolized or not, and re-directed back to the patient for internalization. Bion offered that the psychotic individual, or he/she existing in like borderline states, experiences their mind as composed of furniture, ‘things in themselves’, not modified by symbolic function as language, dream and metaphor (the ingredients of what Bion termed Alpha function), but lost in minutia. Thus we consider the experience of the patient who enters an office in which the therapist has made alterations to the (literal) furniture, and is rendered uncomfortable, and is not only incapable of putting words to that experience, but is also blocking of the therapist’s attempt to reflect back and give meaning. Lacking this fund of knowledge, or ‘K’ as Bion dubbed it, the patient in this proto-psychotic state exists in a world of things, drained of ideas, meaning, and feeling.
Later in his career, Bion expanded his theory to include the concept of ‘O’, or ‘being’, to denote a mystical, transformative experience. In his worldview, the outsider is a key figure: he or she is a genius, an innovator; contained by an established order, that (like me) dilutes ideas so as to make them digestible by a mass audience, the outsider is restrained only by God, ultimately. Bion’s book, Transformations, may have alienated him somewhat from the psychoanalytic community, who appear to have inherited or internalized Freud’s supposed distaste for the spiritual, but it crystallizes for the modern therapist an essential task when sitting with patients. Why? Because patients or clients don’t come into our offices with explicitly organized complaints like “Who am I?” or “I need to figure out how I think?” As therapists, our precociousness (yesterday’s speaker’s term) leads us to give premature insights, to show off our minds, deliver solutions; understand our patients before they understand themselves. We want to do that. I want to do that. And I believe the people who come see me want this also…sort of. But it is not cheaply arrived at, and between complaint and working through there is, more often than not, a nameless wasteland that elicits dread: it is a space of boredom and emptiness; it is painful in ways that are hard to describe on a somatosensory level, though we may be arrested at that point of entry. It is a dead zone of sorts, and a therapist, the person standing before an uncertain process, is a kind of Grim Reaper.
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The war of evidence-based psychotherapy: part three
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.
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The War of evidence-based psychotherapy: part two
Turnaround is fair play. That’s what it seems like when the champions of psychodynamic models like Jonathan Shedler caricature their CBT counterparts. As I’m no more in their offices as they are in mine, I don’t really know what they do or don’t do in their interventions, but I glean. I don’t glean that my CBT colleagues use workbooks like cookbooks, offering rote interventions that they either memorize or read from a sheet. Nor do I think that most CBT therapists interrupt when a client is speaking of family of origin material; that they scoff at such unstructured navel-gazing and inform clients that exploring the past is a waste of time. Many believe in a structured approach, one that mimics a teaching paradigm to some extent: passing out information worksheets, assigning homework…educating. I recall working in an agency that made copious use of defense analysis worksheets. Clients were meant to read along in a group or in one-on-one meetings, examples of typical defense mechanisms matched to illustrative phrases. They were meant to reflect and say, “I think I do that”, and so on, presumably so they’d learn to not exercise those habits in the future. I’d give lectures to groups on defense mechanisms, codependency—a host of topics I liked expounding upon—delivered bullet-point style, to individuals who appeared to lap up didactic material, to learn if not wholly integrate into their minds, because the learning they need isn’t academic. It simply isn’t. Anyway, the promulgaters of structured approaches think it necessary to, as they sometimes put it, set the limb (with information) before they encourage the broken patient to walk (meaning, explore). It was/is a catchy turn of phrase and powerful use of metaphor, only it doesn’t really work. The mind isn’t like a limb.
But ultimately, it doesn’t matter, this debate between proponents of CBT versus the range of psychoanalytically-derived therapies. It doesn’t matter because the establishment that drives mental health treatment has made its choice, based upon economics (the supposition that CBT is a more cost-effective approach), but justified publicly by invoking evidence-based research. Meanwhile, adherents of psychodynamic models ever hold space for a deeper, longer-lasting, sometimes abstruse and painful descent. Students of these models are on the workplace fringe unless working independently. They sometimes meet, in apparent secrecy, in ‘forums’ in hospital basements, Saturday morning church halls, to discuss their older theories like freemasons keeping one step ahead of orthodoxy. Analyst Wilfrid Bion wrote half a century ago that the role of the mental health provider was to be a container for the pathological patient who attacks his or her mind, and to operate without memory or desire so that an unfettered examination of projections and introjections can occur. His approach wouldn’t fly in most mental health agencies, psychiatrist offices today. He ethos is going to sound a lot different on a treatment plan than, say, “Client will use tools to reduce behavior X over the ensuing 90 days”, or “Take 30mgs of Effexor each day”.
The Bion line wouldn’t go on a treatment plan. It would scarcely enter a ‘team’ meeting, or a consult with a fellow professional. And it’s not because professionals don’t think there’s value in the approach of analysts like Wilfrid Bion or his latter day followers. That’s why the debate doesn’t matter, because it’s not really about which approach is better, but rather which approach is more plainly understood; about what can be quantified, studied, measured, published and disseminated widely so that insurance companies, program clinical directors, and possibly consumers—all looking to varying degrees for ‘evidence’ of what works or doesn’t work—can point to something tangible and say, “hey, this looks like it has substance to it.” It’s about what’s utilitarian, more readily conveyed across channels, such that teamwork, professional fusion—that popular if suspect notion of ‘being on the same page’—can transpire.
When I was a clinical supervisor in a mental health agency, back in the day, I used to assuage interns with non-conformist leanings that the external voices of what is evidence-based are not ‘in the room’ with them (though some try to be or think they are ‘in the room’). This ambiguous freedom comes with responsibility, to decide what’s right for a patient, which often means what ‘feels’ right for a patient, when in the dense meaning of a therapeutic moment. Those patients, the consumers of mental health services, rely upon a sage and flexible approach, and they stand to lose if providers simply conform to that which is prescribed. The notion of ‘what works’ in mental health is quasi scientific, semi-observable; the phenomena of desired outcomes in mental health tend to be thinly defined, and observable only over short durations, which doesn’t speak to the lasting and unknown changes that the consumer seeks.
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Graeme Daniels Psychewriter 