Graeme Daniels Psychewriter

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.

  Work in a hospital or a community health agency of any kind and you’re likely to hear the term ‘evidence-based’ at some point, fairly early actually. Also, as a consumer of services you’re l…

Source: The War of Evidence-Based Psychotherapy

The spider that slid out of the trashbag that was inappropriately stashed in the elevator was just shy of an inch long. Small and underprivileged as it was, it would still have struck terror into Sophie, an insurance agent, had she seen it. Luckily, her eyes were locked onto the ceiling, regarding what looked like a cigarette lighter caught behind a shield beside a light fixture, fossilized and forgotten. The five by five foot space was a tight squeeze for the current occupants: the unwelcome, abandoned trashbag; an attentive terrier, hitherto yapping in a hot car in the parking lot, now accompanied by a ten year old boy named Jason. Plus Sophie. The arachnid raced across the worn carpet base only to halt inches before the dog’s lowering nose. Unperturbed, the animal emitted a slight grunt but then withdrew, uninterested. Who knows what animals make of life that moves with unnecessary numbers of limbs, without apparent purpose other than existence? Science knows what kind of instinct or rather reflex will have stilled the tinier creature, motivating its sudden simulation of death.

Jason asked the woman if she’d press the button for the second floor. Though it was a short, benign request, he spoke nervously, as Sophie resembled his Aunt Julie, a severe woman who used to babysit him until he finally spoke up to his parents about her tendency to hit. Jason didn’t think the tall woman by his side would hit necessarily, but she seemed familiarly tense, and might have said something plaintive about his bringing a dog into the building, which would have been bad enough. The time it took for the door to close seemed protracted causing an awkward, silent stalemate, and in Jason’s mind, a complaint about machinery that doesn’t work properly. Someone ought to check its parts, do a thorough maintenance job. Someone ought to do something, Jason thought. When the doors opened for the second floor, he exited hastily, perhaps rudely, while the terrier shuffled beneath his feet, casting another nonplussed glance at the spider. Picking up the dog, the boy rushed across a waiting area to an office where his mother waited, eager to show her fellow realtors the new family pet.

Replacing Jason was a bulky man wearing a post office uniform, who reached in front of Sophie to press a button rather than ask her to do it. It was his rudeness that caught her attention, not that of the boy. The man’s vast armpit opened up like a beast’s mouth preparing to bite—the emanating odor more than doubling the offense of the trashbag that still sat on the other side. The man shook his head, observing the clutter that forced closeness. What followed was a guttural witticism, smothered in heavy breath: something terse, fragmented and nasty about lazy Janitors, people below post office workers in the food chain, he evinced. Sophie returned a look that was not quite a thin smile, more a twitch of lips, followed by a look away, back to that cigarette lighter up above. She changed her mind, looked away from that, thinking the man might follow her gaze, notice the lighter and attempt chatter about that as well. This situation was a quintessential fear for Sophie, and for many women, she considered: being caught alone, in an elevator, with a man who might be dangerous; especially one who was sizeable and seemed gruff and impolite. The halting movement of the elevator was uncomfortable, but at least there wasn’t long to go. At 1600 Sadler Street there were only four floors. Sophie had just one left to go before meeting with her therapist on the top floor. Soon she’d be talking about men, anxiety, tight spaces, spiders, and failed attempts to quit smoking, among other things.

Therapist Daniel Pierce left his fourth floor office early afternoon, hungry for a late lunch on an hour’s break. In the hallway, he passed Bob, a postal worker with whom he shares a manly nod on a daily basis. He and Bob aren’t on a first name basis, just observant of each other’s insignia: Bob’s nametag, the sign on Daniel’s office. By the waiting area Daniel pressed the button that summons the elevator. He hoped its clunky, cumbersome movements would prove quicker than usual, as Bob is surprisingly swift in his circuit of deliveries, and if the elevator didn’t arrive soon, he’d be sharing a ride with the malodorous mailman. Behind him was a familiar sight: a grim-visaged woman, alone in the waiting area, looking flattened, too self-absorbed to read the fluff array of magazines or even notice others. The elevator door opened. Daniel stepped in and hurriedly pressed for the lobby, but Bob made it in time, crossing the threshold just before the doors closed. With a second nod, he acknowledged Daniel but also cast a glance in the direction of Sophie. He faced the counselor as the elevator went down, muttering ugliness: “uptight bitch” was the term Daniel was meant to co-sign with a knowing chuckle, perhaps an exchange of misogynistic platitudes.

It occurred to him—no, it reminded him—that if he doesn’t collude with such beliefs, he risks a dreaded reprisal. Daniel had always been wary of men like Bob; had often worried since he was a kid, and especially since that one time years ago on a commuter train when a thug accosted a female passenger and Daniel was the only other male around, that he’d feel compelled to do something, risk his own health and safety, in the service of either disapproval or actual, as in physical intervention, which wasn’t and isn’t his thing. The smell of Bob—that acrid reek of sweat from walking in the sun—wasn’t the problem. Nor was it the class divide. As the doors opened on the bottom floor, Bob stepped out first, gave Daniel a curt farewell, perhaps registering the counselor’s haughty rejection of him. Daniel moved away with a sigh, noticing a mild jump in his heart rate. It doesn’t take long to feel the specter of violence, he thought, whether it’s real or not. At the brink of the lobby doors he stopped and pulled back suddenly. Cursing and not understanding why he lifted his foot, revealing that which he’d glimpsed an instant before his last step. The spider was crushed.

The office building of 1600 Sadler Street in Worcester Massachussetts is four stories high, making it one of the tallest in town, save for the new Mobile T building that went up four blocks away nearly a year ago. Perched on a slight hill, it has an advantage on three similarly sized department stores across the way, which were recently rebuilt upon plots scraped from the earth. On a wraparound balcony outside his office, Daniel Pierce stands overlooking the teeming traffic of late afternoon. His five o’clock appointment has texted him, saying she’s running ten minutes late, which is typical because of the rush hour, though usually Shirley’s lateness is closer to five minutes than ten. When he first signed a lease, Daniel thought he’d enjoy times like this: late afternoon reveries, peering down over the city, feeling comfortably detached and taking in the view while collecting thoughts ahead of a session. In November, an orange tint blends with brown hues on the red maples that line Sadler Street. From above there seems more vegetation than what’s apparent at ground level. The tree-line even seems uniformly cut, as if there were above it a secret layer of atmosphere created especially for the birds. This rarified space costs more for the humans that occupy it so it’s a good thing Shirley’s fee is on its way, whether she’s late or not.

The hard, damp chill sends Daniel inside, thinking of the time his office mate first walked him around, boasting of the balcony area and the view, the then modest rents. Better in the spring and summer, Daniel thinks after just a few minutes outside. He figures he’ll head downstairs, check in with the janitor, as in remind him that some are still around, working. The guy will be making his end-of-day rounds, storing hefty bags of trash in the elevator as he goes from one office to the next, reeking of New Bedford waste. Daniel hates it when he does this, though he doesn’t say anything. It doesn’t look good to Daniel’s clients, this time-saving habit. What must it say to them to have bags of garbage accompanying their ride to the top floor where the therapists tend to have evening appointments? The janitor’s routine seems to privilege the loud and garrulous realtors on the bottom floor, the insurance company hacks on the second. They’re all typically gone by late afternoon, Daniel notices. For their benefit the dirty work and security is done after hours, or close to it. By the front door, the stocky, lumpen keeper of the building is locking up, only to see Daniel stepping out of the elevator, already sporting a wan, diffident smile.

“Oh, right. You’re here tonight, huh?” the man says, sounding vaguely disappointed.

“Thanks,” Daniel replies, indicating the door, which he needs left unlocked, and then, fleetingly, the garbage bag. He moves subtly to the side, as if beckoning the bag to step outside. No, after you, is what it looks like.

“Sorry,” the man says, taking the hint. Mission accomplished, thinks Daniel. Meaning, he didn’t have to say anything. After a gratuitous trip to his car, he heads back upstairs, there to pass his neighbor in the hallway. Charles Mandalay is a construction consultant from Cambridge originally. He has models of his projects all over his office, as evidence of his good work and career path. He’s arrived at the top floor of 1600 Sadler Street as its oldest occupant and has the best suite in the building, on the east side, facing downtown. Sometimes on a Friday he invites others from his floor to stop by for a quiet party, a few cheese and crackers washed down with a choice of red or white wine. Daniel sometimes partakes of one glass maybe, even if he has an appointment or two left to go, because Charles offers a mint to go with the libations. His think-of-everything generosity and hearty spirit seems easy and authentic, if weary and sad. Charles has the look of a man whom others have left behind with all of his goods and memories. To newcomers who fret over rising rents, he schools about the resilience of the landlord, the indelibility of 1600 Sadler Street, and as he orates he stares out his window admiringly.

“The building’s paid for,” he proclaims, suggesting all should relax. They can’t, including Daniel. From that top floor balcony, they see a city closing in, becoming more crowded, making it difficult to get places, arrive for appointments, of whatever kind they are. The building’s old, someone notices. It has the feel of a place that will be torn down soon, replaced by a clothing store, maybe a condo unit or apartment complex. Daniel comments on the elevator: not so much about garbage left inside, but rather the age of the apparatus. Looking closely, one of his clients recently observed that its permit had expired a year or two earlier, which explained its sometimes staccato movement from one floor to the next. Since then Daniel has preferred the stairs at the back. When he isn’t inspecting the elevator for trash, he’s exercising his limbs, getting a workout on the concrete steps that lead to a heavy door, whose warped sound upon opening heralds hasty arrivals.

For the latecomers, especially the younger ones who are spry in the limb department, the jog to the fourth floor is quicker than the elevator ride. Breathless, they sometimes stride in, crossing the threshold to the therapeutic sanctum, meeting Daniel at his door. He stands like a porter, waving them inside. Some take a moment to orient themselves, to gaze outside at that wraparound balcony, at the view outside, the red maples just about visible from their vantage points. Others flop on Daniel’s couch, relieved to have made it in. The sessions are typically fifty minutes long, sometimes a few minutes longer, in defiance of the managed care rules. Those who stick around beyond the evidence-based allocation, who are there for the long haul to do good, in-depth work, often sigh and comment on the security, the time-out from life. This is their safe place, they say. They don’t want anything to change.