DIRECTORS'S COLUMN

By Seth Warren, PhD

It is easy to feel a bit bombarded as a small private practitioner these days. Medicare fees for psychotherapy have decreased, again, for what must be the 10th year in a row. At the rate things are going, Medicare reimbursements for psychotherapy will drop below the level acceptable to almost any of us.

Earlier this week, I spent a good hour or more, preparing a letter for a patient who was appealing her insurance company's denial of coverage for a portion of her psychotherapy treatment. The reviewers for the managed care company, a wholly-owned subsidiary of the largest private health insurance company in the United States, knew very well that they would not have to explain or justify their decision. As Senator Elizabeth Warren has frequently noted in relation to the banking system, "the game is rigged."

Huge corporations and big government bureaucracies are setting the fees, and the conditions, for much of the psychotherapy work that is done currently in the United States. And as we try to protect and preserve the integrity and quality of the treatment we provide, one of the primary experiences we have in dealing with these entities is helplessness. The disparity in power between these large corporations and government agencies and ourselves - with so many of us being solo practitioners - makes contact with such organizations as essentially traumatic.

It is difficult not to feel wounded, diminished and disparaged by such traumatic contact. Since it surely is not my intention to merely add to the anxiety and despair in my readers, let me get to the point of this column!

There are two points I would like to make. First, I would like to once again state that I am increasingly of the belief that identification with the medical healthcare delivery system as it is evolving in the United States is not a particularly viable long-term path for psychotherapists such as ourselves. I know that some compromises may be struck, some reforms made, and some possibility that insurance reimbursement will always form part of the subsidies to psychotherapy and psychotherapists who provide services. But I'm also aware, and this is speaking for myself as a solo psychoanalytic practitioner, that this system is increasingly stacked against our interests - what we know, our experience, our skills, and how we wish to work. This reflects an ongoing trend that has only been increasing over the past ten or fifteen years.

On the other hand I'm finding that my identification as a psychoanalyst provides a degree of insulation against the gradual de-professionalization of the practitioners that provide psychotherapy. I am finding that the communities that surround psychoanalytic work, practice, and training, provide an antidote to a toxic cultural milieu in terms of offering a space in which there can be a respect for sophisticated theory and serious clinical work. Our institutions offer support for open and diverse discourse on psychotherapy. Our psychoanalytic institutions provide support for an approach with concern for humane and ethical practice, reflecting our shared belief in the value and purpose and meaning of what we do. As I've been saying for some years now, I believe that it is more important than ever that there are communities that support such an approach for practitioners who wish to continue to provide such services in the face of eroding support from the larger surrounding culture.

It seems to me - and I could be wrong about this - that there is little acceptable future for psychoanalytic psychotherapy within our health care system as it is constructed today and given where it appears to be heading. I am aware of trends that go against this mainstream, such as the work that Jonathan Shedler has been doing, making the case for the relative efficacy of psychoanalytic psychotherapy, longer-term psychotherapy, and psychoanalytic clinical case formulations. I'm also aware that the American Psychological Association, for example, has recently put out a working paper on the efficacy of psychotherapy and its importance - hallelujah!

But where else might our power lie? This brings me to the second point that I wish to make. I know that I suggest the following at the risk of being considered overly optimistic and naïve. But my view reflects a fundamental conviction about the value of the work that we do. I believe there is a real need for the kind of work we provide. I believe that the prevailing climate of declining fees, the de-professionalization and industrialization of psychotherapy, the medicalization of psychotherapeutic diagnoses, the devaluation of human suffering we seek to ameliorate, will simply not work.

The first wave of managed care didn't succeed the way we were all told it would back in the early 80's because it didn't really work very well. It is a bad model. Yes, the insurance company makes more, yes, the providers work harder for less. But it does not solve the problems people have. People in large numbers rebelled against the HMO model. People don't like being told who to see, and the 8- or 12-session model they were forced to endure left them without real help.

The same is happening with biological psychiatry. The data are continuing to show that psychotropic medications simply do not work as well as we have told, and that they are frequently more harmful than we are led to believe. For the first time in 30+ years I sense a shift, that the evidence is not there to support they ways such drugs have been used, and more and more research articles and books (and lawsuits) are appearing calling to task the pharmaceutical for their marketing tactics, for their misuse of scientific data, and for outright deception.  There is a widening awareness that drugs are not always the best treatments for many difficulties people experience. 

I believe that the prevailing push for the medicalization of psychotherapy will fail. It is a model that does not accurately reflect the realities that exist, and as psychoanalysts we know very well that we don't change reality by changing the model. It is not what people really want. People want, as they have always wanted, conversations in a context of safety, respect, and compassion, with professionals who are highly trained, skilled, and experienced. Yes, people also want "results," how can they not think that way in a world in which there is always someone who will sell you a product to fix whatever it is they can convince you is wrong with you! But I find that what has not really changed all that much is that, for the most part, people still want a real therapeutic relationship, not a "product," even if they don't exactly know what a therapeutic relationship looks like.

You can't sell just anything. Lies don't work forever. The reality of human life is not going to be changed by the wish for quick and easy solutions, or the promises of such. It's still there, problematic as ever. I know the pendulum is swinging pretty far in the wrong direction for us, as professionals. I believe the crash will come, reality will assert itself. Simple solutions rarely succeed. The truth matters! 

As a psychoanalytic teacher, I have often told my students and candidates that we are marketing what is possibly the worst product (from a marketing point of view) in the history of capitalism: expensive, time-consuming, ambiguous in process, and uncertain in outcome. Who would buy such a thing? 

And yet, people continue to search for something more, looking for what feels to them real and alive and meaningful. It is my opinion that we don't really have a choice about this, although I know very well that the conditions are not always there to support those yearnings. 

Like Abraham Lincoln famously said, "... you can't fool all of the people all of the time..."

Best,

Seth

By Janet Hoffer, LCSW 

For the second year in a row, the CPPNJ community had the pleasure of holding its Annual Holiday Party at the lovely home of our members and gracious hosts, Mana and Bob Levine. Old friends reunited and newer members met friendly colleagues amongst the almost one hundred people in attendance.   Everyone had the opportunity to show off their culinary skills at this pot luck evening in which scrumptious dishes and decadent deserts were plentiful. Stan Moldawsky regaled us with his musical talent at the piano as many others sang along. Joe Braun, Ellen Fenster-Kuehl, and Nancy Sasso were the lucky winners of the annual holiday raffle and canned food collected by guests for the Montclair Food Bank gave the night even a little more meaning. No presentations were made, no assignments given, and there were definitely no CEUs to look for- just a final chance to wish dear friends a very happy, healthy new year!

Irwin Badin, James Garofallou and Nick Papouchis.

Susan Darrow and Seth Warren.

Sandra Sinicropi, Director

Debra Roelke, Clinical Coordinator

The Psychotherapy Center (PC) has been a part of CPPNJ (and formerly, IPPNJ) for 25 years. Its mission has always been two-fold: to provide high-quality, psychoanalytic treatment at reduced fees to the community at large, and to obtain training cases outside of the limits of insurance plans for candidates. There are many institute alumni who were able to use PC patients as their analytic control cases; the goal of the PC is to continue expanding our ability to place patients with candidates who can provide in-depth psychotherapy at a sliding-scale fee in exchange for the casework they need to complete training.

Toward this end, the PC has worked to expand and define our public presence in order to attract patients who can most benefit from what we have to offer. We have a new profile page on the Psychology Today search engine, which has increased our rate of phone inquiries to about 15-20 calls per month. When calls come in, they are screened by one of the institute volunteers to determine whether their needs are a good fit for the kinds of individual psychotherapy cases that candidates typically see in their private practice offices. The majority of callers are seeking individual psychotherapy, but when there is a request for couples therapy, we are able to offer referrals to the trainees in the CPPN J Couples Program. When patients are looking for services that go beyond what we offer - for example, child or family therapy, addictions treatment programs, anger management (usually court-ordered) or intensive outpatient treatment - we do our best to provide referral information to help them find what they are looking for. When patients need something specific (e.g., sex therapy) or prefer to stay in-network on their insurance, we put the word out on the CPPNJ listserv to see if a referral to our membership can be made. Finances are often the most limiting factor; with the economic downturn of the last several years, we have regularly received calls from folks who have lost jobs and homes, and are struggling with the last of their resources to try and get back on their feet. Many of the patients have a limited understanding of therapy but know somehow that we are offering a substantial service and find their way to us.

Geography has been another limiting factor: we receive calls from all across northern New Jersey, whereas our candidates are spread around in various locations that can shift from year to year. In an attempt to expand our reach, we have begun to offer faculty these referrals as well. Faculty members are free to participate in the PC as candidates do, but candidates are given the choice to first consultation with the potential patient,

We welcome inquiries and interest from all active members of the CPPNJ community. If you would like to participate or simply find out more about the PC, please contact Debi Roelke or Sandra Sinicropi for information or to add your name to our list.  

Irwin Badin, PhD

Presentation:

Talk sponsored by the Northeast Counties Association of Psychologists will be on February 10th at the Cresskill Senior Center (38 Spring St, Cresskill, NJ), from 10:30am - 1:00pm.  The title of the talk is: "There is nothing in the world more difficult than another person" (Buddhist monk): Surviving in the therapeutic process.  The talk will focus on the challenge faced by therapists as they strive to maintain an openness and receptivity to their patients' subjectivity.

Kenneth A. Frank, PhD

Publication:  

Ruth Lijtmaer, PhD

Paper:

"Where is home?: Issues of Immigration and identity". New Jersey Psychoanalytic Society. 1-15-13, Hackensack Hospital, Hackensack, NJ  

Please note: If you have an announcement of either a paper you've recently published or a presentation you've given, let us know. Send Cathy Van Voorhees an email at cppnj@aol.com and we will be happy to get the word out. 

All Programs are Co-Sponsored with the New Jersey Society for Clinical Social Workers 

Our E-Newsletter Editorial Staff

Unsolicited articles are welcome.  Something you'd like to write?  Send it to us at cppnj@aol.com.  We're happy to hear from you.   

Thank you for joining us. Look for our next newsletter in February 2013.