What do I do if my time and/or money are limited?
The managed care era has borne witness to a conscious, calculated attempt to reduce costs of health care. The complexity of the mind and its symptoms over the course of a human life do not fit neatly into the cost saving clinical algorithms used to determine medical necessity in mental health treatment. Some companies respond with impossible bureaucratic obstacles, making reimbursement for services far more difficult than before. Some will only allow reimbursement with an unprecedented intrusion into the confidentiality of the doctor–patient relationship. Do not be surprised to find yourself with inadequate psychotherapy or substance abuse treatment benefits relative to the need of your condition. Managed care companies prefer psychopharmacologic treatment models that focus on prescription medication and the use of a psychiatrist primarily as a dispenser of medications; these models cost less money. Psychotherapy, particularly good psychotherapy with a trained professional, can cost significantly more money. Furthermore, many psychiatry residency training programs across the country no longer teach dynamic psychotherapy to their psychiatrists in training; in this way the residents can see many more patients per hour and week, thus providing care for more at less additional cost.
Patients often end up with insufficient resources, particularly if they have no health insurance. When this becomes the case, one option involves looking into treatment options at either academic medical centers, public hospitals and clinics, or through psychoanalytic institutes’ treatment clinics. Departments of psychiatry, which run mental hygiene clinics staffed by residents, may offer treatment at a lower cost, while the residents receive supervision from more senior staff. What residents lack in gray hair or sophistication is usually offset by their enthusiasm, interest in patient care, and openness to the treatment relationship? Resistance to treatment exists at all levels; as one apocryphal supervisor said, “when I was young, people complained that I was too young and inexperienced to treat them, and when I became old, they told me I was too out of touch to treat them.” Psychoanalytic institutes also often offer psychotherapy and psychoanalysis at a reduced cost with their members in training. To find an institute near you, you can log on to www.apsa.org and go from there.
Selma’s comments:
Time
My life for decades revolved around the 45-minute hour I spent from Monday through Friday in that darkened library/office with that couch. I was very active in community life, often centered (but not wholly) on my children and husband. I was hugely involved in theater, where I acted, took workshops, and taught acting and drama. Frequently I had paid jobs, such as project director for an organization. I always took classes of some kind and did hosts of committed volunteer work. In other words, I did not live a passive, withdrawn life, even though there were times that I considered myself to be that when I left the analytic hour. The view others had of me seemed to be vastly different. I didn’t consider myself any different than I was before I had started this treatment, and I didn’t consider myself to be very different from my friends. Respect was perhaps the greatest attitude I learned in analysis. My parents never respected me. They passed over respect, as it seemed to be unnecessary. After all, I was a child. My analyst respected my feelings and me; I had never had that before. Respect was new for me, and it took a long time for me to believe it and to understand it. But once that happened, it was like lifeblood. I did not discuss with anyone where I was from 10 to 11, or whatever the hour was. I was afraid that if I shared my newfound knowledge with everyone, I would lose it. That is, I would make myself lose it. I did not believe I would be able to tolerate the jealousy I imagined others would have and would soon give it up. So I kept it all private so that I could keep it. I became very clever about arranging my schedule so that I could disappear for an hour a day. And I did. Many times the commitments I had and what I had to do to change my schedule became a strain and irritation. But there was never any doubt in my mind about what I was going to go. I was going to my treatment. There was no bond in my life as strong as that bond. And I don’t know why, but I would be there, day after day. The thought that it was difficult was not on my mind. Sometimes the time there was painful. Maybe I couldn’t talk, and maybe I could only whimper with a knot in my throat. But skip it? Never.
Money
The words I dreaded to hear from my analyst were, “I will have to raise my fee.” Maybe he also said, “I am sorry . . .” but I have blocked out that memory. It didn’t happen too often, but I went for many years; and it was announced now and again. Fees were never lowered. I always accepted this reality, and I never commented, even though I was always angry and hurt. I shared so much with him, and in my free association talk, he learned of the struggles we had with five children, a salaried husband, and the financial commitment I had given myself with the analysis. He seemed to have no compassion for that. I went through depressions over this, and in the end, I always accepted it. We made other concessions in our lives to meet this need. The alternatives-to cut down on my hours or to end them-were unacceptable to me. I suppose I could have discussed the fee with him, but I never did. Even being in analysis, one doesn’t actually become what one is not. I suppose the fear of separation was too strong in me to threaten what I would see as rupturing this relationship. I found my rationalization for the acceptance, and they were pretty good rationalizations. Our oldest girl was then in college. She came home to visit and told us that her professor in the first lecture of the school year said that if, at the end of four years, she and her fellow students still admired their parents, then the school would have failed. She came home to tell us that she loved us and wanted to see us, but that we had to keep these visits secret so that she did not fall out of favor with her friends. Rough times were ahead; our children were growing up, and life could be harsh, not what we had hoped it to be for them. I was not only able to hold it together for myself, but alsoable to keep the strength of our family’s ability to communicate intact and to help each other during stressful times. I was still in analysis, and it proved worth everything I had invested in it. I had made good decisions with my life. We drove secondhand cars and still had no bedroom set. But the important things like love and understanding in our family, were stronger than ever and still growing, even though life was now more complicated with grown children, their spouses, and grandchildren. I have never been sorry for the expense but rather consider myself lucky to have been able to have afforded this chance to rearrange formerly self-destructive patterns from my childhood. Today, the cost seems immaterial. But it would be untruthful to say that it didn’t matter. It did, and I had a lot of feelings about it. I also made the right decision.
What is cognitive behavioral treatment?
Cognitive behavioral treatment (CBT) is a rubric that, loosely defined, attempts to treat different mental health struggles via a systematic examination of the cognitive and the behavioral aspects of any particular disorder. In the example of panic attacks associated with flying, various distortions in thinking occur while numerous distortions of behavior can occur. CBT assesses these directly with the patient in 10 to 12 sessions, often using a homework-style approach. The results can be remarkable, as the patient learns to break down the various components of his anxiety and thus becomes more in control of it. A patient’s thinking distortions would include thoughts that the plane will likely crash or that he would likely die from a panic attack while flying. Reassuring the patient against their feared likelihood of a crash or heart attack versus the reported statistics can begin to address these themes. Addressing the behavioral avoidance of the airport and air travel by creating a plan to desensitize the patient gradually to the idea of air travel, traveling to the airport, and in time, purchasing and taking a trip can help the patient regain confidence.
At the same time, you simulate fast heart rate, shortness of breath, and dizziness by recreating those symptoms in the office and teach the patient that they learn to reassure themselves when symptomatic. Active exposure to the panic-inducing situation is elemental to the treatment, as is detailed record-keeping of different physical symptoms and thoughts, with or without combined medication. CBT can be very effective in helping a patient quickly gain control over what otherwise had been crippling symptoms.
What do I do if I start to develop anxiety about my treatment and/or my doctor?
Patients commonly experience anxiety about their treatments. These reasons range from reality to manifestations of the patient’s anxiety. Some of these issues have been addressed earlier. However, even with an entirely appropriate therapist, anxiety can emerge as a function of the treatment. This anxiety can be very painful and uncomfortable, and one of the easiest ways for the mind to trick itself is to attribute the cause of the discomfort to the therapist. One of the most common examples involves the increased closeness of the therapist and the patient. As patients begin to discuss their lives and their symptoms, it becomes clear why they may not feel safe in the world, or they may come to expect that the same traumas that have occurred before will happen again, this time in the room with their therapist. Patients commonly become concerned that the therapist will control them with medications, make their sexual orientation homosexual, exploit their financial resources, or take advantage of special professional information (e.g., stock tips). These, as general examples, show a fear of trusting the therapist. It can be so much easier for the patient to believe that the therapist is untrustworthy or less than ideal than it is to believe that he has experienced again the same fears of closeness that he lives with in his relationships outside of the therapist’s office. With any good therapist who understands a patient’s need to recreate in the room the very patterns that frame that patient’s thinking and feeling outside of the room, these anxieties can usually be understood as important markers in the patient’s treatment course. If your therapist does not seem to feel comfortable discussing your anxieties, either about the therapist or anything else, then you might wish to seek a consultation with someone more experienced.
Selma’s comments:
Slow, slow, slow. There were times, too many it seems, that it felt as if there were never going to be change. I would say to myself that this treatment was a waste of money. I had subjected my family to privation for what? I was the same, indeed, it seemed to me, if not worse. My former glowing self image of my astounding the world with my great acting talent, or of receiving kudos over a brilliant piece of writing were not happening. Instead, I was living over and again the destructive relationships I spent hours on the couch saying that I understood in lucid, articulate terms. My eating habits that had caused me such agony refused to budge; my hypersensitivity to a 1-pound weight gain still kept me home mortified. hy was I wasting this time and money? Better it should go to someone who could apply him- or herself better. I saw it as wasted on me. I remember telling my analyst once (although not the only time, by any means), that there was no change and that I couldn’t seem to get it. I felt I was too dumb. I was literally the dumb blonde I so successfully played on stage.He had no explanations to give me, and he wasn’t the vocal type anyhow. I left crying at my failures. But as always, what he said, even though via such minimal statements, stuck with me. In spite of my doubt and agony, I wondered what hemeant. Where was there change? I thought his words through. It wasn’t the kind of change to write a book about. With much difficulty, I had seemingly automatically responded differently to those relationships within which I now had a glimmer of freedom to act differently. And when I wanted to withdraw and to feel sorry for myself, I did at least move and did get out of the house. Maybe late, but I got there and got involved in what was going on. These small vestiges of self-respect started to occur. No money could ever rival the value this had for me in starting to take charge of my life. I was beginning to live life with less anxiety.
Term:
CBT Cognitive behavioral treatment– A form of psychotherapy that has been proven to be particularly helpful in anxiety and depression.
