To the New York Times. Some analysts hold that organized psychoanalysis must lobby vigorously for long-term psychodynamic therapy and psychoanalysis to be included in a health plan, either at parity with other medical treatments or at the best possible level of reimbursement.
They argue that the tendency for managed care to limit severely the frequency, duration, and types of psychotherapy covered must be fought. Others stress that countertherapeutic intrusions into the confidential relationship with the patient are inevitable under managed care and that “universal” mental health coverage will result in the average provision of three to six psychotherapy sessions. These analysts believe that to fight for such coverage for long-term psychodynamic psychotherapy and psychoanalysis is deceptive to the public and destructive of those therapies. They are sometimes criticized as being uninterested in the welfare of the less advantaged.
The opposing philosophical arguments embedded in this debate parallel certain of Ronald Dworkin's ideas. Dworkin rejects out of hand the “rescue principle,” the idea that a society should spend whatever is needed to maintain health and life expectancy. A “more satisfactory” ideal of justice, he argues, is the “prudent insurance ideal,” a model that requires three assumptions: the distribution of wealth is as fair as can be; the value, cost, and side effects of medical procedures are known to all; and no one (including insurance companies) has any information on the likelihood of any particular person's suffering this or that illness. With such assumptions, it may be surmised that “most prudent people” would insure themselves for services such as prenatal care and well baby visits, but would be unlikely to pay the very high premiums required for extreme measures in the event of catastrophic illness. Most prudent people would choose to spend money on other goods, such as better education. Thus, “If we substituted the prudent insurance approach for the rescue principle as our abstract ideal of justice in health care, we would therefore accept certain limits on universal coverage, … not as compromised with justice but as required by it.”
Many leaders in academic psychiatry espouse the view that psychotherapy is an ancillary nonspecific procedure, in contrast to pharmacotherapy, which is considered a “specific” treatment. Accordingly, the American Psychiatric Association has forged an alliance with the National Alliance for the Mentally Ill, whose priority is full parity for medical coverage of severe mental illness, with a diminished focus on psychotherapy.
Perhaps the best hope for psychoanalysis and psychodynamic therapy lies in specialized treatment, including the low-fee treatment available through psychoanalytic institutes, outside the scope of the routine medical care covered in accordance with the prudent insurance ideal. It is a corollary of Dworkin's idea that medical research and treatment should be subsidized in ways other than insurance coverage. He stresses that not all people will be able to receive such treatment; “but it is important,” he notes, “for the nation (and the world) that some receive treatment rather than none at all.”
Other countries with universal health care provide a medical model of outpatient mental health treatment that is socially understood as adequate. As Peter Kramer states, “the society can tell itself that it provides universal health care, even though those who can afford it seek more comprehensive treatment in the private sector.” Psychoanalysts should heed Kramer's warning that if the private sector is destroyed, “we risk the expatriation of complex care anywhere. One- and three-session therapies just give psychiatry a bad name and cause hopelessness among those seeking hope. Rather than practice in bad faith, we might be wiser to ask that psychotherapy no longer be deemed a covered medical service.”
Leon Hoffman, M.D.
New York