As I sat down to write this article for TAP, the Sunday, March 6, New York Times article about talk therapy and its unpredictable future was on my mind.
The article highlights Donald Levin, a Philadelphia psychiatrist, who was trained in the era of broad-based psychiatry, as were many of us. Psychotherapy was always an integral part of professional life for these psychiatrists. Levin describes how he has changed his practice in order to be able to continue to receive reimbursement.
…our level of devotion to psychoanalysis and psychotherapy exceeds that of many general mental health practitioners who are willing to change their pattern of practice to follow the trail of reimbursement.
He has stopped seeing patients for 45 to 50-minute psychotherapy sessions and instead performs 15-minute medication checks. He is no longer responsive to patient requests for psychotherapeutic assistance and instead refers them to other mental health professionals. The article stirred much interest on our listserv and a number of our members were critical of Levin; I am not. He is merely doing what he considers necessary to protect a certain style of living in the current environment. This represents a challenge for us. Many of the respondents were critical of insurance companies for changing their policies and their reimbursement patterns toward seriously shortchanging psychotherapeutic treatment. I agree with these critics for this presents yet another challenge for us.
We as an organization and as a profession need to do our best to insure that a psychoanalytic career can provide one with an appropriate professional lifestyle, and I do not mean the kind of lifestyle that investment bankers may have, or perhaps even the kind of lifestyle that Levin thought he might have when he went to medical school probably 45 or so years ago. But, it is imperative that individuals coming into our field be assured of a lifestyle comparable to those of at least some of their peer professionals, such as architects, accountants, academics, and professional managers. It is highly unlikely that one would be inclined to put in the effort to become a psychoanalyst, with all the attendant years of training, and the academic and personal demands of our “impossible profession,” unless it opens a door to a lifestyle comparable to individuals who have made similar levels of effort for their own professions. A characteristic of some of us in the American Psychoanalytic Association is that our level of devotion to psychoanalysis and psychotherapy exceeds that of many general mental health practitioners who are willing to change their pattern of practice to follow the trail of reimbursement.
For those of us who wish to continue to champion the value of psychoanalytic training and psychoanalytic treatment, there are a number of responses that we can consider.
We must continue to try to reverse the insurance trends. We can certainly do what we can and APsaA has played its role in advocacy much more effectively than one would predict based upon our size and budget. The problem is that no matter how assertive our efforts and how vigorously we wage our arguments, we do not have much control over this sector of the economy so success may not be certain. This area is no doubt going to be especially unpredictable in the years ahead with health care reform looming and with the huge debt burden that our society is going to have to confront at some point. It is unlikely in this environment that health care is going to gain substantial new benefits in any area.
Another way we can think about this, and this is much more under our control, is to do everything we can to demonstrate the value of talk therapy and the availability of individuals to provide it, and to provide it at a reasonable fee, not at the $600 an hour referred to in the New York Times article charged by “a select group of psychiatrists.” And not just for investment bankers as the article also suggests. The practice survey that APsaA will be conducting in the near future will, I strongly suspect, show that most of our members already engage in the practice of psychotherapy and psychoanalysis for fees that are often more modest.
Warren R. Procci, M.D., is president of the American Psychoanalytic Association.
Indeed, I suspect many members use sliding scales for patients who may well strongly benefit from psychoanalytic psychotherapy, especially psychoanalysis, but who cannot afford even today's restricted full fees.
There are three initiatives currently on our table, all of which I support, which will be helpful to us. One is our practice survey, which will tell us something about the practice patterns of our members and how many are interested in providing psychoanalytic psychotherapy and psychoanalysis and for what level of reimbursement. Second is the development of a strategic plan for APsaA, which will help us identify organizational priorities. I suspect that the enhancement of psychoanalytic ideas, training, and the practice opportunities for our members will be major items in the development of our strategic plan. Third is the psychoanalytic outcome research being organized by Steven Roose.
It is essential that we do all that we can do to assure the continued vitality of talk therapy. Levin has a son in medical school. If we are successful maybe he will decide to join us.