September 2000

The Psychological Imbroglio of Managed Care:
How the evolution of the struggle transforms the clinician

by Joyce M. Cartor, PhD
Appalachian Psychoanalytic Society

During the past decade, our profession has been ravaged by a collision of forces and events, some old and predictable, some new.  I have been struggling to make sense of it even as I have been immersed in it.  This paper is my personal attempt to integrate my readings and observations into an initial articulation of some theoretical considerations.   I think these are necessary for understanding the many-layered significance of the impact of this intersection of managed care and psychotherapy in which we dwell.  It is, of course, a work in progress, just as what’s happening to our field is a work in progress, but despite the depressing nature of the topic, I hope the reader will find something useful here.

This paper was extremely difficult to write.  It seemed that just as I managed to bring one facet into clear enough focus to think about, I would find it blending in with a haze of other considerations, resulting in an nebulous blur that often defied my attempts to put anything coherent into words.  Since feeling garbled and inarticulate is such a noxious experience, I persisted until I hammered out something comprehensible and graspable, maybe even sensible.

One thing that has gotten clearer to me is that clarity is a process, and that the hazing over is a fundamental, significant part of what is happening in this intersection.  And since meaning is always unknown until it emerges, I continue to remind myself that I am attempting to understand the bubble I am inside of without benefit of being able to view it in its entirety from a distance. 

Given that reality, I think at best I can evoke some of clinicians’ shared experiences of being psychoanalytically inspired therapists in the current climate by giving you a sampling of how I have pieced together some meaning in the chaos.   I hope that this will illuminate some of your experiences, perhaps inspire you to go further with the analysis; maybe it will simply break up the monotonous drudgery of having to live everyday with the particular tensions that managed care has brought to our daily lives. 

The emergence of meaning applies even to my title, “The Psychological Imbroglio of Managed Care”, which I feel inclined to apologize for.  I need to blame a colleague for this because he demanded I come up with a title for the paper way back in the Fall – or maybe it was even late Summer – because he wanted to mention it in a  newsletter since the paper was first presented at a local meeting.  Well of course, I didn’t have my paper written by then; and I never get around to a title until after I write something.  So I was forced to contrive a title that somehow captured some of what I was thinking about at the time. I want to explain how a word like “imbroglio” got into the title of my talk because it is such an obnoxious and ugly word, but it’s been an obnoxious and ugly struggle so maybe it fits in some anti-poetic way.

What the title meant to me had to emerge, just as the meaning of managed care’s intrusion into the psychotherapeutic space is still emerging.  We can’t yet definitively analyze it, or be certain if we’ve made the best response to it.  However, we know, just like the therapist in the frozen instant of being handed a gift by a patient knows, that we are in the middle of an organic moment that will have meanings and repercussions.  But there is no way to know with surety ahead of time what the meaning will be.  Still, like the good therapist, we have to momentarily consider certain variables even as we are more or less spontaneously responding to the event at hand.  Our mind speedily runs down the most obvious possible consequences.  But of course we can’t know for sure.   And we attempt to note and take stock of our own emotional responses and associations to what is going on in the moment.  But mostly we just respond and we figure it out later.  And even though our literature is filled with debates about what one should or shouldn’t do by way of technique in all sorts of unexpected situations with patients, still, I believe, the real understanding has to come over the course of things unfolding.  And so it is with our responses to managed care.

Psychoanalysis and psychotherapy have been embroiled in the managed care imbroglio for over a decade now; most harshly for the past 6-8 years.  Enough has happened that we can begin to sort through the debris to see what it means.  An imbroglio is a bitter, violently confusing struggle; a complicated, perplexing, acutely painful embroilment.  It is something you don’t get to look away from.  It’s a chronic condition, like an illness.  Because of its relentlessness, it activates all sorts of extreme coping mechanisms such as denial, undoing, suppression, dissociation, somatization. 

Let me cite two examples of why our going-on-being as therapists has required such extreme measures.  Here’s what we’re up against:  In the last ten years, per capita spending for mental health care has declined by 54.1%.  In comparison, expenditures for overall medical services show a decline of 7.4%.  (That’s a 640% difference.) Mental health care spending by the insurance industry is now just 3.1% of the total healthcare benefit (Hays Group Study on Health Care Plan Design and Cost Trends, 1997).

So just in case you were wondering if it’s all in your head, it’s not.  This is really virulent, and not just for our pocketbooks (although that is clearly a critical and toxic aspect of this that demands a response.  I will be expanding on this later).  Managed care is a virus infecting our faith in ourselves as healers, the public’s faith in our profession as useful, and all of society’s faith in what life can mean and what is possible.  Think about this: You’re just an average guy and you go to a therapist because you can’t stop screaming at your kids and wishing you didn’t have to go to work in the mornings. The therapist says she can see you for 5 sessions and after that gives you some books to read and a referral to a psychiatrist for drugs. How will this affect your faith in the healing arts, your view of the profession of psychotherapy, and your belief in what is possible?

I’ve noticed that right around this point of understanding, when the disturbing statistics have been thrown out, clinicians start to not want to discuss further this noxious and depressing topic.  But I think we have to, despite the strength of our aversions, because in order to get out of a trap one has to understand it. Other tools may be needed, but understanding the nature of the entrapment is imperative.  I have struggled for seven years now, trying to get something articulated about what is going on around us that goes further than an analysis of the facts and statistics.   I have been  struck from the beginning (and still am) with the decreased reflectivity in us regarding the meaning of this process we are immersed in.  Despite the fact that we analytic types are often accused of “analyzing everything”, for some reason we haven’t been analyzing the managed care intrusion into psychotherapy as much as we could.  Instead we have reacted to it as if it is only literal and as if only its literal aspect will impact our lives.  This has seemed so curious to me that I’ve come to believe that this lack of reflectivity is a significant part of the process itself –a lived process in which we are embedded.  I know that when psychoanalytic therapists leave out the psychological, that is an indicator that something is seriously disrupting the very fabric of how we are making meaning in our lives.  The more I’ve thought about this, the more I’ve become convinced that this reveals the degree to which we feel under threat.   The meaning vacuum is our symptom, revealing the severity of our disruption.

I know that when a human being is in the midst of something that is extremely threatening on many levels simultaneously – in our case this would be the financial, the social, the professional, the personal - reflectivity is usurped by hanging on, or survival.  This isn’t any big psychoanalytic insight, of course.  We all know it’s true.  However, it is important to dissect it and to appreciate it as a comment on the enormity of our trauma.  I do think it is imperative that we understand this as prolonged trauma – something enormously negatively impactful, confusing, damaging, entangled, and most of all undigested and not understood and not integrated. 

If you think about what we know about what makes a miserable childhood traumatic, it is not the individual abusive events in and of themselves, but rather the absence of an empathic other that allows the events to be felt and metabolized and made sense of.  I think this is one piece of the puzzle with us and managed care.  Our experiences of being tangled up with it have felt bitter, violently confusing, assaultive, painful and unrelenting, but we have no one to turn to grieve or to make it make sense.  No one has escaped without being wounded. Most of our mentors have been understandably paralyzed, or have failed to register the enormity of what’s happening, or have left the field, or retreated more stolidly into the procedures that have worked for them in the past.  So we find ourselves adrift in the ongoing threatening surround, unable to get grounded enough to breathe deeply and wonder what it all means to us and what our responses mean about us. 

I really can’t emphasize strongly enough how critical it has been that our mentors and teachers have also been, in one way or another, devastated by the managed care virus.  It reminds me of an extremely disturbing article published in a recent Psychoanalytic Psychology (Auerhahn, 1998).  The authors had studied profound trauma and its impact on children and on subsequent generations.  They focused on victims of political torture both currently and during the Holocaust. One of the things they found was that children who are with their mothers when they are tortured are worse off psychologically, post trauma, than children who were separated from their mothers at the beginning of their imprisonment and never saw her again.  Their work with these children suggests that by separating from the mother, these children could maintain a representation of her as the interpreter of experience and the fantasy that she would make sense of their predicament eventually.  But the children who were tortured with their mother present were unable to ever process their ordeals and move beyond the raw experience of them or the symptomatic expression of them because the possibility of meaning making had been shattered by witnessing the mother’s inability to make sane and comprehensible their unspeakable horrors. 

In the early years, after managed care moved into our psychoanalytic communities, I would run into dead ends when I tried to explore our reactivity to managed care.  Although I could certainly feel its all too real external impact, I was also wondering if our intense, frantic move towards action was a symptom.  I think I bothered many people when I mentioned this.  In fact, I know I made a few people just furious. Why, I wondered, did it seem to be impossible to talk about the situation, without someone insisting that we drop back to only its immediacy and concrete reality?  I wasn’t canceling out one with the other, but it was a conversation that mostly couldn’t take place. 

Now I look back and think that we had been so shaken by the sickening specter of the demise of our professions; and the absolute certainty that our freedom of movement would be curtailed; and the heart pounding terror of being unable to go on making our livings, that psychologically we couldn’t breathe.  Many people were speaking from a place of such profound fear that the only thing that seemed relevant was what they were afraid of – namely financial ruin and the shame of having been a fool.  So the thing itself  - managed care’s intrusion into our world - becomes reduced to the terrors which we feel and can imagine, a process which eclipses everything else – including breathing and thoughtful reflectivity.  (As an aside, I think it is interesting and telling, that these days, the fear of having been a fool to go into this field at all is regularly mentioned by our students).

This phenomenon of being unable to look underneath raw experience for additional layers of meaning is what Thomas Ogden, building on Winnicott, characterizes as the collapse of potential space (1990).  This is my second observation about what has been happening to us and builds on the first – the issue of being alone in this without mentors.  Understanding this elusive yet powerful concept of potential space has been critical to my getting out from under the despair inherent in the managed care problem. 

Potential space is Winnicott’s term for the metaphorical space where meaning is constructed of experience, so that experience is more than a feeling state, or a fantasy, or the concrete reality going on around us, or a raw physiological state.  This includes the space where play and playing around with ideas takes place; also the space where creativity emerges. If we follow the spatial metaphor, it lies between the individual and the environment.  That would mean that between us and managed care there should be meaning.  But, in my opinion, our drive to make it mean more than the sum of its parts has been noticeably compromised during this upheaval.  I will talk about this in detail in a moment.  First let me say something more about how potential space is created and then we’ll consider how it can be destroyed.

For the developing child, the necessary conditions for potential space to emerge include the creation and maintenance of a holding environment that reliably and empathically responds to the actual physical and psychological needs of the baby.  When the mothering one creates and protects this space, and enough trust is established, the developing child can begin to live creatively; that is, to play.

A holding environment is our surround.  It must function so smoothly that we don’t have to think about it much.  A prerequisite for its success is that we can take it for granted.  Obviously, in infancy, it is the caretaker who creates and maintains and is the holding environment for the baby.  But, I believe we can also say that we go on requiring holding environments.  Although I do not know whether Winnicott ever spoke about this at length, I do know that he saw the holding environment as beginning with mother and growing outward to the family and eventually to other groups in society (Abram, 1996).  I believe our lifelong reliance on holding environments is what Kohut implied in his theory of the lifelong need for self objects.  Both are attempts to differentiate out of the matrix of events, people and places in which we live the ingredients that are critical to the maintenance of our sense of continuity of self and our ability to go on living without too much paranoia or depression.

I believe that we build and accumulate holding environments as we develop into social adults with professions and communities.  Some of these holding environments have a nesting quality whereby our professional community, for example, can only emerge out of an embeddedness in the larger societal holding environment that can imagine it as a possibility.  If society can’t create the space to imagine us, than we can’t exist in the same way we do now.  You can see how everything starts to fall, like dominoes, if we are not created by our society.  Significantly, our earning power is diminished by the degree to which we are not imagined and held in the imaginations of society’s members. 

In adulthood, we have hopefully internalized a good enough mothering experience and can unambivalently take care of our actual physical needs.  If all goes well, we have a pretty good idea of how to get many of our psychological needs met.  Ideally, this creates the capacity to work, to relate, and to play some.  Since we need to attend to our own physiological needs as adults, we need to have certain conditions in place in order to take for granted that we can do so.  Specifically, in our capitalistic society, we need to be able to work productively.

Our holding environments include our circle of friends, our families, our professional community, our healthy bodies, perhaps our church community, or our neighborhood. This list of contexts that provide us with a sense of place and belonging can be added to, of course.  I’m sure we all recognize it as a list of the things that need to be in place in order for us to relax.  All of those holding environments nest within the societal holding environment.  If the societal holding environment lets go of its grip on us anything can be at risk.

Trauma in the Winnicottian sense is an impingement or intrusion into the holding environment that fundamentally alters the holding environment, decreasing its ability to create an experience for the baby of being able to take for granted that its physical and psychological needs will be met.  Experientially, Winnicott described trauma as something “producing the experience of unthinkable or archaic anxiety……A trauma is that against which an individual has no organized defence so that a confusional state supervenes, followed perhaps by a re-organisation of defences, defences of a more primitive kind that those which were good enough before the occurrence of the trauma” (Winnicott, 1969, p.259).  When we can’t take our holding environment for granted we must, at all times, attend diligently to our needs and the possibility of getting them met, for now the fear that they may not be met has become ever present and central.  This is a psychologically exhausting process.   (This framework has finally helped me understand, for instance, why I was so profoundly stressed out and eroded by the extreme financial jeopardy I lived in during my graduate school years).

When our holding environment (usually the mother in early life) is intact there are all sorts of things we can weather.  There are many studies that indicate that a really good holding environment can metabolize actual traumatic events for the child allowing the child not to become symptomatic later on.  In a general way we can say that a decent holding environment allows the development of Basic Trust.

Well,  Trust is not something we have a lot of anymore.  The superstructure of our professional holding environment – which includes our sense of professional community, our place of importance in society in general, and the place of our profession in the economic order – was crippled by the seemingly sudden, confusing, and enormous impact of the managed care meteor.  It seems that professionally we can no longer take anything for granted. 

Our professional holding environment is uniquely configured because of that nesting quality I referred to.   We are each a building block of our professional community even as we are embedded in it.  This makes it particularly susceptible to impingement because it is compromised each time one of us is professionally wounded and pulled away from it.  If many of us are wounded at once, it is particularly vulnerable.  (I think this is why we are so sensitive and reactive to turf battles.  To borrow from Winnicott again, it’s as if we’re doing this without a mothering one, being the baby and the mother at once, so it is fragile and hangs together only if not too many members at any one time are being overwhelmed or damaged). 

Managed care is no ordinary impingement.  It has gotten so many of us on so many fronts at once that it has left us breathless with fear, able only to attend to the immediate crisis of making a living. This puts me in mind of a patient of mine – a young, energetic, luminously hopeful pre-school teacher.  When she found out that she was pregnant with twins, she and her husband were delighted.  It would be a daunting task, they knew, but they had always excelled at everything through hard work and optimism.  A year after the births of the babies, she sits in my consulting room, her normally silky blonde hair is limp and lank; her eyes are dull; her skin is sallow.  She cries with every attempt to speak, her fists clench, she can’t make eye contact.  Despite her desperate love for her babies and her husband, she can no longer feel that she is capable of shouldering the burdens of daily life.

Since the babies have come the following events have occurred:  The twin boys are placed in infant ICU for 8 weeks; during this exhausting and frightening time, her husband loses his job.  Since the new school year is approaching, she attempts to get her old teaching job back only to be turned down.  They can’t make the house payment and their insurance company informs them of approximately $10,000 of hospital bills that will not be covered.  Soon one of the cars is repossessed and in desperation they rent their home and head North to his parents’ home for shelter.  Once there, her husband does find work but begins drinking nightly with his father and brothers.  She grows increasingly depressed and flees to her mother’s home with the twins.  In her mother’s soothing presence, she garners enough energy and hope to gather the babies and the husband and return to Knoxville to face reality.  He gets two jobs, but they lose the house and he is never home.  The twins are frequently ill, but they have no insurance and no credit, so pediatrician bills mount and they can’t always buy the needed medicine.  They often have to call friends to borrow money for food and diapers.  In addition, the utilities and phone are periodically cut off for non-payment and each time a new fee is assessed to turn them back on.  She wants to try to get a job, but every daycare she calls wants the first month’s payment up front, which, of course, they don’t have. Also, she hasn’t slept through the night in 15 months.    Perhaps we can see why she might not be able to rally towards optimism, or empathic attunement with her children these days – maybe not for a long time.  She and I can’t talk about much in therapy except the immediacy of her needs and her overwhelming fear.  It’s like log rolling – there’s no time to think.

I use this case as an example of the degree to which, even the most resilient people, are reliant upon their surrounds to hold them enough to allow normal functioning to go on.  In our current lives, the surrounding world can feel a little like my patient’s – crumbling; no matter the effort put forth, we’re always one step behind the next wave of damage.  The impingement has hurt and scared everyone – the old ones, the young ones, the robust and confident ones, the dour and self-doubting ones.  No one has remained untouched.  When I go to national conferences I wait with anticipation for the wise elders to say something about all this that will soothe me.  They never do.  So, in a sense, we are operating without an intact surround to help us sort and contain our fears, and without the wisdom of the elders to help us know how things will come out, and therefore without genuine hope.

Let’s return to the notion of potential space and impingement.  When impingement reaches the traumatic level, potential space collapses or is compromised.  Ogden describes the “direction” of the collapse by envisioning four ways in which our ability to use symbol and imagination becomes foreclosed.  I will talk about two of these today.  One direction of the possible collapse is towards Reality; the other is towards Fantasy.  In either direction, the needed dialectical tension between the two is missing and symbolic meaning can’t take hold.

Managed care itself is a peculiar promotion of collapsing potential space in the direction of reality.  Ogden says, “the dialectic of reality and fantasy may become limited or collapse in the direction of reality when reality is used predominantly as a defense against fantasy.  Under such circumstances, reality robs fantasy of its vitality. Imagination is foreclosed” (1990, p. 215).  Yes.  This is exactly where we are supposed to be working, according to the insurance companies these days.  We are not to dwell in the place of meaning, creativity, poetry or excitement (Life).  We are to get the money, count up the symptoms, catalog the behaviors, and set up a time line.  (This will, by the way, temporarily cure a lot of hysterics whom – for awhile – welcome the structure of rigidly formulated, conscious deliberateness. It’s offers relief from the usual affective soup.  However, it generally leads to a, contrived restraint, a disbelieving depression, a lack of zest.)    However, if the insurance industry were to lighten up on their hardcore reality orientation, they would be allowing for the emergence of fantasy, wish, desire, rage, and they would be getting close to the dangerous issue of what has been promised and what is actually available. So managed care’s over-reliance on external or factual reality encourages a shutting down of meaning making and of play and, therefore, of creative living.  No wonder we feel so bad.  It is stultifying.  Without fantasy to enliven reality, there is no vitality.  (Think of black and white TV.)

More internal to us is the second way potential space has been compromised.  If the dialectic of reality and fantasy collapses in the direction of fantasy, then reality is subsumed by fantasy or affect and “fantasy becomes a thing in itself as tangible, as powerful, as dangerous and as gratifying as the external reality from which it cannot be differentiated.”  (Ogden, 1990, p. 215)

This is what we’ve been stuck in – the belief that what is happening to us inside is real and immutable with little distinction made between the actual threats and how enormous the threats feel and where we imagine they will take us.  This type of potential space collapse makes us too literal.

This has also helped me understand in a new way that all patients come to us initially with at least some collapse of potential space.  The degree to which they are miserable is determined by their inability to get out from under the actuality of the trouble long enough to see it and understand its place in their lives.  Without this there is only suffering and despair; no movement is possible; no meaning is possible; no space, no breathing room.    Yet the actual is so compelling (for instance our actual fear of not making enough money to survive or feed our children) that it is sometimes impossible to pull away from it - indeed it can feel literally dangerous to take our eyes off of it for an instant – without the help of someone else to help contain our fear and keep it from blossoming into outright panic.   We know as therapists that we often have to manage the impact produced by the operation of an emotional state before we can get the emotional state calmed down enough to intervene at the level of constructing meaning.  Then it is the therapist’s job to pry open the potential space so that something other than raw fear and need can live within the person  - so they can be human again.  And once pried open, we have to hold it open so that meaning can continue to emerge and to give them a way out of the literalness of the trouble.

At first glance, to apply what I am saying to our current situation may be anxiety provoking or even irritating. The fear and the threat is so big and so real and so in need of an actual response that any comment that doesn’t match the level of the therapist’s terror, is by definition an empathic break.  I remember that when my father died, I experienced almost everyone’s well-intentioned, caring responses as sandpaper on open nerve endings.  I was so raw and so jolted that every gesture set off new reverberations of the pain unless the person could just sit still with me and let me talk.  Sometimes it felt as if people wanted me to get on with things before I could; it was as if their ability to see other layers of life felt insensitive or naive.

I fear that I may have produced similar experiences in some of my colleagues in the early years of all this.  I understand better now that in the moment that one’s house is actually burning down, it is inappropriate and insensitive to ask what it might mean in the course of one’s life.  Nevertheless, like the determined therapist who has delivered a poorly timed, but not necessarily inaccurate, interpretation, I will continue to suggest that the Real must be held in a constant oscillating tension with the symbolic meaning of the Real, and that neither can be ignored  safely.  So it is, for instance, when a patient tells me she has been physically assaulted by her boyfriend.  I immediately feel the pressure to help her take some sort of concrete action towards physical safety.  At the same time, I am aware that she may not and that her ability to do so effectively will be determined by the meaning of this particular type of predicament and relationship in her life, and that I eventually have to help her know all of that.

Just as our patients, at the beginning of therapy, do not usually know to look at or study their own process even as they go about living it, we have often forgotten to look for – in addition to our lived experience - meaning in the impact of the concrete, malevolent reality of managed care and in our reactions to it and in the positions we’ve taken in response to it.  Perhaps this corresponds to the view of Edward Shapiro (who is Medical Director at the Austin Riggs Institute).  He views managed care as “a resistance” to be handled much like any other resistance (for instance, not having enough money to pay for therapy, or not having a husband that will “let” one attend sessions).  In this way, he approaches managed care’s intrusion, with each patient, as something to understand in a personal way and to struggle with rather than dissociating it into something that is actually “bad” to the patient’s “good”.  And even patients who need at first to be intensely managed (like the proverbial extreme acting out Borderline) need us also to recognize that they are blind to potential space, and eventually need room to create new solutions to their pain and to their ways of thinking.  So it is with us and managed care  - it needs to be both managed and understood.

MONEY AND OUR SOULS  

One of the things I actually feel kind of perversely lucky about is that, given the time I entered private practice (1987), my professional holding environment was never entirely intact and unimpinged upon by the managed care scourge.  I got in just as the days of endless insurance reimbursement were ending.  I never got to have those huge monthly checks from the insurance companies that my older, more established colleagues were getting.  I thank god I didn’t because I never had to give up getting them; but  how I longed to be on the right lists at the time.  I wanted it to be that easy for me, too.  Now I’m thankful in a way that it wasn’t because I had less to give up, less to lose, less to expect.

It has seemed to me that we are struggling to hang onto what we know about ourselves in the face of something big enough to cause us to act at times in ways we do not always recognize as familiar or honorable.  The intrusion of managed care into our realm – psychotherapy – crept up on us and we were inside of it before we knew there was an inside or an “It”.   And of course when we each began to realize there was something happening to our professional lives, it had tangled itself up in something extremely personal and potentially shameful – our relationship to our financial life, and its relationship to who we are.

The first psychological symptom, arising from the two potential space collapses, would have to be that there was nothing to look at it.  The it of the process was indeed not there.  There was no process.  Thus my first foray into managed care was blithe and blind.  I just signed up, like everyone I knew was doing.  It was about ten years ago.  The new company had a new idea – something about providers pay a fee to get in the network and we would get all of the referrals and the consumers rates somehow would go down.  I didn’t know how it all worked and somewhere in there I realized that I didn’t get it and I set about to find the missing information.  I did it innocently at first because I really believed that I was just shy of some needed information. My mentors and older colleagues, after all, were okay with the whole thing.  To my amazement, my innocent inquiry brought down upon me a raging attack by the colleague who had made the initial arrangements with the managed care company.   I had no idea what I had set off or what could explain the strength of his reaction.  It took me along time to realize what has transpired.

Now I see that of course I couldn’t ask those questions.  To look too closely at the mechanisms behind it would be to brush too close to what I sometimes think about as “the money issue”.  And the money issue isn’t about money per se, it’s about our desire for it; how much we want it.  We want to be upper middle class.   And who wouldn’t given the opportunity?  The houses are bigger, the cars are newer, the clothes are nicer and you can have more pairs of shoes.  Not to mention more books, more vacations, and a little bit of art thrown in.  Also the food is better up there, as is the education.   So it’s no mystery, nor is it an indictment, that we want it and getting it we want to keep it.  So if this is truly nothing to be ashamed of – in theory – why then is it so unspoken??

I think one of the reasons this has been so particularly awful for us to contemplate psychoanalytically (meaning to wonder as to its meaning in our lives – as opposed to its concrete reality) is because we don’t have a history within our field of examining our relationship to having money, and how we get it.   We have not until now had to examine our experience of making money by engaging in a process that is an essential adaptation to our own life experiences – in fact, an adaptation that often renders psychotherapy as the only field many of us can imagine being in – it’s a vocation; a calling – as well as a meal ticket.

Mostly money is dealt with administratively within psychotherapy and psychoanalysis.  For instance we determine policies for our own practices about such things as fees, payment options, billing for missed appointments, etc.   But many clinicians never even do this with much clarity because they cannot figure out a coherent philosophy in which to ground the policies.  They intuitively recognize that they don’t know how they feel or if they even have a clear opinion about amassing money, perhaps even wealth, and they are very unsure of what they are worth professionally, and they often have nowhere to go to talk this out because the discussion within the profession has been more or less shut down or limited to understanding the meaning of the fee and money to the Patient.  But we do not as a rule examine our own relationship to, ambivalence or conflicts about our own money

David Krueger, in The Last Taboo, notes that “Money is esteemed, yet it is condemned…The Puritan ethic emphasizes hard work, thrift, and victory over adversity, but it is paradoxical in its proscription of the enjoyment of money earned by hard work, thrift, and victory over adversity.  Accordingly, both money and the lack of money produce guilt” (1986, p.4)  and, I would add, shame. 

In my own life I’ve noticed that when you’re poor it’s perfectly okay to talk about money.  It’s often a necessity, in fact, in order to borrow it, or complain about it so the frustration doesn’t level you.  And if you have plenty of money it’s okay to talk about it then, too.  Although it’s not as necessary and so doesn’t happen very much unless you are talking about how to invest your money.  However, if you are in the process of going from rich to poorer, perhaps even to poor, then it is shameful to talk about it.  Once you arrive at the bottom of your descent you can gripe away.  But when in process, we hang our heads and fake it for as long as possible until we swallow hard and come to terms with our lack of “success” in this arena.  John Irving says, “there is no intolerance in America that compares with the peculiarly American intolerance for lack of success”. (1998, p.517)  Boy, do we know what he means – we can hardly stand ourselves during our downward slope.  No wonder we don’t want anyone else looking at us.  

It is generally agreed upon that graduate programs in clinical psychology or social work or psychiatry do not do a good job of teaching budding clinicians how to deal with money.   And we always take that to mean money and the patient.  But I think it ought to mean, and probably does subliminally mean, money and the therapist as a person.  We have been timid about approaching the meaning of being able to become relatively wealthy.  When we got the right to receive insurance reimbursement in the early 70’s the profession didn’t seem to know that it might be a good idea to analyze this gift horse.  It was a kind of group dissociation, and perhaps this was because it was threateningly uncomfortable to have had our own money hunger so excited, as well as the desire for the social confirmation of being sanctioned as a medical profession with all the accrued rights and privileges for taking ourselves seriously.  We really didn’t see to look at this.  It’s that basic thing about denial – if it works, it’s invisible.

And so insurance reimbursement really was a modern day Trojan horse, bearing as it did the seeds of the inevitable collapse of our freedom to go on making a living at making meaning.  The lurking shadow of escalating financial accountability was barely discernible at the time.  It would take a generation before its lethal implications became clear. When the subsequent generation (my own) came through we never thought to look at what it meant that we were going into a profession that was going to be meaningful and lucrative by virtue of a contract with another unrelated industry.

The ghosts of the past haunt our present. When the managed care thing hit us with the fear of loss of our multiple riches - for we have been rich in money, rich in authority, rich in meaningfulness - we became symptomatic, of course.  We were stuck responding to something that had an undiscerned and unarticulated history that was causing us tremendous distress and conflict, yet we could not see all of where it came from or what had created it.  Françoise Davoine and Jean-Max Gaudierre show us that that which has not been articulated in one generation must find a symbolic or symptomatic place in the next.  We are that generation.

Furthermore, we must contend with the unseemliness of our desperation as well as the desperation itself.  We feel a real, but often embarrassing, pain at the thought of giving up some of the luxuries that have become standard in our day to day lives.  Preceding the pain is an absolute terror because at first it feels as if we cannot give them up.  At least by the time we get to the pain we’re on the path out  - which will take us through our grief.  But in the in-between we must confront our own greed (and we aren’t supposed to have quite that much of it), our own culpability, and our unobservable and unanalyzed history.  And the grief waits in the wings as we feel the Space where we have been imagined by our cultural surround closing up.

LOSING, WANTING, AND ADAPTING  

Since managed care infiltrated our consulting rooms, we have been faced with a blind decision:  To accommodate or not to accommodate.   In many ways it is a variant on Hamlet’s great question, because it is about how to be a version of oneself as a therapist that one can live with.  And the answer cannot be the same for everyone.  In fact, I’ve yet to meet two people who take the exact same stance on this subject.  There are countless variations.  But for the moment I will break them apart into three generalized categories:  Accommodation; Refusal to Accommodate; and Denial of the Need to Take a Position (sometimes expressed as, “I haven’t thought much about it. I just do what my patients want with the insurance”).

The earliest Accommodators are those that met the train at the station, so to speak.  I used to be angry with them.  I thought this was selling out and selling the rest of us to the bounty hunters.  But I’ve come to see it as just another variation on trying to cope with the hell of all of this.  (I think we have finally all agreed that this has been Hell.  The few that don’t are probably not reading this.)   The agreement on our unhappiness is important because  it’s allowed a sense of community to creep back in again – it had gotten splintered for awhile when the onslaught began and we became divided about our priorities.

But if clinicians accommodated in some way, for example, by joining panels or setting up new provider systems, they did it to survive financially, or to meet their responsibilities as parents; to some it seemed that it was part of being responsible to their patients,  helping them get the most out of their insurance policies.  The really hopeful ones believed the system needed changing and this was a good way to do it.  It hardly matters why anymore, except for the individual who must continually reflect upon his or her position and its impact and adjust it as needed.  My point is that it had a price - all of the positions have a price.  This stuff changes people.

 The personal costs inherent in the accommodating positions seem to revolve around a guilty shame – shame at one’s fearfulness, shame at being bought; or an angry defense against shame – an injured resentment at being misperceived and not having one’s attempts to do the right thing be acknowledged.  And it’s bearing the burden of these costs that have pushed  individual therapists into further evolutions, transforming some :  There are those that have gotten depressed;  some have gotten manic and agitated; some have become cold and empty, thinking only of business angles; some have become barren and cynical, imprisoned by the enforced limits of managed care therapy; many feel diminished by their shame and can’t believe in themselves as healers anymore. There are exceptions to these scenarios, of course, other variations, too.

None of this should be taken to mean there hasn’t been a price paid for taking a Non-Accommodating position.  Those of us who fought against managed care felt at first virtuous, struggling, embattled, scared, silently heroic.  But in time came the weariness, the disillusionment, the despair, the  cynicism.  For some it has been a gradual descent into a shapeless fury that wrings the life out of the work - so they lost anyway.  Some (maybe the true heroes?) are still out there fighting.  The cost to them is that this has become their whole life.  I gave up the active politically-tinged fighting and now feel guilty at having left the others out there alone with the wolves.  It’s like taking a break in the middle of a war and hoping the troops stuck at the front don’t mind.  But still, despite the guilt, I do it, because there is only so close I can get to the constantly nagging reality that threatens to wear us away.

The latest evolution of my own symptomatology is an inability to listen to a radio story or read a newspaper article all the way through if it’s on managed care.  It threatens my capacity to hold open potential space.  I can feel the tug to believe that this is all there is to the life of psychotherapy and to give into my own cynicism about our self-destructiveness.  I don’t want to go there; I want Life to be bigger than that.

I think the costs of not dealing with the managed care intrusion at all – the “I don’t get involved in politics” position is a soothing illusion favored for its initial comfort level.  But in the long run this leaves a clinician confused and unsure of where to go, and then more easily ambushed and screwed over.  This is a little like the therapist who says “I don’t need theory I just go by my guts”.  That’s great if you’re into hysteria and living exclusively in the land of intense affective states.  But it ill prepares one for periods of overwhelm or choice and it probably doesn’t change patients very much in any fundamental way.

No matter how we position ourselves, we’ve all got to find ways to hang onto our souls.  It’s so easy to want to say there’s only one way, and it’s mine.  But that’s a little too missionary-like for me.  In his “Rules for Keeping a Therapist Alive”, Carl Whitaker said,  “If we can abandon our  missionary zeal we have less chance of being eaten by cannibals” (p. 162). This is something I keep on my desk and frequently read over to remind myself to preach less and listen more.  At some point I realized that the tendency towards the missionary state was another way of taking it all too literally – of having potential space collapse.  And I tried to pull back and see, not just my own position, but what all of it meant -  what we were all saying with the choices we’ve made. 

I can see that this has changed us all.  In different ways, we have been humbled, chastened, eroded.  All of us have had to give up some of our hopes and aspirations.  This is often in the nature of the lifestyle we’ll lead, of the monetary security and freedom we’ll have, or of the things we will accumulate, or the degree of ease we will have in our day to day lives.  In a capitalistic society we cannot underestimate the impact of having one’s income drop significantly. 

Yet we have each had to give up other, more private, things also.  Some have given up on the field itself, no longer finding meaning enough in it to sustain through the fight of it.  Some stay in the field but in name only; their hearts and minds are elsewhere now -  looking for a path out of this monotonous struggle and into something which stimulates and enlightens without taking such a god awful toll on their confidence and security and faith.  Some others stay actively in the field but can no longer allow themselves to be caught up in its magic, in the power of the psychoanalytic vision, because they dread having their own hunger for meaning opened up again.  Even though these clinicians do help their patients, no matter how briefly, bring some sense and concordance to their chaotic struggles, it’s as if they can’t afford to believe they are doing this kind of psychoanalytic work anymore.  It is a painful challenge for a therapist be that stimulated and invested in every patient when they may have to abruptly cut off the process in mid-stream.  It can be too much. 

Sometimes a person has to keep himself from wanting any more than what he’s getting or the wanting is too painful and disabling.  I think that if the clinician doubted herself before this whole thing began, she is particularly vulnerable to this kind of turning-away-from now.  After all, it’s one thing to doubt oneself as a developing psychoanalytic clinician when one can spend most of any day practicing and honing one’s skills, and when colleagues speak the same language.  But it’s another thing to keep challenging oneself when fewer and fewer people think it’s a good idea and when economic pressures bear down as well.

The impact of managed care on this profession of psychotherapy is an ongoing, evolving process.  Like any piece of life, it is something we do make adaptations to in the way that humans always adapt to prolonged crises or threats or difficult conditions like war, drought, military occupation, cancer, physical disability, grief, etc.  But the manner in which we adapt is idiosyncratic and highly personal.  The variables to be taken into account in understanding our own adaptations include our personality style, current values system, and the impact of the particular stressor given the developmental phase we are in.  (For example, think of the possible difference between the response of a new graduate and that of a fifty-year-old man with kids to support.)  All of these things influence our adaptations to managed care in our professional lives, and all of these things are continually changing themselves even as we go on living with this ongoing process.  Because it is not yet over, we can only understand some of what we are doing within it.  A person may make several consecutive adaptations, one falling into the other, over time.  Or one may make an initial adaptation and stick with it, depending upon the way it has worked to protect one from too much despair, or too much emptiness, or too much self-loathing. 

CONCLUSION  

In a recent issue of Psychoanalytic Dialogues (1999), Lewis Aron has an article.  He is saying that each psychoanalytically informed clinician has a relationship to a body of psychoanalytic theory and thought and to a community of other psychoanalytically informed clinicians, whoever we imagine them to be.  He calls this relationship the Third and he insists that it is always there operating within the therapy hour.  It hovers in the background, sometimes the foreground, as surely as any supervisor’s ghost. 

In his recent article, Aron uses this fictional vignette:  A therapist occasionally cleans out his stash of waiting room magazines.  His patient has seen him dumping them in the outside trash can from time to time. One day she begins her session by mentioning that she’s noticed that the magazines are piling up again.  She wonders if she could have some, reminding him that she teaches disabled kids and sometimes uses magazines to make collages.  She knew that the therapist threw the magazines away anyway, and she would only take the older ones, of course.  “Is that all right?” she asks (1999, p. 10).

The question is asked, should the analyst give her the magazines?  Should he not?  Is there a right answer to this?  Aron posits that it is our relationship to the Third, our psychoanalytic theory and community, which determines for us what we each will do.  But we cannot know if it is the right thing to do because the meaning, the costs, the usefulness of our response will only be known after the fact and will continue to be known and re-configured over the course of our future relationship with this patient.  Our theories help elucidate certain possible meanings, obscuring others, but they do not proscribe a certain response.  The meaning begins in the moment, but is organic and has to then evolve and continue to be reinterpreted.

Sometimes the questions facing a clinician are not as manageable as the magazine question.  Sometimes it’s overwhelmingly big, like what’s a person to do about the managed care problem?  I think that perhaps a better question for our purposes is to ask what is the way in which whatever we do will come to matter to each of us over the course of time and in our relationships to ourselves?  Whatever we do it will be aimed at keeping ourselves out of too much despair and hopelessness. 

You know, one of things I’ve noticed about physicians in their responses – or lack thereof  - to managed care, is that they do not doubt their importance.  And I’ve come to see this as critical to their, at times maddening, ability to just keep working throughout this whole juggernaut.  Some get active and reflective and insightful and recognize the need for change.  But I have yet to talk to or read any physician who has also to grapple with the worry of feeling irrelevant to patients or to society, no matter who in the managed care industry says so.  And this is, in part, due to their relationship to their Third – their very solid professional community and the consensus within it about their status.

 But because of the unique experience of finding ourselves in the midst of a cultural and social change before being able to fully understand it and orient to it, and before having truly come into our own as a professional group with consensually agreed upon ethics and values and goals, without a consolidated professional identity, the individual clinician’s experience of the managed care intrusion into psychotherapy can only be understood as a very complex intrapsychic process that goes on in tandem with our lifelong process of understanding how we each relate to our own careers.  Are they jobs?  Managed care has forced us to ask ourselves this – forced us to consider this as an option.  Could we just think about it as job we go to everyday and don’t think much about afterwards; just have to make a living at it, not like it? 

Or does it have to have more meaning to it than this?  In which case, the therapist’s suffering is going to be prolonged, because the space in which we make meaning and feel sanctioned to take ourselves seriously has been diminished.  It’s very hard to believe in oneself as important if the audience no longer believes it.  So if persons with minimal training can supposedly do what we can do just as effectively, are we fakes, frauds, charlatans?  Or perhaps we’ve simply been grandiose and thought we were more important than we were.  Are we better off believing the feelings of doubt in our own guts and in the minds of the insurance industry and the public?  Should we just cash it in and agree that we were pretty silly to take all of that deep psychotherapy stuff to heart?  These are questions that have to be asked.

But as I gathered my thoughts in preparation for this paper, I was struck by the symmetry of noting that the Fall edition of the American Psychological Association’s Division of Psychoanalysis newsletter has a special section on beginning  treatment.  I thought, how amazingly resilient is hopefulness in the midst of all of this destruction.  And even though most of you probably do not usually feel hopeful, I’m willing to bet that you still have moments of it.  And that’s part of surviving this – passing around the hope, keeping the potential space open so creative thinking still occurs.

Each of the four essays on the how and why of beginning deep psychotherapy with a patient contained a belief – a faith perhaps – in what the process, when wielded correctly, can accomplish.  For instance, James Fosshage (1998) says that “to receive the call (for psychoanalytic treatment)… requires boldness …It also requires a specific confidence and conviction about the analytic process and possibilities for change” (p. 23-24).  Daniel Kriegman (1998) goes further to say that “…most patients don’t enter treatment because they believe in the process.  They typically enter into this strangely structured relationship because they have to.”  They arrive with a “vague hope”, he says, and even though we understand that psychotherapy may be limited, “those of us who feel compelled to puncture a new patient’s inflated (but potentially necessary) hopes right from the start are likely to have very small practices indeed….Those who keep the often painful limits of psychotherapy in the forefront of their experience rarely make it in psychoanalytic practice” (p. 26).

I understand him to be saying something important to understanding our process with managed care as well as the process with an individual patient.  He is suggesting that Hope – even at the level of Illusion – is a critical component to the successful coupling of a patient and therapist.  Possibilities must be imagined by one of them at least, in order for the march to go on.  We need hope, too.  We need to keep imagining new possibilities. We need to keep imagining ourselves.

One of the crimes of managed care is that it precludes hope.  It immediately starts with the limits – the practicalities – and believes this is useful to people – not allowing either therapist or patient to stand too long in the restful shadow of awe and hope and grandiosity.  It brings us down to earth before we take flight, making flight seem forever impossible.

The thing is we must meet this impingement – that which so interrupts our continuity of being – not just react to it.  We must use its shattering impact to finish more of our identity work.  We must let it push us into positions of integrity, whatever we each consider that to be. We must use our relationship to our Third to help us reflect upon everything we do or don’t do that impinges on therapy in any way at all.  This will not tell us what is right or what to do.  But it keeps us in the realm of the psychoanalytic which will keep us alive and less terrified.

Why is this important?  If you always remember to think psychoanalytically you pry open the potential space and you can breathe.  Without it there is real danger of bogging down in affect and fantasy and taking them too literally. If we take our despair too literally, we can’t do the work anymore; we lose ourselves.  Stephen Mitchell says that “Good analytic technique concerns not correct actions but hard thinking, in a continual process of reflection and reconsideration” (1997, p.268).  In certain ways managed care presents a problem of technique to the psychotherapist.  We must understand that our responses to managed care  reflect us (our personality and our subjectivity) and they reflect our values and beliefs and ethics and all of these are implicated in our relation to our Third. 

To insist that our decisions and actions about what to with managed care in our professional lives are based on factual external reality and nothing else is untenable.  And none of us really believe this anyway because part of the Third that we share is our belief in the unconscious and the multiply determined motivations of human beings.  And we know we are not exceptions to this rule; we know we are not rats in a maze.  At our ages we never do anything that is that singularly determined.  Even the newborn infant probably has multiple forces driving him or her.  How could it be any other way with someone as complicated as an adult?  So let’s not believe this is simply about any one thing.  It’s not simple at all.

Probably the things most regretted in a life are the things we do because, when we did them, we thought  “we had to” or “circumstances dictated” it, so we didn’t stop to really think about it and analyze our actions.  We didn’t stop to make sure that what we did fit us.  These regrets remain as warts on our intrapsychic complexion.  They feel like distortions of our Self or something imposed upon our self-image, but not truly fitting.  Thus they mar our sense of internal continuity.

Even if our responses to managed care feel like warts now, they must, like everything else in our lives, be continually understood, reconsidered, amended and brought into line with the changing natures of ourselves.   Then we’ll at least have peace and self respect even if we don’t have money and status.

Let me end by quoting Lewis Aron again.  “As analysts, we long for indubitable, foundational knowledge. We want a solid and reliable theory to guide us and relieve our anxieties, to aid in our self-regulation.  But we, like our patients, must struggle without easy solutions.  We can and we must continue to make technical choices, to practice at any given moment in one way rather than in another, to create certain ground rules for ourselves and for our patients, to believe in some things and not in others.  But we must also accept that these choices reflect our own subjectivities; they are personal, reflective of moral values and commitments, and are not only technical or theoretical choices.  We must choose, but we cannot disclaim our choices as inevitable outcomes of abstract and universal principles” (1999, p.24.)

This requires the thoughtful, protective cultivation and honoring of potential space, our holding environments, our relationship to our Third, and of each other.  To invoke a poetic voice with a profound comment on what we must do, let me leave you with T.S. Elliot, who wrote:

“Teach us to care and not to care.

Teach us to sit still.”

T.S. Elliot

References

Abram, Jan.  (1996).  The Language of Winnicott.  Northvale, New Jersey:   Jason Aronson, Inc.

Aron, Lewis.  (1999). Clinical choices and the relational matrix.     Psychoanalytic Dialogues, 9:1-29.  

Auerhahn, N., and Laub, D.  (1998).  The primal scene of atrocity:  The dynamic interplay between knowledge and fantasy of the Holocaust in children of survivors.  Psychoanalytic Psychology, 3:360-367.

Davoine, F.  and Gaudilliere, J.  (1997).  Madness and the social link.  Paper presented at a meeting of the Appalachian Psychoanalytic Society, Knoxville, TN,  April 12, 1997.

Fosshage, J., and Kriegman, D.  (1998).  Therapeutic beginnings.  Psychologist Psychoanalyst, 18:23-28.  

Hay Group Study on Health Care Plan Design and Cost Trends 1988 through 1997. (1999).  NAPHS, Washington, DC.

Irving, J.  (1998).  A Widow for One Year.  New York: Random House.

Krueger, D.  (1986).  Money, success and success phobia.  In The Last Taboo:  Money as Symbol and Reality in Psychoanalysis, ed. D. Krueger.  New York, Brunner Mazel.

Mitchell, S.  (1997).  Influence and Autonomy in Psychoanalysis.  Hillside, New Jersey: The Analytic Press.

Ogden, T.  (1990).  The Matrix of the Mind.  Northvale, New Jersey: Jason Aronson, Inc.

Whitaker, Carl.  The Hindrance of Theory in Clinical Work.  Chapter title, source unknown.

Winnicott, D.  (1965).  The Maturational Processes and the Facilitating Environment.  Madison, CT:International Universities Press, Inc.

.....................(1969).  Mother-Infant experience.  in Psychoanalytic Explorations.  (ed. C. Winnicott, R. Shepherd, &  M. Davis).  Cambridge, MA: Harvard University Press, 1989)

......................(1971).  Playing and Reality.  London: Tavistock Publications.

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