The Issues Facing Ethical Mental Health Care

The following is the text of the speech delivered by Dr. Karen Shore upon acceptance of the "1997 Distinguished Psychologist of the Year" Award from the American Psychological Association's Division of Independent Practice.

Don't Let Them Take Your Mind and Spirit:
On Being Called a "Provider"

By Karen Shore, Ph.D.

It has been six years since I began speaking out against managed care (MC). From the beginning, I have focused on the industry's use of power, and how mental health services, education, and training would be destroyed.   As I speak around the country, the most common question people now ask me is:  "How did you know?  How did you know in the beginning what they (MC) would do?" 

My response is that I knew because I am a woman and a Jew, and because of my awareness as a woman and a Jew, I have always been very sensitive to the ways in which power has been and can be used, and how a determined force can overpower and even destroy anyone in its way. 

Jerry Rubin, one of the "Chicago Seven" charged with "instigating a riot" outside the Democratic National Convention in 1968 to protest the war in Vietnam, once said:  "The power to define the situation is the ultimate power."  The managed care industry is now defining mental health care, and the education and training of new psychologists are following the industry's definition.  As a psychologist in the V.A., I interview applicants for psychology internships.  Over the past two years, I have found the applicants sounding more and more like robots.  They are increasingly focused on "techniques," research, neuropsychology, and on "being marketable."   Few speak of psychodynamics, of understanding their patients, or of forming therapeutic alliances with patients, though applicants just three or four years ago, did.  Several of our interns now come from graduate school never having spent more than 12 or 15 sessions with any one patient, and they haven't the faintest idea what to do beyond that.  Graduate schools are changing their programs and faculty to "prepare students for the marketplace," rather than for the real needs of the real people who will seek psychological care in the future.  Our work and our training are being defined by the MC industry.

There are both overt and covert ways that an invading force takes power over others.  Mostly, I have spoken and written about the overt ways a force takes power over others.  Overtly, the MC industry has taken over by its change in function from insurer to a health care delivery system, and by its control over the flow of money for treatment and clinicians.  This paper, though, will focus on the insidious, covert way that the industry is seeping into your mind and spirit. 

A recent discussion on a professional e-mail list focused on the question of whether or not it matters that the managed care (MC) industry refers to clinicians as "providers."  After all, one psychologist wondered, isn't a rose still a rose?  And doesn't it smell as sweet regardless of what it is called?

In reality, a rose will smell as sweet regardless of what it is called because the rose is not affected by whatever name people choose to call it. The rose doesn't hear, doesn't know the meaning of the words, and doesn't change its fragrance depending on what we choose to call it.  Its self-concept, so to speak, does not change.

We know all too well, though, that language and words greatly affect how people think about self and others.  Words can so easily lead us to objectify others and hurt them.  I cannot count the number of times Vietnam veterans have regretfully told me how Vietnamese peasants and villagers were just "gooks."  It was easier to force them out of their villages or to kill them if they were "gooks" rather than women, children, or old folks.  The women's movement made a big deal out of women on the job being called or calling themselves "girls" rather than "women," and few would deny that it mattered that black men were called "boy" rather than "sir" when addressed by a white man.  When Hitler popularized the notion of "the Jewish Problem," he removed the subjectivity of Jews as sensate human beings, making it easier to see the Jewish people objectively as an economic "Problem" that required a "Solution."

The language of MC represents the dominance of the impersonal industrial culture in health care, a culture that has begun to eradicate the humanitarian culture to which we held.  It is no accident that the MC industry uses the term "behavioral health care" rather than "mental health care," and focuses on "functioning" rather than on the totality of a person's behaviors, thoughts, feelings, dreams, memories, attitudes, capacity for relatedness, fears, hopes, and potentials for satisfaction and happiness.

It is also no accident that the MC industry calls us and our colleagues from other disciplines "providers" rather than "clinicians," "practitioners," "professionals," or "caretakers."  I feel a deep demoralization each time I hear one of us use the word "provider" because I know this means that that person's mind has begun to be influenced by a dominating culture, that that person has begun to accept the dominance of MC and its culture, even if he/she hates MC.  And I know that his/her perceptions of self and others has, without awareness, begun to change.

So, as Shakespeare asked, "What's in a name?"  First, at the very least, the word "provider" is a sterile word that does not even imply that one is a human being.  After all, hospitals, laboratories, and clinics - and even the insurance and MC companies - are also now called "providers."  For that matter, AT&T is my "long distance provider," and the manufacturers of appliances I buy tell me to contact my "service provider" if it breaks.

The old words "professional," "clinician," "practitioner," and "caregiver" all have a respectful and descriptive meaning that makes it clear that we are speaking of a human -- a person -- who gives care to another person.  The word "provider" is used to blur the distinction between people and things, to rub away individuality, humanity, and professional identity and integrity from the minds of patients, lawmakers, and employers, as well as the minds of clinicians, themselves.

Second, the use of the word "provider" leads others to see all those who give care as "interchangeable parts."  It becomes easier to think that any "provider" can deliver any "product" or perform any "service."  One will be less apt in the future to ask for a social worker, a psychologist, a psychiatrist.  One will ask for a "provider" and will be assigned a "provider," with the covert implication that each "provider" is equivalent  to and interchangeable with every other "provider."

Third, the word "provider" is a symbol of the thinking of industrialists who see us as things, as insensate objects to be manipulated, used, and exploited.

Still, some may not yet understand why there should be any great protest. After all, clinicians do "provide" health care, so why not call them "providers?"  Well....flutists, clarinetists, harpists, Yo Yo Ma, Yitzhak Perlman, members of the Boston Symphony Orchestra all "provide" music.  Why not call them "music providers?"  Together, actors, singers, musicians, painters, sculptors, ballerinas, could all be called "art providers!"  Could you imagine their protest!  The de-humanizing and de-professionalizing nature of the label would be so crystal clear, and we would all support their protest.  So why aren't you protesting your new name?

There is a wonderful children's book called My Name is Not Angelica (Bantam Doubleday Dell Books for Young Readers, New York, NY,1989), written by the award-winning author, Scott O'Dell.  The book tells the story of Raisha, a young African girl, who was captured in the early 1770's and bought by a plantation owner in the Caribbean.  The plantation owner's wife re-named Raisha "Angelica," because she "smiled like an angel."  Raisha sorely resented this name, though, because it was not her name and because she only learned to "smile like an angel" after she was advised by the white slave ship owner, who had known and liked Raisha's family, that she would have a better life as a slave if she smiled a lot at the plantation owners and didn't speak unless asked to.  She said, he taught "me to smile as if I had just received a gift I had always wanted...My face hurt from smiling and I felt like letting out a hair-raising scream" (p. 21).

Raisha said that the plantation owners changed all the slaves' names (p. 24) because they "wanted the slaves to forget they were born in Africa, that they were black Africans" (p. 25).  MC industry leaders want us to forget our origins, too.  But do you want to forget that you are "psychologists" and "psychotherapists?"  Do you want to call yourselves "providers" and deliver a "product" to "customers?"  Do you want to "partner" with the very people who have hurt your patients and who have oppressed you, demeaned you, destroyed your independence, and who are removing the intimacy and the personal meaning from your work?

No, a rose isn't just a rose regardless of what it is called if the rose is capable of being affected by what it is called.  Language influences attitude and behavior toward self and others, and it can be used purposefully and manipulatively.  Re-naming a class of people has to do with power.  MC has re-named us.  We must take this as a warning, and as a further indication of who they are characterologically and what they have in mind for us.

We must rebel and overthrow the control of the industrialists and their corporate, bureaucratic culture.  Further, we must do more than rebel.  We must work to create alternative systems of insurance so that we can replace managed care.  Clarence Darrow once said: "As long as the world shall last there will be wrongs, and if no man objected and no man rebelled, those wrongs would last forever."  You must rebel and encourage the development of alternatives to MC so we can replace it with a more pro-patient, pro-quality system.

Along the way to replacing managed care, I implore you to raise the consciousness of anyone who uses the word "provider."  The names "psychologist," "psychotherapist," "psychoanalyst," "practitioner," "clinician," and "caregiver" are perfectly good words - descriptive, inclusive, and they have meaning.  These are the only words I accept for my professional self.  These words connote that I am a person, and not a company, a facility, or an organization.  The words connote that I provide a human service to other human beings and that I have been specially trained in and by a profession I love.

A rose is not always a rose regardless of what it is called.  Roses that can understand and feel are influenced by what they are called.  They either rebel and take back control over their being, or their spirit and sense of identity and purpose withers and, eventually, dies.  Don't let MC have your mind and your spirit. 

The dedication in Scott O'Dell's book, My Name is Not Angelica, reads:  "To Rosa Parks,  who would not sit in the back of the bus."  Like Rosa Parks, rebel.  Make your stand.  Do not accept the will of a dominating culture. Like Rosa Parks, help to change the culture!

I am not being given this award today because I consider myself a "provider" or because I am developing new "products" or "partnering" with anyone other than other rebels and activists who are fighting for freedom in health care, and for the consumer's basic rights to choice, privacy, and the power to make their own treatment decisions.  I am being given this award because I have remained Karen Shore, Ph.D., a psychologist, a psychotherapist, a psychoanalyst, a clinician, a practitioner, a person, a human being, an activist, and definitely NOT a "provider." 

To Division 42, I am deeply grateful for your encouragement, your nurturing, and your recognition and appreciation of my work.

Let us all stand together and defeat MC so we can take back the power to define psychology.

Thank you all very, very much.

Karen Shore, Ph.D., President
National Coalition of Mental Health Professionals and Consumers, Inc.s

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