Silence

The idea for this post came from a reader who prefers to remain anonymous, but I did want to give due credit, so, you know who you are, and thanks.

Silence is very important to me, both professionally, and personally. I'm pretty sure I picked the right profession for myself, because I don't much like talking (I do like listening), and I'm comfortable sitting silently with patients.

As an aside, one of the attendings from my residency did his residency, way back, at Menninger, when the Menninger brothers were there. So he was surrounded by a lot of analysts for 4 years, and he told me, "For people who spend their days listening, when you get them in a room together, they sure do like to talk."

I have found this to be true, but maybe not to the extent I formerly believed. In one of my first analytic classes, we read a paper about choosing patients who are appropriate for analysis. When I walked into the classroom, before class started, the guy teaching the class asked me what I thought of the paper. So I summarized. "You can't be too sick, you can't be too well, and you never know 'til you try." At the time, I thought that was pretty much everything there was to say about the paper, even though we went on to discuss it for 1 1/2 hours.

Now I'm not so sure. Maybe it has something to do with the value analysis places on language-it is, after all, a "talking cure" (Note that the phrase was coined by Bertha Pappenheim, AKA Anna O, while she was being treated by Joseph Breuer for hysteria. Hers is the first case recorded in Studies On Hysteria, by Breuer and Freud). Or maybe it has to do with the fact that the more time you spend listening to a person, the more you discover how much more there is to know about that person. And the same is true for most, if not all subjects. The more you know about a subject, the more complex you realize it is. So if I thought there wasn't much to say about that paper, it was probably a reflection of my ignorance.

What about silence? It's not the therapeutically exclusive provenance of psychoanalysis. It happens often in face-to-face therapy, and it may even be more difficult to tolerate in that setting than in analysis, where both the analyst and analysand are protected by the lack of eye contact.

Silence can take on many meanings in a therapeutic setting. For the patient, it can be withholding and aggressive, as in, "You can't make me talk!" It can be a form of hiding, as in, "I'm ashamed of my thoughts and feelings, so I'm not going to humiliate myself by sharing them." It can be an attempt to level the playing field, "You don't tell me anything about yourself, so I won't tell you anything, and that way I won't feel helpless and inferior."

It can also be an expression of trust, "I'm comfortable enough with you that I don't feel obligated to entertain you or be socially appropriate by babbling or trying to make conversation." And it can represent an attempt to share an experience or idea that is difficult to verbalize.

Patients have feelings and thoughts about the therapist's silence. It may be seen as punitive, humiliating, rejecting, abandoning, empty, containing, comforting, and many other things.

Therapists also have views about their patients' silences. Are they being hostile, or controlling? Are they confused? Are they attempting to sort through some experience that has not existed for them in the verbal sphere? Are they frightened? Am I doing something wrong? Am I doing something helpful? Do they need me to say something? Am I distracted and therefore have nothing to say?

These questions obviously reflect therapists' feelings about their own silences.

One important question is, why is silence often experienced as uncomfortable? The straightforward answer is, because that's not what people do in normal social interactions. But why is that? What's wrong with not talking? It's true, we're social beings, but speech is not the only form of communication.
At parties, people who don't talk much are considered uninteresting. In many educational settings, children who prefer to take in a discussion and not comment frequently are often thought to not be paying attention. And in medical school, when I was in new, complicated settings like the OR, or the ICU, and was asked by residents or attendings if I had any questions, I usually didn't because there was so much new information to absorb, I hadn't yet reached the point of being able to formulate a question. This was sometimes viewed as evidence of lack of interest on my part.

So we can agree, I think, that both silence and speech are complicated. One thing I wonder is, what happens when clinicians not only don't have time to talk with their patients, but don't have time to sit in silence with them, either?


These are some interesting quotes about silence, that I found on PEP-Web:

From the APSaA Winter Meeting, 1948:

CHAIRMAN: President William C. Menninger, M.D.
2:00 P.M. Robert Fliess, M.D. (New York): Silence and Verbalization: On the Theory of the Analytic Rule.
Discussants: Therese Benedek, M.D. (Chicago); Robert C. Bak, M.D. (New York)
Author's Abstract: Verbalization releases regressive affect, collateral to repressed ideation, thus interfering with the maintenance of repression. The speech-apparatus is substituted for different erotogenic zones, whereby speaking becomes excretory instinctual discharge, words excretory product, and silence equivalent to sphincter closure. Technical and theoretical consequences deriving from these “pleasure-physiological” considerations are discussed.


Greenson, R.R. (1961). On the Silence and Sounds of the Analytic Hour. J. Amer. Psychoanal. Assn., 9:79-84

The most frequent silence met with in psychoanalytic practice is the silence of resistance. This silence means that the patient is either consciously or unconsciously unwilling to verbalize. Since the patients in our psychoanalytic practice are attempting to communicate to us in accordance with the basic rule, i.e., attempting to put all their thoughts into words, if they become silent, it means that they are opposing the procedure of psychoanalysis. It is then our task to overcome this obstacle by attempting to find the motives for this resistance. Here, we are often aided in our task by the fact that the patient communicates despite his resistance...
Silence, however, may not only indicate a resistance to a certain content but may itself be the content which the patient is trying to convey. For example, patients may fall silent during an analytic hour when they are unconsciously repeating some historical event in which silence was an important element. Primal scenes and primal auditions often make their first appearance in the analytic hour as a restless, agitated, wide-eyed silence. The patient is repeating in the presence of the analyst the silent excitement and anxiety of the primal experiences.
Silence may indicate an identification with a silent object. This happens frequently in the analysis of candidates, who in this way identify with their silent analyst. This should be kept in mind when the silent patient seems to be not only comfortably silent, but confidently and poisedly silent. Furthermore, silence can represent an identification with an inanimate object, a sleeping object, or a dead object. This reaction, however, I have only seen in extremely disturbed and repressed patients.


Zeligs, M.A. (1961). The Psychology of Silence—Its Role in Transference, Countertransference and the Psychoanalytic Process. J. Amer. Psychoanal. Assn., 9:7-43

Let us first conjecture as to what a state of silence between any two (or more) human beings might signify. Obviously it could reflect many different psychic states and qualities of feeling.2 It might evidence agreement, disagreement, pleasure, displeasure, fear, anger, or tranquility. The silence could be a sign of contentment, mutual understanding, and compassion. Or it might indicate emptiness and complete lack of affect. Human silence can radiate warmth or cast a chill. At one moment it may be laudatory and accepting; in the next it can be cutting and contemptuous. Silence may express poise, smugness, snobbishness, taciturnity, or humility. Silence may mean yes or no. It may be giving or receiving, object-directed or narcissistic. Silence may be the sign of defeat or the mark of mastery. When life-and-death situations are
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2 Because of its ubiquity, silence has been thought about in many frames of reference. Poets, dramatists, and philosophers have loosely used the concept "silence" metaphorically and allegorically to symbolize death, eternity, truth, wisdom, strength, etc. Literary references to silence are frequent in the classics from all periods of history...
3 It is interesting that the aphorism, "Silence is golden, " represents what is left of the complete saying, "Speech is silvern, but silence is golden, " the part about speech having since dropped out of popular usage, historically attesting to the transitoriness of speech as compared to the permanence of silence. This derives from an ancient proverb written in Aramaic which first appeared in the Talmud Megillah and Midrash Rabba Esther (Chapter 6) in relation to prayer, as follows: "If a word is worth one selah, silence is worth two. (Silence invokes Thy praise.)"... The later Hebrew equivalent then became, "If a word be worth one shekel, silence is worth two, " pointing to the material advantage of keeping one's own counsel...
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being sweated through there is little occasion for words.3 Silence may be discreet or indiscreet. A tactful silence serves to prevent the expression of inappropriate thoughts and feelings. The art of being tactful combines the skilled use of silence in verbalized as well as nonverbalized action. Thus there is a hidden component of silence in every verbalization. When complete silence is inappropriate or impossible, a gesture, grimace, or mimetic expression serves as a compromise between verbal and nonverbal communication.

I'd love to hear about people's experiences with silence, so please comment.

Webinar F/U

I mentioned in my last post that I was going to be participating in an MOC Update Webinar sponsored by the AAPS. Let me start off with a disclaimer: I don't agree with a lot of the views of AAPS, but they have some important ideas, and contributions to make, including their suit of the ABMS (American Board of Medical Specialties), so I find them useful.

The webinar didn't cover much new territory. Some highlights:

The main speaker, Paul Kempen, touched on something I'm not sure I agree with, but that I thought was interesting. Namely, the idea that the Performance In Practice (PIP) modules, which involve implementing the use of rating scales, and then following up on patient outcomes, is a form of using patients for research without their specific consent.

There's a lot of corruption-kickbacks, conflicts of interest, among the higher-ups in the ABMS. Even without the corruption, it costs doctors a lot of money to recertify, and even though ABMS is not-for-profit, executive salaries can hover around $1 million a year.

The ABMS is not regulated, and calls itself the sole official monitoring body. In fact, it doesn't do any monitoring of incompetence, in the form of disciplinary actions. And of course, there is no evidence that it improves patient care.

One question pointed out that if you're being judged on the basis of improved outcomes, such as lower blood pressure, and your licensure is riding on that judgement, you might just tend to "round down" a patient's BP.

Those doctors participating in PQRS will be financially penalized if they don't maintain certification.

Even those physicians who are grandfathered in will have to take a recertification exam by 12.31.23, or they will be given the official descriptor, "Certified Without Meeting MOC Requirements".

Exam questions are clinically irrelevant, out of date, or inaccurate.


What scares me is the way Maintenance of Licensure (MOL) is insinuating itself into the picture. If the ABMS is trying to promote itself as the only game in town, what better way to make sure it stays that way than to make licensure dependent on participation in MOC/recertification.


If you'd like to watch it, you can view the webinar in full here.

S.A., It Aint So

In the hilarious and highly underrated movie, Moving, starring Richard Pryor, the main character (Pryor) loses his engineering job of 15 years. Before he storms out of his boss's office, he gives him the finger, only it's his index finger. He then ruminates for days over his humiliation in using, "The wrong finger!" Ultimately, it becomes a family joke.

You Tube Link

Somehow I was reminded of this scene when I was pondering what to do about my self assessment (SA) MOC credits.

I've been dutifully filling out my CME credit details on the American Board of Psychiatry and Neurology (ABPN) site, and I have more than enough credits to take my recertification exam in 2015.

yay.

But I'm short 1 SA credit.
One.
O.N.E.

You may recall from my Alphabet Soup post, or you may not but feel free to link to it, that if you were board certified in 2005, you need 40 SA credits.

I got all 39 of my SA credits from The Carlat Report (TCR). And until a couple months ago, I planned to continue using TCR to complete my SA credits. It was simple. Instead of just taking a post-test for CME credit, I would take a pre-test that asked the same questions. Then I'd read the material, and then take the post-test and get my certificate. That way, I had assessed myself, and I could tell that I had learned something.

That's the idea, anyway. In reality, I could have simply taken the pre-test, which gave me all the correct answers, skipped reading the material, and filled in the answers on the post-test.  And then I would have learned nothing.

The SA requirement was really well thought out, don't you think?

Then TCR changed it's SA policy, and now they have a separate, yearly package:

We are now offering a NEW self-assessment CME product that consists of 12 monthly issues of The Carlat Psychiatry Report, plus a bonus 120+ pageMedication Fact Book. This inclusive product is $377 and is worth 18 Category 1 CME credits and 8 ABPN SA credits.

The subscription can be purchased at any time in 2014, but all tests must be taken by December 31, 2014, at which time SA credit will be awarded. 

This happened when I was one credit short, can you believe? And even if I were to switch over to the new product, it's not clear to me from the description if I can get a credit or two at a time, or if I have to take the whole test and get 8 SA credits at the end of the year (I've asked them about it, but the answer was slightly vague, and seemed to corroborate my suspicions). Since I'm taking my exam in 2015, I would like to have my credits out of the way earlier than the end of this year.

What to do?

I checked the ABPN site, and they have a page with a list of all their approved SA products, most of which are day or weekend seminars that cost more than I care to spend.

The one I decided to do was a Mass General Academy online module in general psychiatry. 50 questions, 4 SA credits, 35 bucks.

I was, of course, expecting the same deal: pretest, read, post-test. But there's nothing to read. Just 50 questions to answer. They don't report your score to the ABPN, but they give you feedback on how you did.

This was convenient for me, but the questions were not great. Here's an example:


48. Which one of the following hypnotics is free of daytime sedation and significant memory impairment:

a) diazepam.
b) flurazepam.
c) triazolam.
d) zolpidem.

Now, clearly, they want you to answer "d) zolpidem", which I did. But honestly, if you were prescribing Ambien for someone who'd never taken it before, would you feel okay telling them they'd be free of daytime sedation and significant memory impairment?  Does a period of time when you don't know where you were or what you were doing and later found out you rammed your car into a truck not qualify as "significant memory impairment"? Tell that to Kerry Kennedy.

Point being, MOC is a racket that costs time and money, and takes time away from patient care and from actual learning. Maybe a board recertification exam MIGHT be worthwhile if it asked questions that were accurate, up to date, and relevant to real world practice.

What questions, you ask?

Let's make some up.

With which of the following would you choose Brintellix as first line treatment for depression?

a) United Healthcare
b) Blue Cross/Blue Shield
c) Aetna
d) Medicare


Okay, enough with the sarcasm. What I'm really thinking is that it would be great if every practicing clinician would submit one or two questions to a giant question bank, and then self-assessment CME, or even board exams, could be generated from that bank.

The questions could reflect, for example, practices that are bread and butter for someone working in one specialty, and more obscure and likely forgotten, or never learned, for someone else. Like, I could come up with a Psychoanalysis question, and Jim Amos from The Practical Psychosomaticist could come up with a C/L question, and George Dawson over at Real Psychiatry could come up with an Addiction question.

Alternatively, the questions could be ones that don't have clear answers, and would require a little looking into, and maybe some discussion with colleagues. For instance, I have this theory that when it comes to antidepressants, there are SSRI people, and there are non-SSRI people. Is there a way to tell, a priori, who's who? I think this is a question that David Healy is interested in researching. But without clear research, it would be nice to have that discussion with other psychiatrists who are dealing with the same dilemma. When faced with a new patient, I kind of know how I go about deciding, but it's more of a hunch than anything else, and of course, there's always the business of trial and error.

All I'm saying is that there are so many better and cheaper ways to generate lifelong learning than stupid APA endorsed SA CME. Like POLL (Psychiatry Online Lifelong Learning), our free online journal club. Please check it out.

Tomorrow, I'll be joining a free MOC Update Webinar sponsored by AAPS, We'll see if they have anything to say about the SA business.

Poppin In

I want to write a quick follow-up to my Pharmaphenalia post. For those who missed it, I selflessly sacrificed my tried and true Zyprexa clipboard, in the name of not running ads for Eli Lilly. And I purchased a clipboard from Poppin, to replace it.

I also bought a few other things for my office, including these cool pens:

They write decently, although they were a little scratchy to begin with, but that seems to have smoothed out. The thing is, I write a lot of process notes, so I started going through them pretty quickly. I tried to find refills for them, but I couldn't, so I emailed Poppin about it. They didn't get back to me, so I kind of forgot about it (they are, after all, just pens, and cheap, at that).

Then, on Friday, I got this email:

First of all, I want to say how sorry I am that this email is so incredibly delayed. I got your original email, wrote you what I consider to be an awesome response, hit send but just found out it never went through! I am so sorry we left you hanging! Here is what I originally had to say about our Gel Luxe Pens. 

Those pens are actually intended to be single use. But, I did do some digging and searching with our product team to hunt down replacement cartridges and unfortunately came up short. They don't quite fit standard refills and I even took one of our Luxe pens to the art and stationary store next to our office hoping they might have a suggestion but no such luck.

Your best bet is to get some brand new ones from us! Since my email never got out to you and I know exactly how great those pens are, I am going to make sure that is exactly what happens. I am sending you two boxes of our White Gel Luxe Pens plus a Pen Cup so you have somewhere to put them...on us! I want you writing happy and I would hate for you to think that your email was ignored.

This is my definition of exceptional customer service. And I've since received another email letting me know that the package has been shipped.

The expression, "The customer is always right," was coined by Sears President, Julius Rosenwald. It seems like the kind of idea that shouldn't need to be coined as an expression, it should just be intuitive. But then, as now, it was necessary. 

And Poppin seems to get it. Insurance companies could take a lesson from them.

Buncha Stuff

Stuff #1: I'm now on Twitter. Yay! Follow me, @PsychPractice1. You can just click the button to the right.

Stuff #2: Check out Ben Goldacre speaking at Mach 1 on the topic of nocebo. Really, you can hear the boom as he breaks the sound barrier. It's at the bottom of his most recent post, which discusses his article on the side effects of statins, and has a link to an interesting article that compares the results listed in Clinical Study Reports (CSR's) with their corresponding publications. Wanna guess the conclusion?

Stuff #3: I'm fascinated by a company I read about in Wired. It's called Theranos, and its product is lab tests. Cheap lab tests. From 1 drop of blood. With results in 4 hours. The founder, Elizabeth Holmes, dropped out of Stanford, and started the company with her tuition money. A few months ago, it opened its lab doors in a Walgreens on Palo Alto.
So let's take a look.
You have 1 drop of blood drawn from a finger stick. You can order up to 30 labs from this one sample. Here's a link to the menu of tests, which includes their costs. A CBC with Diff costs $5.35. Hemoglobin A1C is $6.67. And according to the Wired article, a panel of fertility tests, which normally costs $2000, is $35.
You can even add on a lab later, from the same sample. And they get results in, on average, 4 hours. This includes measuring the DNA of pathogens, rather than culturing, although I couldn't find the test for this on the menu-I don't know what it's called.
My question is, how does the accuracy compare to standard testing. Holmes claims that most error is due to humans, and all their testing is automated. But I'm skeptical.
If it turns out to be true, though, I'll be impressed (and I'll want to plunk some investment money into the company).

Confused about Control

I'm confused about Ambien. I don't love it as a sleep aid, but it works for some of my patients, so I do prescribe it.

What's confusing to me is not the confusion it causes some of the people who take it, even the ones who mistake it for synthroid. What's confusing to me is its status as a controlled substance.

It seems to me that some pharmacies allow refills, others don't. Some will allow you to order refills on the phone, others won't. Some will require a cover for a phone order.

The most recent time I had to mail in the cover, I asked the pharmacist what exactly the deal is with Ambien, and he told me that it's a Schedule IV substance and as such, is controlled.

The weird thing was that before I called it in, I checked the PMP registry, even though I wasn't sure I needed to, and none of my previous ambien prescriptions showed up. I told the pharmacist this, and he said some doctors have complained that no information ever shows up for them. But this is the first time it's happened to me. Mostly, when I check for benzos and ritalin and whatnot, I see all the prescriptions I've written.

Well, this puzzle sent me into research mode. And this is what I found (on the DEA site):

(a) No prescription for a controlled substance listed in Schedule III or IV shall be filled or refilled more than six months after the date on which such prescription was issued. No prescription for a controlled substance listed in Schedule III or IV authorized to be refilled may be refilled more than five times.


Okay, so I can write for 5 refills of Ambien, and the prescription is good for six months.

What about calling in a prescription?

(e) The prescribing practitioner may authorize additional refills of Schedule III or IV controlled substances on the original prescription through an oral refill authorization transmitted to the pharmacist provided the following conditions are met:

(1) The total quantity authorized, including the amount of the original prescription, does not exceed five refills nor extend beyond six months from the date of issue of the original prescription.

(2) The pharmacist obtaining the oral authorization records on the reverse of the original paper prescription or annotates the electronic prescription record with the date, quantity of refill, number of additional refills authorized, and initials the paper prescription or annotates the electronic prescription record showing who received the authorization from the prescribing practitioner who issued the original prescription.

(3) The quantity of each additional refill authorized is equal to or less than the quantity authorized for the initial filling of the original prescription.

(4) The prescribing practitioner must execute a new and separate prescription for any additional quantities beyond the five-refill, six-month limitation.

No problem, even with up to 5 refills.

So what's the problem? It seems to me that it's a lot of work for the pharmacist. I left out a bunch of stuff on the link, which you can check out yourself, but there's a lot of initialing that needs to be done, and recording of names, etc. Is the real problem that pharmacies don't want to be bothered with the paperwork (HAH! Tell me about paperwork!), or that they're not clear on the details?

Even more puzzling, here's a link to Schedule IV meds, also from the DEA site. Zolpidem is down at the bottom, with the other "Z"s, (ZZZZ for sleep). But what else is on the list? Let's see, alprazolam, clonazepam, diazepam, lorazepam, a veritable cornucopia of benzodiazepines.

Now, I'm not advocating for a benzo prescribing free-for-all. There are good reasons to keep it contained. But if I am writing for benzos, do I and my patients really need to be inconvenienced?

Can I write refills for benzos? Can I phone in benzos with refills, and without a cover? Is this one of those lies that's perpetuated so benzo prescribing doesn't go haywire? And if so, why not just change the law to what everybody thinks it is anyway?

Am I missing something here? What gives?

Follow the Fantasy

I just had this weirdo idea. I saw a commercial the other day for Nasacort, which is now over-the-counter. This is awesome. I have seasonal allergies, antihistamines make me groggy, sudafed makes me jumpy, so every year I have to procure some prescription flonase. And now I don't.

Here's my idea. What if SSRIs were sold OTC? What would that be like?

I poked around online to try to find out if SSRI's are sold OTC anywhere, currently. Maybe India, China, Mexico. I could not find any current information-most recent was 2009.

So I'll have to stick to the fantasy. What would that be like?

In medical school, they taught us that the best down-and-dirty way to find out if a patient in a primary care setting was depressed was to ask, "Are you depressed?" Embedded in that is the notion that people know when they're depressed.

So maybe you'd realize you were depressed, and then you'd mosey on down to your local drug store and pick up a pack of zoloft, along with a birthday card for your niece and a couple of pieces of bazooka gum.

Maybe people would take SSRIs PRN, like tylenol. Maybe this would help with PMDD (I still find it hard to believe that women who take SSRI's for PMDD don't end up with withdrawal symptoms each month, even if the PMDD effects do work via a GABA-ergic mechanism).

Maybe people who weren't depressed would take them. Maybe they'd feel sad that they're hamster died, and think, Oh, I'm bereaved and depressed, I should take prozac.

Maybe there would be more suicides. Maybe there would be fewer. Maybe there would be more work days lost due to side effects and withdrawal. Maybe there would be fewer work days lost due to depression. Maybe there would be more substance abuse. Maybe there would be less.

Maybe people would be emotionally disengaged and spend hours on Facebook and Twitter and playing League of Legends online without ever leaving the house to see their friends. Oh, right, that already happens. Maybe because SSRI's are so freely prescribed by primary care providers.

Maybe there would be fewer starving people in the world, because those taking SSRI's would stop having sex and reproducing, and the population of the planet would be contained.

Maybe people would begin to realize that pills won't fix their character pathology or their interpersonal problems. Maybe more people would make use of therapy. Maybe insurance companies would be forced not to find sneaky ways to withhold reimbursement for therapy.

Maybe the reason I have so much conjecture about what would happen if SSRI's were freely available to whoever wants them is because not much is actually known about what they do. Or more accurately, they do so many things, or are SUPPOSED to do so many things, that it's hard to tell what they are and aren't doing.

Insurance-Speak, a Mini Book Review

Language is a funny thing. Sometimes literally.

In preparing for this post, I've been using these little sticky notes that were given to me by a friend, a few months ago. They're these cute, cold-weather animals-penguins, otters, seals-and they're made by some Asian company. The mangled-English description on the back reads:

STICK MARKER
Composure creates time to the full.
It is convenient to carry.
It can be used as prompts, footnote to use, convenient recording and reading.

If anybody has a clue about what "composure creates time to the full" means, please do comment.

I got a book from the library, Psychodynamic Practice in a Managed Care Environment, by Sperling, Sack and Field. It was published in 2000, but it's surprisingly less out-of-date than I would have expected. I found it useful in trying to understand the concept of medical necessity, which it breaks down into "the notions of (1) treatment need (i.e. the patient presents a diagnosis and symptom picture that are reasonably treatable), (2) clinical efficacy (i.e. a given treatment has demonstrated results), and (3) cost efficacy (i.e. a given treatment is less costly in comparison to other equivalent treatments)."p. 30

With respect to the confidentiality issues that come up around working with insurance companies, it makes what I think is an interesting point, when considered in light of today's mandatory insurance coverage. "Managed care organizations would argue that third party reimbursement is not a mandatory enterprise and that if an individual is contracting with a company for health care payments, he/she needs to abide by that company's rules for exchange of information." p.27

But what I found most useful were the suggestions for how to communicate with insurance companies to get approval for care.

The book claims that insurance companies are not interested in psychodynamic formulations, and that, in fact, the language of psychoanalysis will be confusing to reviewers, who are more comfortable with clinical language that "draws particularly from those bodies of theory that can be construed as supporting time-limited, and therefore purportedly cost-contained, psychotherapy."p. 41 

"Such descriptors as psychoanalytic, transference-based, interpretive, and insight-oriented are red flags that can scare off the managed care organization. Alternative and roughly similar descriptors such as, respectively, interpersonal, relationship history, cognitive reappraisal, and promoting reality testing would be more understandable..."p. 25

In fact, the book goes so far as to recommend always using "interpersonal", when you mean "psychoanalytic" or "psychodynamic".

The bottom line, though, is function. Insurance companies don't think treatment for intrapsychic difficulties that cause suffering is necessary, unless the suffering individual has trouble with work or relationships. So you need to speak to them in a language that emphasizes function and symptoms. "Such a language is rooted in the principles of mental status examination and the various symptom- and observation- based descriptors that it engages." p.42

The following are from Table 1. Psychodynamic Concepts and Their Behavioral or Cognitive Parallels p. 43

Psychodynamic                                          CBT/Functional

Intrapsychic Process                                 Underlying Psychological State

Transference                                              Cognitive Schema; graduated exposure (in vivo
                                                                    and imaginal) to earlier relational experience

Therapeutic Alliance                                 Positive Attribution; modeling

Working Through                                      Self-efficacy; stimulus control; contingency                                                                                                management; cognitive self-monitoring

Rationalization                                           Cognitive reconstrual

Projection                                                     External attribution

Suppression                                                 Avoidance

Repression                                                   Exclusion of information

Clarification                                                 Distancing

Confrontation                                             Decentering

Interpretation proper                              Reattribution; shaping; identifying alternative                                                                                         cognitive patterns


The idea is not that these concepts are the same. Just that they are parallel, and that the right-hand column is more easily understood by insurance companies.

To me, that means, "dumb it down, so you can give them what they want, because they can't understand what you're doing, anyway." This may be my interpretation of the authors' views on the sophistication of function- and symptom- based treatments.

There are other interesting topics in the book, and good explanations of various types of managed care. Some of these may no longer exist, but it's useful to have a history. And there's an almost comical paragraph about a future trend, "Focus on Quality of Care":

"...in addition to controlling costs, employers, health insurers, and consumers are all realizing that saving money is not worth much if the quality of care stinks. this seemingly obvious realization is a welcome addition to the prevailing zeitgeist in the managed care industry, and we hope it will increasingly filter into the review and credentialing practices of managed care organizations." p. 116

Little did they imagine how "quality of care" could be used to limit actual care.

The final language-related admonition has to do with the use of the term, "long-term treatment".
"Unless there is compelling reason to [use it], the phrase long-term treatment should be erased from your communicational vocabulary with managed care. It is simply anathema to their way of doing business. When managed care patients need long-term treatment, it is best to present the work initially as moderate term, and keep justifying on subsequent communications why the targeted treatment closing date needs to [be] extended." p. 113

I don't know how well the authors' advice translates to current day interactions with insurance companies. Will altering my language be the reimbursement difference for my patients? Maybe, maybe not. But it's interesting to note that not all that much has changed since the book was written.

And because I couldn't resist, here's the ultimate example of mangled English, from South Park's ninja episode, Good Times With Weapons. The song is called, "Let's Fighting Love".