Fascinating!

The idea for this post is based on a post by Jim Amos, The Practical Psychosomaticist, entitled, Getting Small Again About MOC. At least, that's how it started.

Dr. Amos wrote to someone at the ABPN to find out if instead of doing PIP modules, often at substantial cost, a diplomate's use of PubMed could be tracked by the Board. He was informed that PubMed use was not an option as a PIP alternative, but that, "You have the option of seeking individual preapproval for either one (PIP) that you develop, or one that you may already be doing as a QI project in your hospital/institution."

And he was given a link to the Individual Part IV Improvement in Medical Practice Approval Request.

So I started to think about the possibility of designing a PIP for the practice of Psychoanalysis.

This is how it works:

Clinical Module: A clinical module requires that you do a chart review of at least five patients in a specific category, (for e.g., diagnosis or type of treatment, treatment setting). You must then compare data from the five patient cases, utilizing a minimum of four quality measures, with a standard specialty practice guideline. Based on the results of the review, develop a plan of improvement, carry out the plan, and in no more than two years, do a second chart review utilizing the same guideline to see if improvement has taken place. The charts may be the same or different patients but must be in the same category utilizing the same guideline and quality measures. (boldface mine)

Where do I get a standard specialty practice guideline for Psychoanalysis? I started looking online, and that's when the idea for this post changed. Because I found an Evidence Based Guideline for Psychoanalysis from BlueCross BlueShield of North Carolina.

This is a short but fascinating document. How to explain?

It has a nice, brief description of Psychoanalysis as a "procedure or service". A bit about theory, how it can be helpful, the logistics, what kind of patient is suitable for analysis, and how analysts are trained. Really quite nice.

Then it goes on to describe the "Evidence Based Guideline", and completely contradicts everything in the preceding section.

For example, in the first section, there's this paragraph:

The person best suited for psychoanalysis is one who is generally successful in most aspects of his/her life but is still unhappy. Psychoanalytic therapy is said to be beneficial for those with troubled relationships, poor self-esteem, anxiety, chronic irritability, unresolved grief, phobias, and many other conditions where they want to understand themselves and see how their own thoughts and behaviors contribute to their difficulties. Psychoanalysis is thought to promote self discovery, personal growth and development. (boldface mine)

But then, in the guideline section, it states, "Psychoanalysis is not recommended for...treatment focused on increasing self awareness, self discovery, or personal growth."

I get that they're saying self-discovery shouldn't be the purpose of analysis-not an analysis they're paying for, anyway, but really, at least change the language so it's not identical.

The guidelines are antithetical to everything an analysis is supposed to be. The "A" criteria are:

Psychoanalysis (PSA) may be appropriate if nothing else has worked.

The patient needs some kind of problem that corresponds to a diagnosis
AND
The patient has distress in work/school/social
OR
an ongoing disorder that requires "behavioral assessment to maintain symptom relief and/or function"
OR
"additional treatment sessions are needed (documented by clinical evidence) to prepare for termination of therapy consisting of a clear treatment plan with well defined goals, methods and time frames to support discharge from therapy"
AND
The patient doesn't need to be in a locked unit.

"Well defined goals, methods and time frames" in an open ended, free associative psychoanalysis. How does that work?

The "B" criteria are even worse. I'm just gonna cut and paste and highlight the phrases that particularly annoy me:

B) All of the following criteria are met;
1. There is documentation of a mental disorder diagnosis, AND

2. There is a medically necessary and documented treatment plan or updated plan
individualized for the patient with at least one of the following outcomes;

a) focuses on alleviating the patient’s distress and/or dysfunction in a timely manner, or
b) pursues achieving maintenance goals for ongoing conditions, or
c) focuses on discharge from therapy, AND

3. The individualized treatment plan includes all of the following:

a) the status of the patient’s dysfunctions being treated and documentation shows
progression toward the treatment goals, and
b) the current treatment is focused on each psychiatric symptom, and
c) treatment framework, and
d) modality of treatment, and
e) frequency, and
f) estimated length of treatment, and
g) the status of the involved family or friends in support of the patient, and
h) the status of any necessary community resources, and
i) an alternative plan if the patient does not make sufficient progress in the time frame
specified, AND

4. The treatment must be rendered by a "certified psychoanalyst" from a nationally recognized
institute for psychoanalysis.

And now my corresponding comments:

How do you define "medical necessity" for PSA?

PSA often increases the patient's distress in the short term

Timely?

Focus on discharge: You better hurry up and change a lifetime's worth of patterns so we can terminate!

Status of dysfunctions?

Symptom focus? That's not PSA.

What do they mean by "treatment framework"?

The modality is PSA, duh!

You don't do family meetings in adult PSA

By their own description, PSA is appropriate for people who are generally successful. What kind of community resources are they talking about?

Define "progress"!


It sounds to me like they just took guidelines for some other kind of psychotherapy and pasted them in.

Now the worst part. The evidence.

There are 4 reference sources listed. The first is:

Dewey R. (2007). Psychoanalysis. Retrieved 7/10/2008 fromhttp://www.intropsych.com/ch13_therapies/psychoanalysis.html

This seems to be some kind of online Psychology Intro text. Psychoanalysis takes up one page. One very short page. It includes no information that would constitute a guideline, evidence based or otherwise. It describes what I consider a misinformed and outdated notion of PSA.

The second source is the "About Psychoanalysis" page on the website of the North Carolina Psychoanalytic Society. It's just a brief blurb about psychoanalysis, the couch, frequency of meeting, and the like. Nothing here in the way of guidelines.

The third source is the American Psychoanalytic Association's Standards for Education and Training in Psychoanalysis. This is a 23 page document that describes requirements for training in PSA. Like, who is eligible to be a candidate. How many case write-ups do they need to complete. It has nothing to do with guidelines for practicing PSA.

The last is the DSM-5. We'll ignore that, since it's just about diagnoses.

What we have is a completely bogus "guideline" that has no evidence base whatsoever, nothing to do with PSA, and everything to do with not wanting to cover the cost of an analysis. If you're an insurance company and you cover mental health, then you really can't afford the cost of an analysis for everyone who would benefit from one. And I guess they can't just outright state that they won't cover PSA because it's too expensive. I get it.

And in case you were wondering, this is not an out-of-date document. It was written in 2008, and reviewed in 2010, 2011, 2012, and last updated a year ago, when some (unspecified) references were removed, and others added. No changes were ever made to the guideline statement other than wording. It's up for another review this month.

I wonder if the ABPN would accept it as part of a PIP module.

Actually, the title of this post is wrong. Mr. Spock says, "Fascinating," when there's something interesting that he doesn't understand. If he does understand it, he just says, "Interesting."

Video Games-Could They Make You Feel Worse?

A NY Times article, Video Games Could Be Good For Your Mind, writes about a recent study In Psychological Science, Computer Game Play Reduces Intrusive Memories of Experimental Trauma via Reconsolidation-Update Mechanisms, in which subjects were shown a movie with disturbing scenes. The next day, some subjects were asked to play Tetris, some were shown stills of the movie, some were shown stills and then asked to play Tetris, and some did nothing.

The ones who looked at stills and then played “Tetris” had fewer intrusive memories about the movie over the next seven days than the other groups...bringing back the memories via film stills made them vulnerable to change — and Tetris appears to have done the work of changing them.

 [The authors] believe that keeping track of the colored blocks in Tetris “disrupted aspects of the visual memory from being ‘re-laid down’ in the sensory part of the brain.”

There are obvious difficulties with a study like this, such as the fact that it doesn't address real life trauma. But I'm more interested in something else the Times article mentioned, namely, video games currently on the market that directly address mental health conditions.

One such game is, Elude, which is supposed to simulate depression, to help educate friends and family members of a depressed person. Your character wanders in a grim-looking forest, jumping from one branch to another. Sometimes his depression lifts and he's in the sky, like froggy jump, picking up leaves and daisies. Sometimes he sinks into a quagmire of depression. I didn't get that far when I played, but the description of the game seems to indicate that in that stage, the character has less control than usual, and can't just jump out of the muck into which he's sinking.

It's a metaphor for depression, and the music is upsetting, but ultimately, it's just a standard video game with miserable atmospherics. I don't know if it would help someone who's never been depressed understand much about what depression feels like, but it would probably put him or her into a bad mood.

Personally, I think the best metaphor for depression are the Dementors in the Harry Potter books. Foul creatures who live on the misery of others, they will literally suck out your soul if given the chance. The paralyze you, make you relive your worst memories, and feel as though you'll never be happy again, and more broadly, like all happiness has gone from the world. Instant depression.


Another game is Depression Quest, "...an interactive fiction game where you play as someone living with depression. You are given a series of everyday life events and have to attempt to manage your illness, relationships, job, and possible treatment. This game aims to show other sufferers of depression that they are not alone in their feelings, and to illustrate to people who may not understand the illness the depths of what it can do to people."

You can pay what you want, or play for free, and a portion of the proceeds go to the National Suicide Prevention Lifeline. The music is even more depressing than elude's, and I would worry about someone who is moderately depressed sitting down to play this game.

Here's an excerpt from the first decision-making point:

Notice that the non-depressed option isn't even available to you at this stage.

There are all kinds of sympathetic remarks and disclaimers at the beginning of the game, but I have concerns about some depressed teenager searching online for solace and finding this.


On the flip side, a Playstation game like Flower (not mentioned in the Times article) is not intended to treat or even address depression, but I can see where it might help temporarily lift the mood of someone who isn't too seriously depressed. You play a flower petal drifting about through lovely landscapes:

Then there's Sym, a game, "...designed to help players understand how someone with social anxiety feels."

.Sym is a platform puzzle adventure that takes shyness and social anxiety as its theme...

Sym centers on a 2D character called Josh, who exists in two worlds. There is an above ground that is colored white. It is the real world. There is also an upside-down below ground, a negative, that represents Josh's internal landscape.

Puzzles are solved by making use of both worlds, though the levels are not always single-laned, and there is often a progression choice between both plains. The world is full of eyeballs watching Josh's actions. Words appear that draw obvious as well as cryptic allusions to the game's theme.'

I found Sym to be the most disturbing, yet simultaneously, the most energetic of the bunch, with phrases like, "If I could simply die," and, "I am in control...or am I?", as well as some cryptic biblical quotes.

I don't know what to make of these games. What do you think?

Switching the Labels

For no particular reason I can discern, I took my current ABPN Board Certificate off my wall today, and turned it over to see if I could figure out a way to simply replace the little rectangle that states my certification expires at the end of this year.

Certainly this was prompted by not wanting to put up the new certificate, which I wrote about in Signed, Sealed, Delivered. But why today I have no idea.

Anyway, this is what I saw on the back:

Sorry for the crummy iPhone photo-I hope you can read it. The main points are that these are instructions for adding "Future Recertification Labels", and the backing removes easily for the replacement of the label.

I guess I hadn't looked at the back of the thing in quite some time, because I couldn't remember why I thought all I'd have to do when I got recertified was replace the little rectangle.

But this is why. The plan was clearly to have a recertification label every 10 years. NOT, mind you, a big, galumphing new certificate that wags its finger at readers as if to say, "Your doctor had better cough up the annual fee and do those PIP modules, otherwise she'll lose her certification and your care will be compromised and she'll be very, very bad!"

So now, I'm just going to remove the old label, and replace it with a decorative swatch of my choosing.

These are some possibilities:

I'm looking for suggestions, so pipe up with ideas.

Termination

Nothing has distracted me from getting things done lately more than the fact that I'm terminating my analysis at the end of the month. This is not new information for me. I started talking about terminating last Fall, and the date was set at least six months ago. But none of that prepared me for the extent of the mourning involved.

Or the craziness. What other human relationship do you end just when it's starting to go well? And the real point is, I'm the one who's ending it.

This is supposed to be a good thing. And that's how it felt when I started discussing it last Fall. I came in one day and said, "I think I'm done." Not in an angry way, as I've felt in the past when something had come up that was upsetting or hard to think/talk about, or I felt like I was being criticized, and I just wanted to leave. And not in a hopeless way, as though there was no point continuing because nothing was ever going to change.

It just felt like I'd gotten a lot out of the experience, including the fact that I could take it from here. I certainly didn't feel "cured", or no longer neurotic. I just felt like I wouldn't be overwhelmed by expectable life circumstances, or even unexpectable ones that aren't too horrible, and I could handle my anxiety and my weird worries on my own.

Or well, not quite on my own. It's like my analyst has become part of me, so I don't need to go to sessions anymore to do the work, and I can manage my own reality checks.

Yeah. A good thing. Exciting, even. An accomplishment.

And let's not forget about the tangible benefits. Like more time freed up, and more money, both from not spending it on sessions, and not taking time for sessions, and the commuting to and from sessions, that could be spent seeing patients.

And what about the relief? Analysis is painful. It forces you to look at things you've been hiding from your whole life. Four days a week.

These are the things that make termination appealing, aside from the fact that termination is the ultimate goal of the treatment.

I want to share a few quotes from a paper by Glen Gabbard, What is a "Good Enough" Termination? (2009. Journal of the American Psychoanalytic Association, 57:575- 594):

...we lack a paradigm for termination. This is as it should be. There are multiple scenarios that are “good enough.” (p. 591)

“Termination,” as opposed to the ending of an analysis, generally implies that the analysis has come to an end through mutual agreement and negotiation by patient and analyst rather than by a financial setback or an unplanned relocation of the patient. There is also the implication that patient and analyst must allow sufficient time to work through the patient's feelings regarding the loss of the analyst and the changes that have been made in the course of the analytic work. (p. 578)

...the interpretive resolution of the transference neurosis, the eradication of symptoms, the achievement of “full genitality,” the modification of the superego, and the ability to love and work are often clustered together as indications for a termination process that will take several months and be mutually agreed on... [However]...terminations are based not on predictive theories, but on permissive models that are reinvented each day.

We must accept that no analysis is complete—rather, a process is set in motion. Orgel (2000), in a thoughtful contribution on the reality of termination, asks poignantly if any analysand ever ends analysis with an emotional conviction that it is complete. Kogan (2007) notes that “there is no such thing as an ideal termination; the symptoms never disappear completely; the patient does not achieve all of the structural changes one would like; nor does he manage to acquire a totally integrated personality”...The terminated patient is not “fully analyzed”—he or she is simply embarking on a life of self-analytic reflection that offers depth and richness to one's existence. Suffering, intrapsychic conflict, and problems in work and love will continue. A tragic vision is central to the psychoanalytic journey. (pp. 585-6)

...both analyst and analysand must disentangle themselves from a significant connection with another human being that has shaped their lives. To some extent analyst and analysand lose themselves as separate individuals in the analytic experience, and it is only through termination that each “retrieves” a sense of being a discrete mind (Ogden 1997). Both parties are different from what they were when they set out on the analytic journey, however, and the mind retrieved is not quite the same as the mind that began the analysis. (p. 587)


Excitement and accomplishment are all well and good, but still, I'm in mourning. Analysis has structured my days and weeks for a very long time. Even my years-the August break is always there, along with some time off at Christmas/New Year, Spring break, Thanksgiving, etc.

The sessions are clearly delimited, and almost always end with the statement from my analyst, "We do have to interrupt," which I find pretentious, although I understand it makes the point that an analysis is really just one very long session with lots of commercial breaks. I'm dreading what she's going to say at the end of the last session. "We do have to terminate," maybe? "It's time to terminate?" "It's time to stop?"

Whatever the phrasing, it's a little bit heartbreaking.

I'm losing the place I go to deal with all the built up frustration and pain. And even though I often clam up when I'm there, I still know it's my time, set aside from the rest of the world.

I'm losing the place that taught me it's okay to look at anything about myself and not feel ashamed or guilty in doing so.

I'm losing an important person in my life. I don't really know her. I know just this one aspect of her. But there is still tremendous intimacy, and I leave with the conviction that, to quote a friend who finished his analysis several years ago, there's someone in my corner. And that someone cares what happens to me.

Of course, there's the weirdness that I'm ending this intense, intimate relationship with this person, but I'm still going to see her at meetings, etc. Only there, she'll be an unapproachable stranger. This is not conjecture or possibility. It happened just last week. But unlike last week, I won't be able to talk to her about the weirdness the next day.

So it's not a death. She'll still be around. It's not a divorce. We're not ending because we can't get along. It's not the gradual drifting apart of a once strong friendship. If anything, it's grown progressively more comfortable , and we've developed our tropes and can even joke around at times.

During one recent session, thinking about endings and "nevermore", I brought up the poem, The Raven. It's a terrible poem. Poe is a terrible poet (though I happen to think he's a master of the short story). The content is all sad and morose, but the sound is jaunty. Silly, even. He uses ridiculous words like, quaff and nepenthe. And the rhymes are too perfect. When I mentioned this, my analyst laughed and told me about a New Yorker cartoon with Poe scribbling phrases like, "Shut the door," and "Sweep the floor."

This exchange would not have happened early in my analysis. This kind of relaxed jocularity. Or if it had happened, it would have upset me, as though a boundary had been inappropriately crossed, and my analyst had behaved, "unanalytically". But the boundaries are now long since established, and I've learned that if one of us occasionally puts a toe across, we'll both survive. That it's possible to survive disappointment or discomfort or ambivalence without losing a relationship may be the greatest lesson analysis has taught me.

Which is why it's okay to lose this relationship.