Delicate Business

I’ve spent the last eighteen years working in a community mental health center. Such centers usually charge according to the patient’s ability to pay, and many patients pay nothing for their treatment. As Keith Russell Ablow suggests, there is no convincing evidence that such treatment is any less effective than that offered in private practice.

Over the years I have heard many psychiatrists express their liberal anguish about extracting fees from their patients. Very few of them, however, are willing to abandon their lucrative practices in order to do something about the problem.

Keith Russell Ablow’s “Delicate Business” [Issue 200] was poignant reading for me. As a psychotherapist, I too have often felt like a “prostitute feigning romance.”

Practicing psychotherapy reminds me of when, as a teenager, I’d sit with friends at our local diner, shoving quarters into the jukebox, selecting our favorite ballads of unrequited love. Only now, I am the one inside the plastic bubble that harbors the (oldies but) goodies. I am the one spinning the tunes, engaging the pain of my clients’ unfulfilled relationships. I am the one the quarters disappear into.

I marvel at how I and other psychotherapists deny the inherent, obvious conflict of interest in our role: on one hand, the integrity of our work demands that we be as effective as we can, that we finish with our clients as quickly as possible; on the other hand, our livelihoods may depend on our being relatively ineffective, so that we can have repeat customers over an extended time.

If we’re willing to play the game with the insurance companies — give them the diagnostic codes they recognize as a legitimate basis for treatment, and stay within the time and dollar limits that they dictate — we can make handsome salaries as prostitutes for the examined life.

It is refreshing to hear from a member of the psychiatric profession who continues to examine his own life.