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Inside Dope on Health Care Reform Timetable: Predictions of a DC Health Policy Wonk

A friend of a friend of the American Psychoanalytic Association has worked for many years, in many capacities, as a health care policy "guy" in Washington DC. The members of APsaA are understandably concerned about and invested in numerous aspects of health care policy, both reform and otherwise.

Among our top concerns are protecting patient privacy, preserving the right to private contracting, making sure that treatment that is individualized and personal is supported as much as treatment that is "evidenced based" and more. We eagerly take stands, along with sister mental health professional organizations on these issues.

As a group, we are probably less unanimous on some of the economic issues such as public insurance options or single payer. So with these issues, our organizational stance is to share information but to remain neutral.

We asked our source in Washington about the timetable for the massive changes afoot. We like other groups with an interest in advocacy, want to make sure our voice is heard not just loudly but at the right time. Here's what he had to say about when he thinks the legislation will be done:


Optimistic Scenario:
Committee approval between now and July 31st
Floor votes: First week in August
Conference committee staff work during August
Conference agreement by September 30
Final floor votes by October 31.

Realistic Scenario:
Committee approval by July 31
Floor votes by August 15
Conference agreement by October 1
Final floor votes by Thanksgiving

Pessimistic Scenario:
No committee approval before August recess
Committee votes in September-October
Floor votes in November
Conference agreement on scaled down bill by Xmas

Our source thought there will be plenty of opportunities for input during implementation in 2010. Many of the detailed issues, he said, will be left to the Secretary of Health and Human Services to decide.

Many of the issues the American Psychoanalytic Association cares the most about -- reserving the right to private contracting, privacy of medical records, advising caution about total reliance on Evidence Based
Medicine may well fall into the implementation
stage.

"Words are the healers of the sick temper"

My colleague Paul M. Brinich, Ph.D., Clinical Professor, Departments of Psychology and Psychiatry,University of North Carolina at Chapel Hill, and faculty, Psychoanalytic Education Center of the Carolinas offers this wonderful collection of quotes --primarily from literature with a few from Sigmund Freud-- that convey in a few perfect words the muddles of human nature, the misery of neurosis, and the healing power of words.

Brinich uses the quotes as points of discussion in the classes he teaches. To me, they convey the enduring "discoveries" and underlying tenets of psychoanalysis, though they were written as long as two millennia before Freud laid it down in his works.

Boswell's quote:

What a curious creature is man! With what a variety of faculties he is endowed! Yet how easily he is disturbed and put out of order!

This captures the wonder of my work as a psychoanalyst as well as any 26 words I can imagine.

Psychoanalysis--quotes to provoke and inspire

If you be sick, your own thoughts make you sick. [Ben Jonson, 1598]

What a curious creature is man! With what a variety of powers and faculties is he endued! Yet how easily is he disturbed and put out of order! [James Boswell, 1763]

Oh the nerves, the nerves; the mysteries of this machine called man! Oh the little that unhinges it: poor creatures that we are! [Charles Dickens, 1844]

The bow too tensely strung is easily broken. [Publilius Syrus, 1st century BC]

Everybody in the world has the sensation of being tied down hand and foot -- Everyone has his own private bloodsucker. [Ugo Betti, 1953]

[Will Ladislaw] was conscious of being irritated by ridiculously small causes, which were half of his own creation. Why was he making any fuss about Mrs. Casaubon? And yet he felt as if something had happened to him with regard to her. There are characters which are continually creating collisions and nodes for themselves in dramas which nobody is prepared to act with them. Their susceptibilities will clash against objects that remain innocently quiet. [George Eliot, Middlemarch, Book II, Chapter 19, 1871-1872]

As every man is hunted by his own daemon, vexed by his own disease, this checks all his activity. [Ralph Waldo Emerson, 1860]

Psychiatry's chief contribution to philosophy is the discovery that the toilet is the seat of the soul. [Alexander Chase, 1966]

Canst thou not minister to a mind diseased, pluck from the memory a rooted sorrow, raze out the written troubles of the brain, and with some sweet oblivious antidote, cleanse the stuffed bosom of that perilous stuff which weighs upon the heart? [Shakespeare, Macbeth]

Do you not know, Prometheus, that words are healers of the sick temper? [Aeschylus, c. 478 BC]

Once read thy own breast right, and thou hast done with fears. [Matthew Arnold, 1852]

The greatest happiness is to know the source of unhappiness. [Dostoevski, 1876]

All cases are unique, and very similar to others. [T. S. Eliot, 1949]

To have known how to change the past into a few saddened smiles -- is this not to master the future? [Maurice Maeterlinck, 1896]

All the art of analysis consists in saying a truth only when the other person is ready for it, has been prepared for it by an organic process of gradation and evolution. [Anais Nin, 1932]

Every life is, more or less, a ruin among whose debris we have to discover what the person ought to have been. [Jose Ortega y Gasset, 1949]

Man is tied to the weight of his own past, and even by a great therapeutic labor little more can be accomplished than a shifting of the burden. [Philip Rieff, 1959]

To understand oneself is the classic form of consolation; to elude oneself is the romantic. [George Santayana, 1913]

Let us not seek our disease out of ourselves; 'tis in us, and planted in our bowels; and the mere fact that we do not perceive ourselves to be sick, renders us more hard to be cured. [Seneca, 1st century AD]

It might be said of psychoanalysis that if you give it your little finger it will soon have your whole hand. [Sigmund Freud, 1917]

Look into the depths of your own soul and learn first to know yourself, then you will understand why this illness was bound to come upon you and perhaps you will thenceforth avoid falling ill. [Sigmund Freud, 1924]

All the world's a stage, and all the men and women merely players: they have their exits and their entrances; and one man in his time plays many parts . . . [William Shakespeare, As you like it, II, vii, 139]

Our revels now are ended. These our actors, as I foretold you, were all spirits and are melted into air, into thin air: And, like the baseless fabric of this vision, the cloud-capp'd towers, the gorgeous palaces, the solemn temples, the great globe itself, yea, all which it inherit, shall disolve and, like this insubstantial pageant faded, leave not a rack behind. We are such things as dreams are made on, and our little life is rounded with a sleep. [William Shakespeare, The tempest, IV, i, 148]

So, if I dream I have you, I have you. For, all our joys are but fantastical. [John Donne, Elegies, No. 10, "The dream"]

The American Psychoanalytic Association and Torture--no Moral Ambiguity

For those of us in the mental health field, one of the more shocking aspects of the Department of Justice memos regarding “enhanced interrogation” released by the Obama Administration last weekend was the description of the central role of a psychologist (or psychologists)  in justifying the techniques used—waterboarding, isolation, humiliation, etc.  It appears that the psychologist's “expert opinion” was used to maintain the position that no prolonged mental harm was caused by these techniques, and therefore, by the then current (reinvented) definition of torture, they could not, (again, by definition) constitute torture.

 

The DOJ memos reveal that a psychologist was present when an al Queda subject was interrogated.

 

Then follows a morally astounding section of the memos that argues that though waterboarding clearly constitutes a threat of imminent death, as long as the technique is not intended to cause prolonged mental harm, it is not torture because of the alleged intention of the interrogators.

 

So the psychologist involved comes in handy in two ways.  He or she states that based on his or her expert opinion, waterboarding does not cause prolonged mental harm.  A story on National Public Radio yesterday (April 21) added the background that the basis for this claim came from a study of volunteers in the American military undergoing the same procedures for training purposes (the SERE experience) which showed that these soldier/volunteers suffered no long term mental harm.  But you don’t have to be a psychoanalyst to figure out that being a volunteer undergoing certain awful experiences administered by your colleagues is a really different experience from being an “enemy combatant”, helpless and confined and completely unable to control your present or your future.  Also you don’t have to be a psychoanalyst to know that it takes a long time to evaluate the presence of long term effects.  Duh.

 

The other role for the psychologist  in the interrogations was to play some role in the peculiar and disturbing dance around the issue of “intent to torture”.  This too boggles the mind.  What was their intent then?  Why does the intent of the interrogator change the assessment of the effect of the technique on  the person questioned.  If I run you over and kill you you’re just as dead if it were an accident or intentional.  Perhaps my punishment would differ, based on my intent, but the ill effect you suffered would be the same.

 

All the major mental health organizations now have statements opposing torture.  The American Psychoanalytic Association unambiguously and unambivalently opposes torture in all its forms.  I hope that no mental health colleague will ever again engage in the moral shell game these memos reveal.

In 2008, the American Psychoanalytic Association approved this position statement on torture:

POSITION STATEMENT

The American Psychoanalytic Association joins with other mental health and medical professional organizations in strongly condemning the use of torture. As an organization of psychoanalysts who have devoted their lives to helping people undo the effects of trauma in their lives, APsaA strongly protests all torture, including any governmentally administered and governmentally approved torture of people who are detained. Torture degrades those tortured and those torturing. The effects of that physical and moral degradation, we know, are transmitted to the families and offspring of both victims and perpetrators. APsaA also strongly condemns the participation or oversight by any mental health or medical personnel in any and all aspects of torture. Such actions are contrary to the basic ethical principles fundamental to the helping professions.

 

 

 

 

 

 

Psychoanalysis and gay rights--40 years of change

Reflecting on the 40th Anniversary of the Stonewall rebellion, the New York Times published a most peculiar piece on Sunday April 12. Titled “Word for Word: Deviates and Inverts” the anonymous "Week in Review" piece seemed to be a kind of apology for the language and attitude the Times presented as “news” about homosexuality in 1963.

In their broadly quoted “news” story of the early 1960’s, the Times relied upon the expert opinion of a psychoanalyst. The April 12 2009 piece also relied heavily on quotes from this psychoanalyst, who argued, among other long since abandoned ideas, that viewing homosexuality as an illness can be very helpful (now we know that view causes great pain, and even the loss of life especially in vulnerable young people), that homosexuals are inherently emotionally unstable (huh), that homosexual relationships suffer more from jealousy and personality clashes than  heterosexual relationship  (really??).

The Times notes that “the article’s language, from sources and reporter alike, is outdated at best, derogatory at worst, and many of its assumptions and assertions are long discredited” I'll say. 

But as a psychoanalyst, and president of the American Psychoanalytic Association (APsaA), it deeply troubles me that the Times did not bother to note how profoundly psychoanalysis has changed in its attitude toward homosexuality in the decades since Stonewall. Like other mental health professionals, we know that homosexuality is NOT an illness, that gays and lesbians are NOT inherently unstable, that gay and lesbian relationships and families are no less rich and resilient and stable than heterosexual ones. (which is to say, I guess, that relationships and having strong families is hard, gay or straight, but being gay does not give you a handicap in this arena.)

My colleague Ethan Grumbach, Chair of our Committee on Lesbian, Gay, Bisexual and Transgender Issues, writing on behalf of the American Psychoanalytic Association, wrote this letter to the editor of the Times on April 13:

Deviates’ and ‘Inverts’ (Sunday, April 12) references the study of gay men by Dr. Irving Bieber, a psychoanalyst who believed that homosexuality was an illness that could be treated or prevented. Like New York City, psychoanalysts have come a long way- in their case, by the fact of having discredited Bieber's view. Today, The American Psychoanalytic Association, 3,300 members strong, ardently supports gay marriage and opposes and deplores public or private discrimination against male and female homosexually oriented individuals. Social justice is paramount to psychoanalysts in all aspects of human life- regardless of sexual orientation.

At the American Psychoanalytic Association we are particularly proud of a series of position statements we have approved over the last decade addressing issues such as gay marriage, gay adoption, and gays in the military. Please take a look.

The Ethical Centrality of Patient Consent

A few days ago, I received a call from a company describing itself as an agent of my patient's health insurer, charged with the task of determining the "medical necessity" of her treatment. (A haunted term I was pleased not to have heard in a while). I told the caller that I didn't have a consent from the patient to release the information they wanted, which included "physician's orders, treatment plan, progress notes, and lab results" and in any case I only responded to written requests. The caller became irate, and said "everybody does it [on the telephone]" and eventually hung up on me.

My patient wanted me to provide the information, since in the economic downturn he needs the money the coverage provides.

I finally got a written request from the "health management system". It contained the following extraordinary paragraph:

This review and request for medical record information is part of the utilization review process and is performed at the request of the patient, provider and/or health plan. As such, there should be no charge for the medical record. [why is this exactly?] In accordance with HIPAA regulations, the requested information will only be used for payment, treatment and health care operation purposes and does not require a release of information, consent or authorization. [what would require a consent in their view?] [As a practitioner, I thought the whole point of HIPAA regs was to provide consent, though I understood that provisions allowed companies to have patients give blanket consent] [comments in color obviously my own]

Perhaps the "health management system" meant to say that they had previously received a blanket consent from the patient that allowed them to bypass the need for specific consent this time. However, it interested me that it didn't occur to them that I might need to have consent to release the information, that went beyond their angry assurance that (1) I had to do so and (2) "everybody does it".

I know this story happens every day to psychoanalysts and other therapists, doctors, nurses and "entities" as we have all become in the healthcare-industrial-complex.

APsaA's legislative representative Jim Pyles recently wrote a somewhat heartening note, regarding APsaA's history in the fight for the patient's right for consent, and a promising new development in which it seems that at least one hospital sees a marketing and economic advantage in providing electronic medical records which remain in the patient's control.

This comment is from Jim Pyles on April 6, 2009:

An article in today’s New York Times states that one of the largest hospitals in New York is implementing an electronic personal health record controlled by the patient. Of course, the essence of the right to health information privacy and consent is the patient’s right to control the use and disclosure of the information. Some of you may recall that we fought hard in 1996 to defeat inclusion of legislation drafted by Senator Bennett (R-UT) that would have prohibited this type of control being offered to patients. He apparently understood that unless the right of control and consent were outlawed, it would become the health care standard when the first health care provider offered it because it is what most patients want.

Our success in the original HIPAA legislation, in the HIPAA Privacy Rule and in the latest health IT legislation in preserving the opportunity for patients to obtain a consent process has led to this development where health care providers are using patient control to gain a competitive advantage. It is a good thing when hospitals and health IT vendors compete to see who can best protect the patient’s right to
privacy.

Jim Pyles

New York Times: A Hospital Is Offering Digital Records By STEVE LOHR

News Analysis

What's up with all the rude people? Viewers of a Boston television station wanted to know, and the reporter assigned to investigate ended up on former APsaA president Dr. Robert Pyle's psychoanalytic couch in order to find the answers to his troubling questions about human nature.

Why do trash collectors throw around the cans? Why do drivers fail to signal a left turn? And why do smokers drop their butts in the gutter? Take a look to find Pyles' deft answers.

I have argued that psychoanalysts can say something interesting and useful about just about everything human. In answering the questions about the garbage cans, cigarette butts and rude drivers, Pyles managed to work in the concepts of isolation, grandiosity, narcissitic resentment, the psychical effects of ostracism and low status, and the healing balm of community. Not bad for a handful of seconds on the tube.

By the way, when you look at the video clip, take a look at the unusal and beautiful psychoanalytic couch, which was handmade and designed by APsaA member Harvey Rich, M.D.

Patient Privacy and the Stimulus Package

Round one of the Stimulus Package passed the U.S. House of Representatives this week. The American Psychoanalytic Association has been lobbying for privacy protections in the bill, since on of its major components is a section that would promote development of a comprehensive health information technology system. APsaA has long been concerned about the potential for violation of confidentiality in electronic medical records and has been fighting for a number of years now to ensure the systems promoted by the government provide the maximum possible protections for patient privacy. Our legislative representative Jim Pyles offered the following analysis of the House bill and where it stands on the issue of protecting confidentiality, the right to consent, and other privacy issues.

Yesterday the House passed the "American Recovery and Reinvestment Act of 2009" (H.R. 1) which contains a Title IV entitled the Health Information Technology for Economic and Clinical Health Act (HITECH Act) that provides for policies and standards as well as incentives and penalties intended to promote a national electronic health information technology system. The HITECH Act has also been approved by two key Senate Committees and is part of the stimulus bill still pending in the Senate (S.1).

The HITECH Act passed by the House has the strongest privacy protections of any bill that has moved in either the House or the Senate to date, however, it does not contain several provisions championed by APsaA and the mental health practitioner community generally. It does not contain recognition of the patient's right to health information privacy, an express right of consent for the routine disclosure of health information or a definition of the term "privacy".

There are important privacy provisions that APsaA and others were able to get included. Perhaps the most important is that the House bill includes a provision stating that nothing in the bill shall constitute a waiver of "any privilege otherwise applicable to an individual with respect to protected health information of such individual." Section 4405(g). This acknowledges in statute the privilege recognized by the Supreme Court in Jaffee v. Redmond . The psychotherapist-patient privilege recognized in that decision, was only based on an interpretation of the Federal Rules of Evidence and could have been eliminated at any time by statute. If this provision remains in the final HITECH Act, the psychotherapist-patient privilege recognized at the federal level only in case law, will likely be preserved. The privilege essentially gives the patient a right of consent because the privilege can only be waived, other than in extraordinary situations, by the patient. Of course, the privilege is broader than the definition of "psychotherapy notes" in the HIPAA Privacy Rule.

Second, the bill includes the interpretation of "minimum necessary" that we were able to get included in the preamble to the HIPAA Privacy Rule. The bill states that the determination of what constitutes the "minimum necessary" information for any purpose is to be determined by the covered entity or business associate disclosing the information. Section 4405(b)(2). This means that a psychotherapist can determine whether a request for patient information by a third party is the "minimum necessary" for the purpose of the request.

Other significant protections and improvements for which APsaA advocated include the following:

1. An early provision in the House and Senate bills that would have prevented consumers and patients from having "undue influence" on health information technology policies and standards was deleted. APsaA took the position that patients are the most important "stakeholders".



2. Health information technology standards must be published in the Federal Register and made available for public comment before being adopted.



3. Enforcement measures for privacy violations were strengthened holding business associates liable for privacy violations and requiring the Secretary to investigate any "possible violation due to willful neglect".



4. Covered entities are required to grant requests by patients for restrictions on disclosures of identifiable health information for payment and health care operations purposes if they pay out of pocket. (Unfortunately, disclosures without consent can still be made for treatment even if the individual pays out of pocket.)



5. Technologies are to be developed that would protect the privacy of health information by allowing for "segmentation" of specific and sensitive information due to privacy concerns.



6. Technologies are to be developed that would allow individually identifiable health information to be rendered unusable or unreadable by unauthorized individuals when transmitted in a nationwide network or outside of the physical perimeter of a health care provider, health plan or clearinghouse. APsaA worked closely with Congress Markey (D-MA) on this provision.



7. Covered entities must notify patients of breaches of electronic health information, and report such breaches to the Secretary of Health and Human Services who will publish a list of significant breaches (involving more than 500 individuals) on the agency's website.

We are continuing to work with Senator Snowe (R-ME) to get a broad exception to the definition of "breach" narrowed.

In short, we have achieved many significant victories, and your patients' privacy rights should be much better protected because of APsaA's efforts, but there is still work to be done on the Senate bill and in working with the Obama Administration on implementing regulations.

Jim Pyles

The Emerging Evidence Base for Psychodynamic Psychotherapy--named a top psychiatry story of 2008

Seven stories were chosen as the Top Psychiatry Stories of 2008 by Journal Watch Psychiatry, a publication of the Massachusetts Medical Society, which describes itself as "an editorially independent literature-surveillance newsletter summarizing articles from major medical journals".

The January 2009 issue (Vol 15 No. 1) introduces a new feature, Top Stories of the preceding year. The editors write,

In making our choices, we have tried to strike a balance between relevance to the clinician, recognition of landmark studies, and media publicity and public awareness. Each Top Story draws on several related summaries, and most include new citations to enlarge their scopes.

Of the seven "winners", "The Emerging Evidence Base for Psychodynamic Psychotherapies" received the most column inches. Several meta-analyses were noted (and critiqued), including the study now famously reported in JAMA 300.

Findings regarding the value of transference interpretations, the value of transference focused treatment of patients with borderline personality disorder, psychoanalytic psychotherapy in the treatment of panic disorder were cited. Even countertransference was cited as a researchable phenomenon.

The authors of the top story piece delineate areas for further research, but they conclude with these thoughts:

In a year that has seen the passage of a u.S. mental health parity law--and in a treatment environment where psychiatrists are doing less psychotherapy, due in good measure to falling reimbursement for this modality--psychodynamic psychotherapies for specific conditions may have earned their place at the evidence-based table (third party payers, take note).

Journal Watch Psychiatry is a tremendous resource for busy practitioners. It's reviewers are not only sound thinkers but excellent writers. While psychoanalysts can be proud that new research in our field has made it to the Top Stories list, I do recommend this publication for a solid and reliable review of psychiatric research.

Readers can find references to the entire literature relating to psychoanalysis and empirical research by visiting the website of the American Psychoanalytic Association

The Long Haul--Meeting the needs of those who serve

I've just returned from APsaA's winter meeting, which was so full of riches that it could feed this blog for months to come.  One of many important themes at our meeting related to the needs of those who suffer psychological injury from war, and their families who suffer secondary and often severe trauma as well.  

Marie Rudden (chair of APsaA's Psychoanalysis and the Community Committee) and I were interviewed by a reporter from Medpage Today on psychoanalysis and treating soldiers with PTSD.  A video of the 9 minute interview can be found at the Medpage Today site.  We were able to get news of the important psychoanalytic  volunteer projects SOFAR and The Soldiers Project into the interview, as well as mention of APsaA's advocacy for privacy of treatment, a central issue in the military.  

Please take  look at the interview, and also visit the APsaA website and click on the Soldiers and Veterans initiative link.