Medicaid: Therapy by bureaucracy

Beast

The new client enters your office and sits on couch or chair. After all the right introductions (confidentiality and exceptions, informed consent, “non-judgmental environment,” maybe the therapy method), you gain her “presenting problem” and record biopsychosocial information. Following this, there may be time to discuss the all-important, the be-all and end-all, the cat’s meow, the cat’s pajamas – the person’s purposes for therapy. If not this hour, then the next: Treatment Plan or ISP (Individualized Service Plan) session.

Here is where the government makes (or has already made) your brain and soul shrink, and simplify yourself and your client into a specific brand-name problem –  Depression or Anxiety or Communication or Anger or etc. – then turn the problem into What do you want to do about it? This will be followed by specific Goals or proposed markers of success. For example: “I am depressed. I want to not cry anymore.” Or “I have anxiety. I want to be able to go shopping without my husband having to come along every time.” You, the therapist, will then glue the icing on the cake with the Objectives that Medicaid – which audits you when you’re sleeping, audits you when you’re awake, audits you when you’re eating your Corn Flake – needs to see. It needs to know that you are a mathematician solving an equation, a construction worker placing the final brick, a therapist not just listening to feelings forever, sinking no teeth into concrete ends, going nowhere or many places. No! “Client’s depression will mitigate as evidenced by fifty percent fewer crying episodes over the next two months.” “Client will report no suicidal thoughts over the next month” or “Client will contact a support person or secure transportation to the ER if she feels unsafe” or “Client will be able to stay in a Whole Foods for half-an-hour once a week without the presence of her husband.” This is what Medicaid needs, to pay you and to not take back many thousands of dollars fraudulently earned by virtue of your notating an intangible.

What we are looking at here is not a mere protocol or guideline, but a change in the culture of psychotherapy as juggernaut-like, global and dehumanizing as the Trump Era’s deification of callousness, racism and primitive-mindedness. Therapists both young and experienced, all over the country actually believe that the client is these discrete problems, is or has a diagnostic label. They believe that a behavior change or a symptom mitigation means the person is improved, is different, has been helped.

Jesus Mother-f**king Christ. This is a delusion so sad and terrible that Freud and Ferenczi and Janov should leap from their graves and spray you Little Brothers with dog shit.

The client is a person who was injured, in her childhood, in countless possible ways, and now suffers oceanically in body, thought, feeling, motivation, visceral or molecular sense of deadness or wrongness-to-live; in his somato-emotional urge to jump out of his skin and make a million dollars; need to cut her arm open to see her blood and feel good; having no sense of identity; feeling desires that evaporate the moment they are named; becoming a tower of idea or belief clouds; feeling not far below the surface like a blind and rape-able child, or out-of-sync with the entire world. She is someone who at age fifty looks out her living room picture window and sees her front lawn from forty-five years ago, and wants it, but despises it.

You apply a label to this person, see her as a packet of symptoms, and you are destroying her.

Beauty 

The 35-year-old woman came to therapy because of “anxiety.” This was in a part of Colorado where there are the small mountains called hogbacks. She lived on one of them and sometimes would find herself out of breath at the foot of it, after midnight, in her nightgown, in a confused panic and not knowing how she got there. For some reason in the third session I suggested Empty Chair, the Gestalt-derivative way of talking to an important person in one’s life. She put her mother, no longer living, in the facing chair. There had been a different kind of abuse in my client’s childhood: She had felt compelled to watch her mother, possibly psychotic, mutilating herself. I had a large office then, and wheeled my chair effectively out of sight. The woman talked, screamed, cried, emphatically to her mother for ninety minutes without cease. She was there but not there, in the chair. Needless to say, a history of pain and need, of real self child and later, came out (along with tears and snot), all for the first time. When it ended, on its own, she was different. She “felt” different, and looked different. But she was really different. It’s not often you see the world change right in front of you.

Later that evening – I had stayed after hours – I retrieved a voice mail from her. She was grateful. She had left her husband, her home, and was sleeping on the floor of the small business they owned. During the first two sessions she had not even mentioned her husband, any marital problems. But during the purging of her wrong history, voicing everything to her mother, something happened. No one can know exactly. Some tumblers fell, some penny dropped. Many anchors were vomited up. Something happened that therapy aided by inviting her to be totally real. Not everyone can reach real. But she could.

Imagine having the client record, from fear of Medicaid’s ass shining down on us: “I have anxiety. I want to have no more panic attacks,” and our establishing that “Panic episodes will reduce from average three per month to one over the next six months.” As it was, not long after her Empty Chair session I left Colorado to return to Ohio, and never learned what happened with her anxiety. In the short term, though, you could say that we would have failed the Plan for having sailed far off course: It hadn’t read, “. . . I will end my marriage, be different, be happier.”

————————

To clients: If you are wondering about your therapist’s way of seeing and understanding you and trying to help you; if you know or suspect he or she may be doing therapy to the form, check your feelings over the course of half-a-dozen sessions. If you feel good, bright, slightly easy and lightly challenged, you might consider that things are not really going well. The therapy may be “Cognitive,” meaning that you stay in your thoughts which naturally feel in your control and strong. But you will leave sessions with that underlying dis-ease — the same as always. Or you may sense that the therapist is focused, session after session, on some symptoms, and you also sense that you are more than that. The process that may do you the most good will stir you in the bottom of your gut, and in your chest, and in your eyes. You’ll find yourself, maybe without words, questioning “everything.” While you feel different, exactly simultaneously your feelings about the world and people in it will also feel different. You’ll sense, or know, that you are now called on to act different toward them. You may get the realization — as Yalom suggested somewhere — that therapy has become the most important crisis in your life. You decide to stay with it or leave. Rest assured the next therapist will help you land on that burdensome symptom.