Legal, Ethical, and Professional Issues in Psychoanalysis and Psychotherapy
to Eliminate the External Management of Care:
What Does Character Have to Do With It?
Karen Shore, Ph.D.
In this column I would like to expand upon the reasons why I believe it is so crucial to rid health care of the external managers of care. I have sometimes said that the fight against managed care (MC) as a fight of good vs. evil. Many consider this an extreme position. Recently, I had the opportunity to think and write a bit more about why I see it this way and I would like to share these thoughts with you.
As you probably know, the Coalition seeks to protect all generally accepted forms of therapy and I personally believe all major forms are very needed by our nation’s citizens. At the same time I am personally quite embedded in psychoanalytic thinking and see psychoanalysis as my primary orientation. I had just begun my postdoctoral work in psychoanalysis when managed care hit New York State back in 1991.
Among the people I spoke with early on was a training analyst in our area. He told me of a chilling meeting he had had with a former student who was now building a MC company. When the analyst expressed concern for the future of psychoanalysis under MC, his former student told him straight out “we will kill psychoanalysis.”
Now, why would anyone want to “kill” psychoanalysis? It is not just that these MC folks do not want to pay for psychoanalysis and psychodynamic therapy. They want them dead. In fact, it seems that MC would prefer it if all forms of therapy that take longer than 5 or 10 sessions would just drop out of existence, and they have done what they can to influence students, practicing clinicians, and training programs to drop longer forms of therapy and convert to learning and teaching only MC’s favored forms of therapy. Graduate programs have largely succumbed by stopping any significant teaching of psychodynamic theory and practice and by modifying theory and practicum experience to focus on short-term, crisis- and problem-focused therapies. Thus, the perception that MC wants to “kill” psychoanalysis and other forms of traditional therapies is not so far-fetched. Certainly, if new therapists no nothing other than MC therapies, opposition is reduced. This is a classic totalitarian tactic.
Moreover, with all the deaths that have occurred under MC—many of which could have been or were predicted--it seems that MC execs want people dead--that letting costly people die would be preferable to paying for their care. I remember an Op-Ed article in The New York Times that appeared several years ago entitled “Do They Want My Wife to Die?” I do not remember what illness the author’s wife had, but it was a medical problem that required treatment that was being denied by his MC company. The clear message he had gotten was that the executives in his MC company would rather his wife die than pay for her treatment. My sister, a pediatric radiologist in Washington DC, had trained to do a special procedure for children that would save the children a great deal of pain during radiological testing. However, doing this procedure required the presence of a specially trained nurse. MC companies were refusing to pay to have a nurse present. Thus, this new procedure cannot be done and children needlessly suffer pain. The MC companies want this new procedure to die. In addition, it seems, they just don’t care that small children will experience more pain than necessary during certain radiological procedures.
What kind of person can try to “kill” psychoanalysis and other traditional forms of psychotherapy? What kind of person can see to it that newborns and their mothers are kicked out of hospitals 12-18 hours after birth? What kind of person can insist that mastectomy patients be sent home the same day as surgery, with drainage tubes attached? What kind of person can insist that less painful procedures be denied to children? What kind of person can deny hospitalization to psychiatric patients, deny more than a few days of rehab to stroke patients, and can intrude into the content of a person’s psychotherapy in order to justify their Draconian ideas of psychotherapy? Clearly, these people lack some basic amount of empathy.
From a psychoanalytic point of view, the problem with many (certainly, not all) of the people who now control or heavily influence health care lies in their character. Even some of those who mean well have a basic characterological make-up that prevents them from being as empathic as patients need them to be.
Health care in general, mental health care in particular, and especially the longer-term, more subjectively based psychotherapies are endangered by more than the corporate chiefs of managed care. They are also endangered by the rigid empiricists, the bureaucratic mind, and by some of our lawmakers and policy makers. The bureaucrats, the corporate chiefs, the rigid empiricists, and many policy makers are killing people, personal freedom, personal privacy, and a portion of the human spirit.
There are large and small deaths that these people cause. I have often thought that knowingly causing the deaths of people who could be saved, or allowing them to die and making a profit off of their deaths, is a downright sadistic, murderous act. On a smaller scale, patients and clinicians also are reacting to MC’s smaller acts of the attempted “murder” of their sense of self and their sense of agency, privacy, dignity, and integrity. To the extent that any form of authority, be it parents, a political system, an organization, a cult, etc. squelches individual freedom of thought and expression through the use of power over people, it is committing what is referred to as “Soul Murder” (Shengold, 1989). Shengold discusses the most extreme forms of soul murder: torture and severe abuse and deprivation. He defines soul murder as severe harm under conditions of complete dependency, causing helplessness and rage. He cites Hitler, Stalin, and Orwell’s Winston Smith in 1984, who was told by his captor, torturer, and brainwasher, O’Brien: “You will be hollow. We will squeeze you empty, and then we shall fill you with ourselves.”
Shengold also cites Judge Daniel Paul Schreiber (Freud, 1911), a paranoid man whose delusions he linked to torture by his father, the famous Dr. Schreber of German education who devised mechanical devices that inhibit childrens’ pleasure and freedom of motion ostensibly to force them to act in “proper” ways. Through his hallucinations and delusions, which clearly reflect his father’s sadistic treatment, Schreber describes his experience as being the victim of soul murder. Niederland (1960, 1968, 1974) describes the unempathic treatment Dr. Schreber showed toward his son, treatment in which the boy was handled as if he were a thing, being deprived of his own will and the capacity for pleasure and joy (see also, Shengold, 1989). Shengold also relates these ideas to the abuse we often see in the histories of our patients.
To a less severe but still palpable degree, many of us feel that the MC industry is doing something similar to patients and clinicians. MC not only deprives people of needed care and sometimes kills them. It restricts the freedom and agency of patients and clinicians, intrudes into patient’s privacy, and prevents clinicians from protecting their patients’ privacy. It also has tried hard and sometimes succeeded in squeezing clinicians empty, trying to force out their humanistic, empathic sensibilities, to remove their basic philosophies and beliefs from their clinical souls and replace them with a belief in their own simplistic, superficial, rote, mechanical forms of treatment. Feeling that MC is stomping on their values and beliefs, many patients and clinicians have expressed their sense of helplessness and rage.
So, what kind of people are these who continue to hurt others so badly despite the protest of so many? The problem with the corporate chiefs, the rigid scientists and many policy-makers, lawmakers, and bureaucrats has to do with their character structure. To understand this perspective, I turn to psychoanalyst Erich Fromm.
I do think that the battle between us and the MC industry, the rigid scientists, and the bureaucracies and philosophies that support and encourage MC, even mandate it legislatively, it is a battle between good and evil, between what Erich Fromm would identify as life-furthering forces and life-thwarting forces. Many of those who seek power over other peoples’ lives tend to squash freedom, aliveness, and humanness; they squash loving and empathic caring; and they squash complex reflection and thought. Many of our educators are as much a threat because they cannot trust anything other than what seems like objective fact. Very few programs still teach students to look under the surface and inside a person’s heart, mind, and soul.
Fromm’s ideas, more than those of anyone I have read, explain the destructiveness of many of those who gravitate toward MC, to the corporate world, and governmental bureaucracies, and to the more rigid sciences. Fromm’s theories on character structure and his descriptions of the effects of industrialization on the psyche are crucial to understanding the impact of the “industrialization of health care” on both patients and practitioners (Fromm, 1947, 1955, 1964, 1973).
Fromm believed that we all seek solutions to our existential needs—our needs for relatedness, union, stimulation, effectiveness, and so on. As we seek solutions to these needs, if our environment is life-furthering, we tend to develop the biophilous passions of love; tenderness; a striving for justice, independence and truth; and the desire to grow and unify things and to further life. The person with a biophilous character, Fromm wrote, loves adventure and spontaneity more than certainty. He sees the whole rather than only the parts. He wants to mold and influence by love, reason, and example. Psychoanalysis is a life-furthering endeavor for both patients and their analysts.
If, however, life-furthering solutions to our existential needs are thwarted, we are likely to develop the malignant character-rooted passions of hate, greed, jealousy, envy, vanity, ambition, cruelty, evil, sadism, masochism, destructiveness, and narcissism. We might develop a sadistic character, which involves a desire to influence by force and control, or a necrophilic character in which we have a desire to tear things apart, a desire to bring living things to a stop, and/or an attraction to all that is dying, decayed, or dead. Fromm included in the necrophilic character-rooted passions the attraction to all that is technical and mechanical rather than what is alive. Necrophilic characters favor certainty and tend to control through bureaucratic methods, numbers, and statistics, by administering people as if they were things. Fromm clearly defined these malevolent character-rooted passions as evil.
I see the struggle with MC, policy-makers, bureaucrats, and the rigid scientists
as a struggle of good vs. evil. I
am not so naïve as to think that we are all solely good and they solely evil.
We are all a mixture of both. However,
it does seem that those who have a larger quantity of necrophilous passions are
too frequently the ones who seek positions of control over others, whereas those
who try to further life on a one-to-one basis are not as interested in power and
control over others.
Fromm said that those with a sadistic character would be essentially harmless without access to positions of influence. In health care before MC, the number of people these folks could hurt was limited. Now, through the MC organizational system, they have the opportunity to hurt tens of thousands, even millions, of patients and professionals. There has to be coldness and hate in their hearts to knowingly hurt so many people.
Hannah Arendt, in Eichmann in Jerusalem: the Banality of Evil, said that the trouble with Eichmann was that so many were like him and the many were neither perverted nor sadistic, but terribly and terrifyingly normal. Erich Fromm said that if you look for horns, you will not spot the evil man. These words were written as warnings.
Our training programs must stop “training students for the marketplace” and return to training them to meet the real and complex needs of the real and complex people who will seek help. In addition, we must prevail over the scientists in our professional communities whose focus is too narrow to measure that which makes us truly human. The need to end MC is still very present. The goal of a health care system should be to ensure that the United States is a mentally and physically healthy nation. An industrial, authoritarian system using a narrow science cannot achieve this.
Regulation of MC is not enough, for MC is run by bullies, by people who knowingly control and hurt others for their own gain and who often take pleasure in doing so. We cannot simply regulate bullies and let them stay in power hoping they will act honorably. Bullying is in their character structure and they will always tend toward bullying whenever they think they can get away with it. In addition, there is the problem of the many others who are not bullies, who are well meaning, but who still have great influence and power over health care, who still harm those under their power. This refers to the narrowly focused scientists, bureaucrats, legislators and policy-makers, and even many of those who work in MC companies. Many of these folks mean to do good things, but because their attraction is to the technical and mechanical, to numbers, statistics, deadening rules, etc., they end up destroying good things and hurting others because they characterologically lack the sense of empathy needed to truly understand the more subjective needs of those whom they affect.
Freud, S. (1911). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides). Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 12, pp. 3-82. London: The Hogarth Press.
Fromm, E. (1947). Man for himself. Greenwich, CT: Fawcett Premier.
Fromm, E. (1955). The sane society. New York: Ballantine Books/Fawcett Premier.
Fromm, E. (1964). The heart of man. New York: Harper & Row.
Fromm, E. (1973). The anatomy of human destructiveness. New York: Fawcett Crest.
Niederland, W. G. (1960). Schreber’s father. Journal of the American Psychoanalytic Association, 8, 492-499.
Niederland, W. G. (1968). Schreber and Flechsig. Journal of the American Psychoanalytic Association, 16, 740-748.
Niederland, W. G. (1974). The Schreber case: Psychoanalytic profile of a paranoid personality. New York: Quadrangle.
Shengold, L. (1989). Soul murder: The effects of childhood abuse and deprivation. New Haven: Yale University Press.
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