Wednesday, November 11, 2009

The Three Stooges of the Mind

If you sit still and try to clear your mind, as in meditation, one of the first things you’ll notice is how quickly you start judging your experience and yourself. This is boring. My back hurts. I must not be doing this right. Meditation isn’t for me. This is the voice of your judging mind, your Inner Critic. All of us have one. The voice is a product of stress, of the need we feel to classify our experiences quickly into simple categories without experiencing them too deeply—so we can quickly move on to the next thing stressing us. When we’re scared or anxious, that Critic is most active, putting down your friends and loved ones, your accomplishments, and yourself. It’s the voice that gives you a disproportionate share of the blame when things go wrong. It’s the voice that makes mountains out of molehills. What’s wrong with you? There’s nothing to be scared of, don’t be such a baby! Why haven’t you started exercising yet? You can’t stick to anything! Sound familiar? It’s something most of us hear whenever we’re feeling stressed. Automatic judging like this your frontal lobe, the “higher” mental center, trying desperately to hold on to control, while you’re trying to clear your mind. Most of us, when we’re unhappy, are caught between that Inner Critic and another part of the self that is busy defending ourselves. I call it the Timid Defender. It wants to silence the Critic, but it can’t, because it uses the usual habits of the mind—denial, rationalization, dissociation. Alcohol and drugs. Shopping and overeating. It has us trying to escape or forget about the Critic, but that only works for a little while, because while we’re escaping or forgetting, we’re giving the Critic more ammunition. You idiot, pretending to be something you're not. Trying to drown your sorrows. You can’t get rid of me that easily! The critic and the defender are both sealed up together in the same little tuna fish can, and they’re not even trying to get out, they’re so preoccupied with each other. When we’re bouncing around between the Inner Critic and the Timid Defender, who’s at the controls? Who’s running our lives, making our decisions? It’s like we have the Three Stooges up in our heads. Moe the brutal sadist, torturing us while the ineffectual Larry whines pathetic excuses. Curly, the id in this metaphor, full of appetites and drives, causes all the trouble in the first place. Nobody’s in charge of our lives, and the plane is yawing and swooping all over the sky, never getting anywhere and always in danger of crashing. And this is how unhappiness persists. We blame ourselves far too much, and make ourselves more miserable. Then we defend ourselves ineffectively, and perpetuate a vicious circle. We have to try something radically different. That’s what therapy does. I don’t turn off the Inner Critic and I don’t strengthen that Defender for my patients; instead, I help people detach from this struggle. That’s what mindfulness does too. A good friend of mine uses the phrase compassionate curiosity to describe the ideal therapist’s attitude toward the patient. We begin therapy with a much more compassionate, kind, understanding stance toward the patient and his problems than the patient has himself. And we are curious, in a calm, unafraid way—we want to understand how things got to be so bad, and we assume that by fearlessly facing reality we will help the patient find relief from his distress. Compassionate curiosity is the attitude most of us, depressed or not, need to apply to ourselves as well. What a change that would be for almost everyone I know! That battle between the Inner Critic and the Timid Defender is much like the way inconsistent parents treat their children. When the Defender is in charge we indulge and spoil ourselves; we let ourselves off the moral hook, we make promises to ourselves we know we won't keep. But that Inner Critic is still there, waiting for our defenses to slip—as they always do—ready to condemn us, always finding that we don't measure up. We vacillate between spoiling ourselves and punishing ourselves. And, as with children who are raised that way, we end up frightened and traumatized, with no self-esteem and a lot of self-hate. Compassion replaces all that with patience, gentleness, love, grace, mercy, concern. It suggests giving up judging and replacing it with empathy, a willingness to face the truth and all your feelings about it, without fear but with confident strength. Curiosity suggests a little cool detachment from the emotional heat, a desire to understand objectively why we feel what we feel, why we do what we do—especially when it’s troublesome or self-defeating. Why did I get angry just then? What’s making me so blue today? We look at ourselves, not to torture ourselves, not to give ammunition to the Critic, not with desperation for a quick fix, but with compassion, sincere interest, and the belief that there are answers that make sense. No matter how nonsensical our behavior, no matter how odd our feelings, there are always reasons—and knowing the truth will help set us free. We look a little deeper than usual, with more objectivity, and we don’t just slap ourselves on the wrist and make an empty promise to do better next time. Why? What’s bothering me? Why am I afraid to look? We understand that our feelings are just human; they won’t destroy us or drive us crazy. Most likely, they are tapping on our shoulder, trying to tell us something important.

Sunday, November 1, 2009

Mental Health and Healthcare Reform

Now that it looks like some form of health care reform will be passed this year—barring a catastrophe like Joe Lieberman—we have some idea of how the eventual act will affect mental health services. All of the plans now under consideration will mean some real improvements for mental health consumers, and there doesn’t seem much likelihood of these improvements being cut out before passage. However, it appears that individuals and employers will still have to purchase their insurance from private insurance companies, without competition from a strong public option like Medicare available for everyone. Nevertheless, the “reform” aspect of the bill would require private insurers to make some real changes in how they treat mental health issues. Here are the key benefits:

· “Parity” for mental health and substance abuse services. As it is now, when you see a mental health provider, your insurance company will probably pay him or her less for your visit than they would pay your GP or specialist for a similar service. They might require a higher copay from you for a mental health service than a GP visit. They might limit your total annual or lifetime benefits for mental health services. For instance, I have many chronic depression clients who need year-round supportive therapy, but their annual benefits run out in August or September. Most patients have to pay me a $30 or $40 copay from their own pockets, rather than the $10 or $15 that their GP charges. With a reform bill, private insurers would have to end these practices. That will make it much more possible for patients to receive the care they need without added expense. It will also make it possible for patients who need medication to see a specialist, and not have to rely on the family doctor to prescribe medications he’s not really expert at. Eventually, it may lead to more practitioners entering mental health, a real benefit because credentialed providers are in short supply.

· No discrimination based on pre-existing conditions. The fact that insurers currently can, and do, refuse to insure you for pre-existing conditions is one of the major factors that keeps consumers tied to their jobs. It also forces them to contort themselves anxiously through COBRA plans and sensitive negotiations with their employers to stay on their old plan. And of course the old plan is currently still free to let you go, cap your benefits, or charge you a higher rate for those pre-existing conditions. This doesn’t hurt only mental health consumers, of course, but also those with cancer, heart disease, diabetes, or any other chronic/recurring illness. The current policy thus causes a great deal of stress for many, many consumers, which hopefully will be greatly eased by the new legislation.

· No rate changes based on health status. With reform, insurers will no longer be able to raise your rates because you develop a chronic or expensive condition. All subscribers in the same age group will pay the same rate.

· Greater availability of insurance, at lower cost. Though the details haven’t been worked out yet, all the bills have as a major goal greater availability of insurance plans to individuals and to people who can’t afford healthcare now. Many people with mental health disorders like long-term depression are not able to sustain themselves in challenging or stressful jobs, resulting in poverty or underemployment. The current economic collapse and the fact that insurance rates keep rising more than twice as much as the general cost of living has put health insurance out of reach for many. Reform is meant to make insurance much more available.

· Expansion of Medicaid. Medicaid is the government-run healthcare plan available to the poor. It’s a program that works well, and though there are some problems they are nothing like the problems with private insurance. The bill would basically expand the definition of the poor to include more working-class, low-income families. The fact that so many households have parents working two or three part-time jobs, none of them providing private insurance, means that Medicaid expansion and the greater availability of low-cost private plans will take a tremendous worry off of working people’s backs.

These are all great steps forward, especially for everyone who sees a therapist or takes an antidepressant or other psychiatric medication—or needs to. However, the devil is always in the details. Here are some potential pitfalls I haven’t seen addressed in the reform plans.

· “Managed” care. Over the last twenty years, private insurers have added huge expenses to the cost of care by employing thousands of people whose sole job is to restrict benefits. For instance, many plans will only pay for a few counseling sessions before requiring the provider to file a form justifying continued treatment. This is sometimes referred to as “Mother may I” care. The insurer is free to make arbitrary decisions to change the treatment plan or limit the kind of care available to the patient. The army of bureaucrats employed to run managed care programs has provided a way for insurers to vastly add to the cost of care, in the name of controlling the cost. Obviously some form of management is necessary to prohibit greedy practitioners from overcharging and overprescribing, but I haven’t seen anything in the bills that would control or regulate this practice. This may lead to the point where some practitioners will not accept some plans because they require unnecessary hassle to pay legitimate claims. This is the case now in my geographic area, and doctors accept some plans and not others because of this. Consumers have no means of knowing about this practice, so they often choose a plan that none of their providers will accept. If there were some form of standardizing these practices, most providers would then accept all, making comprehensive health care much more accessible, and reducing insurance company’s overhead.

· No reform of drug industry practices. The pharmaceutical industry is no longer honest or reliable when their drugs are reviewed in academic journals. The FDA has been fooled regularly by tainted research. In work on depression, some highly respected researchers have taken drug industry payments under the table—as much as $500,000—to distort their findings in favor of a particular drug, or to support drug use in general. Your home-town psychiatrist can receive payments of $5- or $10,000 for adding their name to ghost-written research, and their prescribing habits can be monitored by drug companies, giving them a powerful incentive to prescribe a particular drug. I’m sure the same practices apply to drugs for other diseases. These developments are not addressed at all in this round of reform, and they should have been. They add tremendously to the cost of care, and they often result in patients not getting the best medication available.

· No real guarantees of reduced cost. There’s a long time between when a bill is passed and the actual practical guidelines are worked out. Given the influence of insurance and drug industry lobbying, there’s a lot of opportunity to find ways for costs to be passed on to consumers. I fear that whatever final bill is passed, it will lack the teeth to enforce some of the benefits we’ve described.

· No emphasis on preventive care. Relatively simple screening tools for depression, anxiety disorders, and other conditions are available and effective. If they were implemented routinely, a lot of pain and suffering would be alleviated and the overall cost of health care would decrease. Public attitudes about mental health issues need to change. The biggest obstacles to treatment remain the patient’s own self-blame and fear about what mental health services are like. Though there is some promise in some of the bills for services to address these needs, this is a soft area that remains vulnerable to misguided cost-cutting.

· Lack of a real public option. If there were some form of universal, government-administered plan like Medicare available to everyone, private insurers would need to compete with it—and Medicare is much more cost-effective than private insurance. Every other developed country in the world offers a government plan of some sort. All of them have their good points and bad points, which we could learn from. But Americans pay twice as much for health care as the next most expensive country (Belgium) and receive second-rate care. By most measures of public health, we rank well below the top ten of all countries. A good public option would change all this; our total healthcare expenses would drastically decline, resulting in a vastly improved economy. Employers would be spared the expense and administrative costs of providing care (we’re also the only country in the world that ties health insurance to employment).

I work with several Medicare patients. They don’t abuse services, but they take advantage of what’s available to them. Without Medicare, their depression would leave them withdrawn, isolated, unable to make the best decisions, and panicked about their future. And that’s exactly the state many depressed people are in right now—all those who lack insurance or have restricted care. I think we as a society are better than that.

SO—like most of life, it’s good news and bad news. The planned reforms should make health insurance cheaper and more available to everyone. Those who need mental health services will no longer be made to feel like second-class citizens because the care they need is more expensive and more restricted. Mental health consumers out-of-pocket expenses for their care should decline. People won’t have to worry so much about losing their insurance if they require expensive care or change jobs. People who don’t have insurance now will be able to get it more easily. But as it is now, reform leaves a lot to be desired. Private insurers will still play a central role, and their incentive is always to make a profit rather than provide the best care. You will have no guarantee that the doctor or therapist you want will accept your insurance plan. The drug industry will continue to drive up the cost and reduce the quality of care. Without a strong public option, there’s no real guarantee that our individual health care expenses will be greatly reduced. Still, we will probably see big steps in the right direction, which may gather enough support that the further reform we need will take place without such great resistance.