Sunday, September 18, 2011

The Ethics of Palliative Psychotherapy

Michael Kahn, a psychiatrist at the Beth Israel Deaconess Medical Center in Boston, has an excellent short article on "Palliative Psychotherapy" in the September American Journal of Psychiatry.

Here's how the article starts:
After hearing my doubts about whether I had done anything to help a middle-aged, talented, but characterologically difficult patient lead even a marginally better life, a trusted colleague said, "I think you made his existence a little less lonely and painful."
The conversation with his colleague led Dr. Kahn to these reflections: treatment could be thought of as palliative psychotherapy. After all, I had provided comfort, if not cure. I had avoided inflicting harm. I had provided some humor and perspective for a life chronically lacking in both. I had helped a habitually poor problem solver to solve many basic problems. I had even met with several of his family members. What if fundamentally altering his many decades' worth of maladaptive coping was beyond my skills, and perhaps anyone's?
Dr. Kahn is on to something important!

Palliative care - which focuses on improving quality of life for people with serious ailments - is increasingly recognized in circumstances like heart failure, cancer, and other chronic conditions. But it's a newer concept for psychiatry.

Dr. Kahn identifies the major objection to applying the concept of palliation to his patient's treatment - "it [may] represent a fancy way of defining expectations downward and rationalizing failure."

This definitely happens, often in the form of blaming the patient for resistance to making changes rather than blaming ourselves for conducting an ineffective treatment.

I learned a valuable lesson about palliative care early in my practice. I was seeing a man in late middle age who had suffered from a major psychiatric ailment for all of his adult life. His wife often joined the meetings. I cast about for ways of making things better, but was feeling guilty for not being helpful.

At that point I wrote for tickets to a cultural event. (This was in the pre web era.) The tickets came with this letter:
Dear Dr. Sabin

This event was sold out. But when I saw who the request was from I managed to find two tickets. You've been such a wonderful doctor for my parents that I wanted to say "thank you."
Without knowing it I was doing palliative psychotherapy, but I was asking myself to bring about a definitive "cure." My patient and his wife knew that this, alas, was not in the cards. They responded to the fact that I liked and respected them, and took the issue of their happiness in life seriously.

In my eyes I was a flop. In their adult child's eyes I was doing a great job.

As Dr. Kahn points out, making a differential diagnosis between which aspects of our psyches are susceptible to change and which appear to be "hard wired" is difficult. An error in either direction can be harmful. Unwarranted pessimism can deprive our patients of potential improvement. But unwarranted optimism about the capacity for change can also cause harm.

I learned this lesson vividly with another patient. We began the treatment with great optimism about "cure." It took us both several years to recognize that what had looked like a problem of adolescent development actually represented a very serious psychiatric condition. My effort to "cure" the condition via psychoanalytic psychotherapy actually made things worse. When this finally became clear I said - "I won't be your therapist any more, but I'm happy to counsel you on how to manage your ailment. If you had diabetes we wouldn't expect psychoanalytic psychotherapy to make it go away, and the same applies to the condition we're dealing with." I haven't seen this patient for years, but we still exchange letters in which I offer coaching and support.

Given the need to constrain health care costs, how should insurance deal with palliative psychotherapy? In my view, the health system gets this question wrong in both directions.

Often insurance coverage for mental health services requires an expectation of substantial improvement within a limited time period. As a criterion, that's too rigid.

Here, for example, are excerpts from the CIGNA guidelines for outpatient therapy:
The treatment plan should include clearly defined, realistic, and achievable goals and discharge criteria, with specific timelines for expected completion.

Treatment is [not] primarily supportive in nature.
For patients like the person Dr. Kahn describes, it would be easy for the insurer to conclude that the treatment is "primarily supportive" and lacks "achievable goals" with "specific timelines."

But as occurs so hilariously in Woody Allen films, it's possible for therapy to degenerate into an unending process that is sometimes disparaged as "rent-a-friend." This form of pseudo therapy should not be paid for by insurance funds.

In my experience, monitoring the value of therapy is best done by a collegial group that cares for a population within a budget. Rather than depending on a third party to judge the value of the therapeutic process via telephone review, clinicians manage themselves within the limits set by a budget. This is the framework Kevin Grumbach and Tom Bodenheimer argued for in their brilliant 1990 article "Reins or Fences: A Physician's View of Cost Containment."

I experienced what Grumbach and Bodenheimer described in my years of practice with the not for profit Harvard Community Health Plan HMO. We had a population of patients to care for and a budget that came from the premiums we received for them. In the mental health department we set expectations for how many new patients we would take on, but were free to manage our own practices. With patients whose needs were palliative we would seek the most efficient ways of meeting their needs, as by using groups and referral to community supports.

Between (a) the "fence" created by an overall budget, (b) ethical commitment to our patients' welfare, and (c) the freedom to innovate created by a payment system not based on counting widgets, (d) palliation could be part of what we offered without breaking the bank.

These are the values the much beleaguered health reform law is trying to advance. Too bad it's in the cross hairs of a political system currently run amok!

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