I consider myself lucky because my practice has changed for the better, in spite of everything I hear about my colleagues' troubles with managed care. It is better because my patients either have broad coverage insurance or pay out of pocket, so I don't have to deal with 'case-managers'. Some of my patients actually prefer to pay out of pocket because they don't want their names on computers, in order to protect their confidentiality. I am fortunate to live in Grosse Pointe, Michigan, a lovely Detroit suburb and practice out of my own home, so I don't have to commute or pay rent. Half of my expenses are legitimately tax-deductible.
But the finances and the convenience of not commuting are the least of it. I finally have a practice of highly-functioning, successful people, without any borderlines. Therefore, my analytic group is sophisticated and hardworking, dealing with unique and classic issues in the old-fashioned way of free-associating, analyzing the transference and resistance, and working-through the unconscious complexes.
This process of change has been developmental and transpired across nearly four decades. It can be best described by taking each decade, one by one:
The Sixties:
This decade was the end of my residency and the beginning of my full-time faculty teaching, my part-time private practice and the onset of my personal analysis. I cut my psychoanalytic teeth on intensive work with a severely disturbed schizophrenic, utilizing the theory and technique of H.S. Sullivan, Frieda Fromm-Reichman, Harold Searles, Otto Will and Silvano Arieti. This afforded me invaluable experience with the primitive magic and poetry of the primary process and a knowledge of the ravages of early trauma combined with genetic predisposition. At the same time I observed the full extent of human self-destructiveness and irrationality. After many years of inpatient hospitalization, the patient recovered her creative functioning despite the fact that she was given a nil prognosis by many seasoned experts. The fact of her recovery gave me a confidence in psychoanalytic theory and practice which enabled further successful work with psychotics and borderlines. She was a well-known case and so I was referred many other 'difficult cases'.
The sixties was also famous for the Detroit riots, the sexual revolution, drugs and anti-authoritarianism. Interviewing the victims on the street, I could see they had the same roots as the perpetrators, and questions were raised then which still do not have answers. There were also pressing questions about the depth of resistance to psychoanalysis, and so I also learned about bio-energetics, gestalt and encounter techniques, all within the framework of Freudian psychoanalytic theory. Studying with Alexander Lowen I learned the power and depth of character-analysis, according to Wilhelm Reich. The body-work was helpful to me personally and was incorporated into work with patients, in groups and individually. I became a Master Instructor in the Institutes of the American Group Psychotherapy Association, teaching body-work to other Master Instructors. There was a period of great enthusiasm and word of mouth brought referrals of patients with motivation for such work.
The Seventies:
The seventies were a continuation of eclecticism, with transactional analysis and cognitive therapy having their hayday. Still, my practice had at its basis the classical Freudian conceptual structure. Some of my patients were in intensive therapy for over a decade, and were making continual incremental progress. My referrals were almost exclusively from former students, former patients and friends and relatives of patients and former patients. I gradually stopped using bioenergetic body-work as I found there was no therapeutic advantage over verbal therapy. However, I was more attuned to nonverbal cues, posture, breathing and grounding. There was a strong connection between breathing and depression. Almost invariably, depression, whether psychological or neurochemical, was associated with shallow breathing. It was obvious that useful interpretations were followed by a deep inspiration. My reputation for the successful treatment of refractory depression came from a judicial combination of analytic therapy and anti-depressants. For the drugs to be effective, what was required was a compliant patient with insight and a positive transference.
The Eighties:
The eighties were a time of further consolidation--- of drive and object-relations theory, a refinement of technique and an attunement of perception. Many of my referrals were borderlines who had been hospitalized frequently or who received useless supportive psychotherapy and medications. When they were seen three times a week in psychoanalytic therapy, there was no further need for hospitalization. In fact, the tendency toward behavior that raised the question of hospitalization, was shown to be resistance. The threat of suicide was interpreted as an attempt to avoid the next therapy session. The analytic groups were cohesive and longterm and provided an arena for multiple family transferences. The combination of individual and group analysis was invaluable for working through character-resistances and neuroses.
The Nineties:
A few of my patients switched to managed care providers and I had several experiences of reporting to case managers who disputed my theory and technique. It was clear they were young and unsophisticated, and their job was to cut costs. One in particular was sophisticated and enabled continuation of longterm, intensive psychoanalytical work, but that was the exception. I refused to talk to those who were intransigent, and one patient who was significantly improved chose to leave therapy, while most others preferred to pay out of pocket. Another patient successfully challenged the restrictions of her new managed care plan by threatening litigation and compiling expert witnesses who attested to 'medical necessity' of her longerm, intensive psychotherapy. In this creative process she learned to redirect her destructive anger in a positive direction.
I was confident that I could weather the managed care storm, but a few years ago, for the first time, my practice dwindled to half and I had to consider that this was my fate. I started writing articles for the Grosse Pointe News and conducted workshops locally on parenting and creativity. This PR did not bring in more referrals. But recently, my old sources spontaneously revived and I am happy working thirty hours a week with interesting patients.
These are patients that some call "the worried well", but having worked with both the rich and the poor, I find that the rich and successful can be every bit as miserable as anyone mired in poverty. The diagnostic classifications and the human condition cuts across intellectual and socio-economic lines. Free-association reveals the commonality of the unconscious and the endless conflict between the id and superego, destructiveness and creativity, love and hate.
At this time in my life, I have just received my Medicare card and am prepared, like my mentor and role-model before me, to practice for at least another twenty years. From this perspective, my being a grandfather eight times over reminds me of the developmental vicissitudes of infancy and early childhood. At the same time, I am treating the nineteen year old son of a former patient I treated for twenty three years. In many ways I see history repeating itself, but with an early analysis, there is a better chance for repair and optimal development.
And speaking of optimal development, I cannot help but realize that my own analysis, and that of my children, led to their respective optimal developments, and their being ideal parents. And one of my present patients, in addition to improving his business and family relationships, has improved his golf game to the point where in his midlife, he is winning tournaments and trophies again. For those in the know, golf is a microcosm of life and a philosophy, and the pastime should not be scorned. He always felt that however talented he was, he was not living up to his potential, and now he is beginning to think he might be. And it just so happens that his business success is inversely proportional to his golf score, as the two are inextricably entwined.
After the Millenium:
After the millenium I look forward to many more satisfying years of doing combined analysis, individual and group, confident that my source of referrals will not be dwindling as long as I am happy and successful in my work. I can say without hesitation that psychoanalysis is a rare and unique calling, and that the satisfactions run deep.
Victor Bloom, M.D. is Clinical Associate Professor, Department of Psychiatry, Wayne State University School of Medicine. He is in private practice out of his home in Grosse Pointe Park, Michigan
1007 Three Mile Drive
Grosse Pointe Park MI 48230
(313) 882-8640
e-mail: vbloom@comcast.net