By Allan Scholom
My intention in writing this piece is to contribute to an emerging view that psychoanalysis offers a methodology and a morality that can and should be directed toward the understanding of how individual dynamics and social forces interact. The history of psychoanalysis has been saturated with a splitting off of the personal from the societal. This began with Freud who in his early years believed it was necessary for the survival of the psychoanalytic movement. But whereas Freud changed his perspective later in his life we have only in recent years begun to try to connect the individual to the social. Among the consequences of this splitting have been a marginalization of psychoanalysis both professionally in our practice and theory as well as in our relevance to the world our patients live in (Tolleson, 2009).
In the spirit of healing the split, I will take up the Affordable Care Act and two of its actors – Barack Obama the star, and the American Psychological Association as a supporting actor. My purpose is to elucidate the connections between the societal, personal and community from a psychoanalytic perspective. In doing so, we can offer a more comprehensive perspective as to what is happening in the world that might then lead to more effective action, much like a good interpretation.
With the passage of the Affordable Care Act in 2010 the battle between Democrats and Republicans has centered on the role of big government in health care. Fears that “big brother” is exerting ever more control over our lives dominate the scene as demonizing or defending the Act continues to unfold. In reality, the Act represents a capitulation by both parties to the continuation of a fundamentally market based solution to the problem of universal coverage, quality healthcare and cost containment. A senior Bush administration official responsible for driving the Medicare drug bill through Congress in 2003 recently assured a group of investment managers that “(Obamacare) is not a government takeover of medicine. It is the privatization of health care” (Davidson, 2013).
As such, the current system remains essentially the same one ranked worst in the world among developed countries (Davis, Stremikis & Squires, 2014). Americans suffer poorer health and these outcomes are getting worse since the 1970’s (Woolf & Aron, 2013) in almost all categories compared with citizens of every other industrialized country. The US is ranked 70th out of 132 nations worldwide in health and wellness (Porter & Stern, 2014). This is despite the fact that the US spends more than twice as much in GDP and per capita health care costs as nations with single payer or non-market based systems. In reality, Americans get fewer services, including outpatient visits, hospital days and surgeries, for far greater cost with far worse results.
How can this be? In essence, it is the costs of the for profit/market based system that are responsible. These include administrative costs (about 30% going to the health insurance industry versus less than 5% for Medicare), excessive profit (due largely to drugs costing more than twice what other countries pay), and profit unrelated to health care service delivery (for stockholders, advertising and marketing, debt repayment from mergers and acquisitions and executive compensation). The bottom line is that in health care, the market does not work effectively. Nor does it work humanely, as health care is a privilege of wealth and not a right for all. Thus, the market IS the problem, which is reflected in exorbitant profits for many corporations not directly providing health care services (Scholom, 1997, 2013).
Under the ACA, many millions more people will get coverage (10 to 20 depending upon who is doing the estimating) which, to be sure, is a positive step. However tens of millions will remain uninsured and many, if not most, will become increasingly underinsured (the new normal). “Malinsurance,” as in insurance so limited that it compromises our physical and economic health, will vastly rise (Gaffney, 2014). Quality of care will increasingly depend upon financial resources and costs will continue to escalate well beyond inflation. Americans will be spending more on healthcare (premiums and out of pocket costs will rise to an estimated 37% this year) as our incomes continue to deteriorate and economic inequality grows. At root, this amounts to cost shifting, with average citizens paying more so corporations can increasingly profit. There is no evidence that anything in the ACA will stop, much less reverse, this direction.
While 75% of Americans believe the US healthcare system requires fundamental change (Davis, Stremikis, & Squires, 2014), the public debate centers on the role of big government and not the limits of the market. How is this so despite these facts? Put another way, how is it that we continue to act against our own best interests by allowing to remain in place a system that is harmful to us? The situation is not unlike one we see as practitioners when a patient arrives at our office knowing something is wrong with her/his life but having little to no awareness of what the real problems may be. We are charged with helping our patients look more deeply into their struggles to facilitate understanding and acting on their own behalf.
Herein lies the potential for the psychoanalytic approach to aid in our understanding the connection of the individual to her/his social world. Lynne Layton (2006) has called attention to the unconscious pull to dissociate individuals from their social milieu in the US. In seeking to comprehend this unconscious pull in the health care context, it is important to consider the mythologies concerning big government and the free market and to elucidate the fantasies that permit such myths to go unchallenged.
Regarding big government, the actual size of the government or spending by the government has not changed appreciably over our recent history. This has been the case whether Republicans or Democrats were in power. What varies are the directions one party takes in contrast to the other regarding how resources are to be used and what laws are passed that direct our lives. For instance, when Republicans (generally seen as against big government) push to control women’s choice or marital freedom, or determine what children are taught and tested on in school, or decide who can vote, they use big government for their own ends.
Concerning the free market, this too is dependent on the rules made that determine the direction the market may take. For example, when the rules allowing banks to consolidate banking and commercial activities were changed under a Democrat (generally seen as more protective of individuals and the environment against the excesses of the market), the stage was set for the economic crisis of 2008. Similarly when the various free trade agreements starting in the 1990’s were written favoring corporations without sufficient labor or environmental protections, jobs were lost and the environment degraded.
I cite these examples to illustrate that there is no such thing as “big government” or the “free market.” Rather, these are myths that serve to confuse and mystify the public such that it cannot see its own self-interest. Big government and the free market become potent oversimplifications, illusions or mythologies, used by both parties to manipulate the public for political ends. This largely is to preserve their own influence, the status of which is vastly dependent upon serving the interests of those who provide the financial resources necessary to gain power.
From a psychoanalytic perspective, we can endeavor to explicate the underlying fantasies these myths speak to. As to big government, concerns about the dangers of dependency are foremost. We might remind ourselves how we typically face patients who are afraid of close relationships (for understandable historical reasons) such that being influenced by others can become threatening or coercive. Many may seek the illusion of independence or self-reliance as a potential solution. This may find some expression in an idealization of the free market as an embodiment of individualism and safety, free of external threat. Of course, the opposite may be true in that some people may seek to be overly dependent so as to avoid the perils of separation/individuation.
To be sure, I am oversimplifying, as the fantasies around independence and dependence underlying the myths of “big government” and the “free market” can take myriad forms in the same person and certainly in a collective sense as well. My point is not to map, in some one to one fashion, how a given person or group may travel from fantasy to mythology and back, but rather to illustrate that there do exist fantasies that make us vulnerable to political mystification. Furthermore, we in the psychoanalytic world are uniquely positioned to help with the demystification on an individual and collective level.
Let us turn to the role of Barack Obama, undoubtedly the star actor in the creation and passage of the ACA to examine how his personality dynamics may have contributed to the bill. I do this not to assign undue responsibility either on him individually or on the numerous other actors in the story but rather to draw attention to the unconscious forces that are at play in significant ways. If we are to understand and act with clarity in the social realm, these dynamics are important to be aware of. Certainly, any president will be an object for all manner of projection and transference. For Obama, supporters on the left express disappointment that he has not done more, while those on the right see him as doing too much, an embodiment of big government.
Let us look at Barack Obama in his own terms and examine the difference between what he has said and what he has done using health care as a case in point. Were he a patient of ours, we would tend to look at this as a measure of conflict, ambivalence or splitting. Obama, in his early political career, was a single payer (enhanced Medicare for all) supporter (Holan, 2009). He viewed this approach, used by all the other countries ahead of the US in access, outcome and cost containment as the best way to achieve universal coverage. Further, even during the debate over the Act, he indicated that a single payer solution would be the best way to reach these goals. However, he never put the enhanced Medicare for all option on the table, not even to stake out a negotiating position. This stance is despite the fact polls continually indicating a significant majority of Americans (60-70%) are supportive of such a system (McCanne, 2015).
Instead, he embraced the Romney plan established in Massachusetts, which was developed by the health insurance industry in order to solidify its own position. He did this despite the fact that the industry itself is largely responsible for the costliness of our current system (as they constitute an expensive middle man providing no necessary benefit to the provision of health care). The last straw, of course, was the abandonment of the “public option”, which would have been the more cost effective and comprehensive approach.
Even those in the health insurance industry acknowledged this point, but argued that the government plan would be unfair to the private sector precisely because it would be a superior solution. This extraordinary anti free market argument prevailed despite the fact that entities that do a better job at lower cost are supposed to win! Since single payer or a public option would have been better solutions we can surmise that the exploitation of conscious and unconscious fears embodied in the big government myth of controlling peoples lives played a major role.
To return to the hypothetical Obama as patient, we might wonder why he gave in before the battle began and later during it. Lest we see this as an isolated issue, we could point to what he has done on numerous other issues not subject to Republican control. For example we can cite his: failure to prosecute bankers for their role in the 2008 economic crisis, while continuing to bail out the banks; increasing militarization by sending more troops to Afghanistan and significantly stepping up drone attacks; deporting more immigrants and prosecuting more whistle blowers by far than any other president, while increasing spying on the public; rejecting climate control treaties other countries have put forward while negotiating more free trade treaties without adequate labor or environmental protections; and so on. All of this is despite his speaking out on behalf of economic justice, decreased militarism, civil liberties, immigration reform, climate control and so forth. I cite these examples as evidence to illustrate the extent of his splitting or conflict –being of two minds without one.
Were we to analyze why our patient was unable to stand up for what he says he believes (along with hurting himself in the botched roll out of the health insurance exchanges,) we ought consider the difficulties in his history. To begin, he is the bi-racial child of a white mother, who twice abandoned him when he was 10 and 14, and an absent father. From that point on, he was raised by white grandparents. Referring to his race as a teen, he “wondered if something was wrong with me”. At the time of his father’s death Obama said “my father remained a myth to me, both more and less than a man” (Barack Obama, 2015).
We might hypothesize about his need to bring people together despite it being impossible, as is often the case in the political arena (and of course in the personal realm as well). From another vantage point we might consider this as a conflict between ideals and actions, as his powerful eloquence and intelligence is often not matched by a capacity to follow through. His extraordinary drive and ambition may lead him to identify with and idealize those who have made it (whether economically, politically or racially). In so doing, he splits off painful feelings related to the rejection and unmet needs of childhood. All of the above make it difficult for him to stand up to the powerful forces that dominate the political landscape, as in health care. Sadly, this speaks to Cornell West ‘s contention (2014) that “he lacks backbone”.
Certainly, I do not say this to offer some definitive analysis but rather to illustrate that Barack Obama, like the rest of us, brings personal history to the table that has significant implications. This background plays a role that can and ought be understood in the sociopolitical realm. Herein we can make a substantial contribution.
Lastly, let us come closer to our professional home and take up the role of the American Psychological Association (APA). While the APA was certainly not a major player in the passage of the ACA, it is important to look at its participation as one of many supporting actors. We might see this as the place of our community in contributing to the ACA and moreover how societal realities become constructed and maintained at this level. First of all, we ought bear in mind that the APA is an organization made up of diverse constituencies. Secondly, the APA is a bureaucracy with all that this entails, including its own preservation. All professional associations have been authorized by the government for the purpose of organizing and policing themselves in carrying out their public responsibilities. As such, they are subject to governmental pressures. In appreciating this, we are better able to understand the APA’s avoidance of taking controversial public positions.
For example, in light of the money and membership that come from the military, the APA has avoided taking a stand against torture. Furthermore, in the last decades, all of the professional mental health organizations have offered little opposition to the fact that total health care spending nearly doubled from 1986 to 2009 while mental health funding remained about the same (Rampell, 2013). In essence mental health funding has been cut in half since 1986 relative to all health care spending, a direction spearheaded by the insurance industry and government. In this context, APA has kept very much in line with and reactive to current political and economic forces.
The ACA seeks to restrain cost by pushing people into Accountable Care Organizations, which are virtually the same as HMO’s. This is a re-trying of the failed capitation model of the 1990’s that shifts financial risk onto practitioners such that the incentive is to provide less service under the guise of “accountability” (essentially code for austerity or most people getting less). Since Americans do not get more services (in fact generally less, but do pay more for those they get) compared to other countries, the current fee for service system is not the problem. Thus, patients are paying increasingly more for services and practitioners are being paid less so that the insurance and drug industries, among others, can continue to profit. As previously stated the free market is the problem in health care – too many entities making too much money while contributing little or nothing to delivering services.
The role of the APA comes into play here under the banner of “accountability” with so called “evidenced based practice” (and “practice guidelines”). I am referring here to how science can be misused for political and economic purposes (Hoffman, 2009). In this case what is at issue is how EBP functions as code and rationale for more limited service (people getting less or austerity), usually seen as being embodied by cognitive behavioral therapy. Thus, the APA and large numbers of psychologists actively participate via EBP in what is currently being pushed by the ACA, which undermines longer-term, depth oriented approaches in particular. It’s no surprise then that the health insurance industry, which has been driving the severe curtailment of mental health services over the last 30 years, played a major role in the development of the ACA.
Psychotherapy before the EBP movement was already among the most research supported of all health care treatments. Yet, an important implication of the EBP mentality is that the effectiveness of psychotherapy, including longer-term treatment, is somehow not yet well established. This undermines what has already been done, leaving the playing field to short term double blind studies. One result is the ongoing marginalization/elimination of psychoanalysis from curricula and training programs.
This is not the path that those of us committed to depth psychotherapy and humanistic values would take, whatever divisions we belong to or professional affiliations we might have. We would oppose the movement toward commodified, manualized and minimized approaches to mental health care, or living for that matter. We would stand for subjectivity and personal freedom as opposed to objectification and adaptation.
In fact, we would support Barack Obama, our hypothetical patient, in standing up for the values and positions he speaks of rather than surrender to market forces. Similarly, we would want the APA and all in the mental health world to more actively resist efforts to reduce human suffering to what the market profiteers are willing to pay for. Ought not our professional organizations fight more vigorously against the insurance industry, whose creation of the term “ medical necessity” (the vehicle through which the surveillance and control system known as managed care functions) is used to determine what gets paid for, thereby ensuring their profit? Ought not patients and practitioners decide what is “medically necessary?”
All professionals, and in particular those of us in the psychoanalytic world, are left vulnerable to practicing outside the narrow realm of what is called EBP and practice guidelines. The specter and reality of treatment denials, audits and lawsuits follow from the involvement of the APA and many of its members in providing justification via EBP for the health insurance industry to limit service and increase profit (Walls & Scholom, 1996). More broadly, this further permits the domination of a market based ACA to continue to enhance the very system that excludes so many and limits what so many more could and should get.
To illustrate another aspect of APA’s approach, its own EBP guidelines (APA, 2006) include three criteria for judging whether a ”treatment “ is sufficient to be called evidenced-based: research support, therapist expertise, and patient characteristics. Nevertheless, the latter two are not generally addressed when a treatment is called evidenced-based by researchers, policy makers or health insurance companies. While the APA strongly endorses EBP, there is no designated body responsible for determining whether a treatment can be called evidenced-based. This would necessitate including these two crucial criteria when a treatment is said to be evidenced-based. Could manualized treatment ever constitute therapist expertise?
On a final note from a personal vantage point, I hope I have some realistic perspective as to what I or we can do to make the world a better place. For the last 35 years or so I have been trying to make sense of things from this personal–social point of view and live with this in mind. In working with patients, students and colleagues or within organizations and in politics, it has been heartening to find so many open to taking in this perspective and taking up the cause. When we in the psychoanalytic world push for change, we are far better positioned as allies with our fellow citizens when we are guided by our own values and commitments, whether we work inside or outside of the APA. By using our expertise to analyze on the individual and social level, we can make ourselves increasingly relevant in the struggle for constructive social change. By standing for the health and well being of all Americans, psychoanalysis might then be viewed as the force for human freedom it can be. We have been reluctant to take the power of psychoanalysis into the wider world. We can change course by using more broadly the perspective, method and values we share and make an important contribution to the kind of society we want. This is after all, all we can do.