Through some combination of these methods, I manage to average around $95 per hour. Many doctoral-level professionals make more money than that. But, on the other hand, most people make far less for doing work that’s much harder than sitting still and listening to unhappy people. In return for the money I leave on the table, I receive some semblance of my integrity, I get spared the paperwork, and I get to explore an important subject that too often goes unexamined. Those conversations about my fee, in short, can be worth their weight in gold—and not only for me.
I once saw a woman who worked as an escort, the kind who charges men for the girlfriend experience. I challenged her choice of professions, and she responded by suggesting that our jobs weren’t all that different. Her hourly rate, she told me with some relish, was higher than mine (and speaking of sliding scales, when I discovered what her fee was, I raised mine to match it). The conversation forced the subject of money to the surface. It also gave us the chance to talk about the critical difference between us: that, among other things, she was paying me not to have sex with her. Most importantly, however, by bringing to light the disturbing fact that we were both in the business of renting out love, it forced us to pay attention to what exactly our relationship was about, why she had the need she did, and what she could do to make it possible to fulfill it without paying for the privilege.
Few people present us with this kind of built-in opportunity to explore the value and meaning of therapy. Indeed, to practice the diagnostic ritual, complaining and waxing ironic even as we cash the insurance company checks, is to lose the chance to scrutinize this crucial, if upsetting, aspect of what we do. When accountability is mediated through our (and our clients’) relationship with an insurance company, we’re both beholden to the corporation. We tend to notice this only when the corporation wants to know if it’s getting value for its money and asks for treatment reports, or tosses you off its panel, or insists on a psychiatric evaluation before it will approve any more sessions—at which point we may well respond with the victim’s indignation, rather than recognize this as the price we pay for letting the third party into the room. But we don’t ignore it when our clients repeatedly cancel appointments, show up late, or call us on the phone. Neither do we let our own lapses go unnoticed, or lose sight of exactly what the purpose of the therapy is—a question that money focuses wonderfully.
To diagnose people is to hide uncomfortable truths about what we do, why we do it, and how we get paid for it. We wouldn’t leave unchallenged evasions like the ones our diagnostic ritual affords us if our clients were committing them. So why would we continue to accept them in ourselves?
Should We Abandon Diagnosis?
There are a couple of reasons to think that diagnosis is worth preserving. The first is that the authority conferred on us by the DSM does help our clients—and not only by giving them access to money. There’s plenty of evidence that psychotherapy succeeds, when it succeeds, through nonspecific factors—or, to put it more bluntly, through the placebo effect. That’s not to say it’s a sham. I tell people all the time that I provide a placebo treatment, by which I mean that it works by means of the relationship between healer and sufferer. That relationship is often strengthened by exactly the kind of clout we gain by our association with the medical industry. To render a diagnosis is to provide a token of our power to heal, and thus, at least potentially, to increase our effectiveness. Whether the ends justify the means depends on how you feel about noble lies. I tend to value the truth over effectiveness, but I may well be woolly-headed about this.
The second way to salvage diagnosis, and with it our access to healthcare dollars, is to recognize that what we therapists do can be seen as a medical practice—but only if you expand the definition of medical beyond its usual boundaries. In the last 150 years or so, we’ve come to define medicine as a discipline that seeks the sources of our suffering in biological pathologies. This is an historical accident, due largely to the discovery of germs and the drugs that could treat them—developments that turned doctors into gunslingers who sought out the biochemical culprits of disease and killed them with magic bullets, and patients into the cowering populace waiting for the marshal to ride into town. The medical model, as we have come to call it, is really a bacteriological model, and it works best with illnesses like infectious disease, the ones that have straightforward causes and cures. As time goes on, it becomes more and more apparent that the low-hanging fruit has been picked, and that the diseases that continue to elude the magic bullets—autoimmune conditions,
cancers, Alzheimer’s disease—may be indications that we’ve run up against the limits of that model.
Nowhere in medicine is the mismatch between paradigm and phenomenon more pronounced than in psychiatry. The DSM’s claim to fit the medical model is purely aspirational, based on a notion that the causes and cures of mental disorders will be found in the brain, and that when this happens, the DSM will turn out to be an accurate map of them. To the extent that we have evidence for this claim, it appears to be incorrect. For instance, family studies show that schizophrenia and bipolar disorder may have a common genetic underpinning, and biological studies have shown conclusively that depression is a heterogeneous condition, not the result of a neurotransmitter imbalance. But even without this evidence, the claim is troubled—first, because it hinges on the unproven, and possibly unprovable, assumption that the brain is both the necessary and sufficient condition of our conscious experience, and second, because the brain is immensely complex, perhaps the most complex object in the universe, and may well be beyond its own comprehension.