Mind Over Matter

For two decades, psychoanalysts have held fast to their slow, deep exploration of the psyche, reaping only scorn from the science-driven psychiatrists at Washington University. Good thing they didn't listen.


Moritz is one of those bright, poised and articulate women who, after confessing shyness, has to insist it's true. The surface makes a lie of any qualms -- her fingernails are perfect polished ovals, her hair curves softly on her cheek, her clothes are silk and wool, smoothly draped. Her ideas are polished, too, honed in that excess of perfectionism she's worked so hard to lose yet delivered so nicely that people miss their bite.

But in the spring of 1993, she surprised herself.

The phrase "managed care" was dangling in front of America like a horror-film string puppet, and the American Psychiatric Association had brought in the CEO of an insurance company to explain the facts of life to its legislative committee. "He said there were three important things about managed care: money, money and money," recalls Moritz, her mouth twisting. "He said they'd decided to decrease the number of psychiatrists by 50 percent and that those psychiatrists would treat only the sickest patients in hospital settings; talk therapy would be done by the least trained social workers."

She walked out furious, nerves zinging with a frustration she didn't need Freud to analyze. In France, psychoanalysis still reigned; in Holland, it was available even to prisoners. But U.S. psychiatric hospitals were folding as fast as nomads' tents, and managed care's new standard for a psychiatric session was eight minutes -- 12 for geriatric patients. "You can't even write down their meds in 12 minutes," she exclaims, "much less establish the kind of relationship they're hungering for!" As for children, they weren't likely to sit down, fold their hands and begin reciting their symptoms; you had to set aside lots of time, talk nonsense, listen for tangential clues and worm your way into their confidence. It was time well spent, because you could rescue them, restore them to a normal path before they got hopelessly lost.

But what managed-care company was going to reimburse you for building a tower of Legos?

Shyness now looked like a luxury, and she cast it aside. She became the president of the APA's Eastern Missouri branch in 1995, then the St. Louis Metropolitan Medical Society, and she started pushing through state bills to put mental illness on the same insurance footing as every other kind of illness. "There is a tract in the brain that uses dopamine as its neurotransmitter, and a disordered state in this tract becomes Parkinsonism," she testified at late-night hearings in Jefferson City. "An eighth of an inch away, there is another tract that uses dopamine, and a disordered state in that tract leads to schizophrenia. For those two illnesses to be covered differently makes absolutely no sense."

Three bills later, she's still working for full equity, and nobody's remarked on the irony that the strongest local champion of insurance rights is a psychoanalyst who long ago removed herself from all managed-care panels. "I don't think they know," she grins. "I just call myself a psychiatrist when I do this. I'm still fighting that CEO!"

One day a colleague at the Institute stormed in, his face mottled red. A child psychiatrist under his supervision was working in a managed-care setting, and a 6-year-old had just begun to haltingly describe sex abuse by her uncle, when a nurse banged on the door: It was time to move on to the next patient.

Another day, Moritz was lecturing to a group of physicians, and she described three problem patients: a suicidal alcoholic, a belligerent and litigious man who refuses to believe his diagnosis and a young woman harboring erotic delusions about her doctor. A man in the back of the room raised his hand and said, "I'm a primary-care physician, and I get paid $7 per patient per month. I wouldn't treat any one of them." His calculus made perfect sense. But, as Moritz warned fellow psychiatrists at a recent grand rounds at St. Louis University, "If they own you economically, they own you, and they can change us in that way. They can change what we think of as illness, what we think is treatable. They can change the essence of our profession."

It's easy for her to say this: The Institute is funded by patient fees, sliding-scale clinic fees, tuition fees from about 10 new candidates each round of admissions, and donations. Its 33 faculty members avoid managed-care reimbursements whenever possible: They don't want artificial constraints on their treatment time or methods; they don't want demands for confidential patient information; they don't want to spend 45 minutes on the phone requalifying their patients every week -- and managed care doesn't want them. Patients pay out-of-pocket for privacy and unfettered treatment, and the reimbursers apply their pressures elsewhere.

In today's system, the elitism Moritz once saw as a curse looks more like a blessing.


Moritz lights up when she talks about her students, many of whom came to the Institute seeking a humanity they can no longer find in managed-care psychiatry. The current poster child is Dr. Todd Dean, a gently intelligent young psychiatrist who wears a Mr. Chips-ish bow tie and listens carefully before he speaks. Dean did his residency at Wash. U. and stayed on to work there for another four-and-a-half years. In the beginning, he liked Wash. U.'s assertion that therapy shouldn't go on for years. "We saw tons of patients, and you did see bad symptoms get better really quickly, and that reassured me," he recalls. "It wasn't until the third year, when we started seeing people over longer periods of time, that I realized the quick fix often didn't last very long. That's when I began to think that the symptoms are not the problem. People spend years chasing their symptoms with meds, and no one ever asks why the symptoms are there in the first place."

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