Managing Managed Care: Habitus, Hysteresis and the End(s) of Psychotherapy

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Abstract:

In this paper we examine how clinicians at a community mental health center are responding to the beginnings of changes in the health care delivery system, changes that are designated under the rubric of ??managed care.?? We describe how clinicians? attitudes about good mental health care are embodied in what sociologist Pierre Bourdieu calls their habitus, i.e., their professional habits and sense of good practice. Viewed in this light, their moral outrage and sense of threat, as well as their strategic attempts to resist or subvert the dictates of managed care agencies, become a function of what Bourdieu terms the hysteresis effect. The paper is based on ethnographic fieldwork conducted by a team of researchers at the mental health and substance abuse service of a hospital-affiliated, storefront clinic which serves residents of several neighborhoods in a large northeastern city. Data consist primarily of observations of meetings and interviews with staff members. We describe four aspects of the clinicians? professional habitus: a focus on cases as narratives of character and relationship, an imperative of authenticity, a distinctive orientation towards time, and an ethic of ambiguity. We then chronicle practices that have emerged in response to the limits on care imposed by managed care protocols, which are experienced by clinicians as violating the integrity of their work. These are discussed in relation to the concept of hysteresis. Culture, Medicine and Psychiatry

White House Issues Alert of New Terrorism Threat. Ridge: “The threats we are picking up are very generic. They warn of more attacks but are not

specific about where or what type. We do know that the next several weeks, which bring the final weeks

of Ramadan and important religious observations in other faiths, have been times when terrorists have

planned attacks in the past.” NY Times

Eyes Focus on Trade Center’s ‘Bathtub’ as Debris Is Cleared NY Times

A Fresh Look at a Quick Fix for Heroin Addiction. The New York Times explores the controversial procedure in which withdrawal is precipitated rapidly by giving an opiate antagonist to a patient under general anaesthesia; a number of patients have died in high-profile cases. Critics say it’s a moneymaker for hospitals and clinics to treat high-rolling celebrity addicts. My concern is that, psychologically, addicts are addicted not so much to drugs as to quick fixes — for their ‘jones’, and for coping with stresses. The use of their drug of choice has replaced, or prevented the elaboration of, other options for coping. This new technique is essentially just another quick fix, and will leave the pitiful addict bereft of replacement strategies that would develop during a more gradual rehabilitation from drug dependence. In short, it won’t prevent the unchanged, vulnerable, addiction-prone person from relapsing.

And next question: what position will health insurance providers, who historically want to do as little as possible for their chemically dependent customers, take on paying for the treatment? Two possible scenarios: (1) Despite evidence that doing the procedure safely (after all, it does involve general anaesthesia, and it has killed people…) necessitates inpatient hospitalization, they may refuse to cover costs; (2) They may push people toward the procedure, despite its physiological and psychological dangers, as more expedient than the detox admissions they now pay for. Over the past decade, I’ve seen inpatient detoxes whittled down from 21 to 7, 5 and now most commonly 3 days under managed care pressure; here’s a great opportunity for cost-savings by pushing the envelope down further.

This search connects you to previous FmH discussions of opiate addiction, including a reference to the investigation of the physician whose patients were dying during rapid detoxification.

When I read the Times‘ headline above, I thought for an instant I might find mainstream press discussion of ibogaine, the powerful (and toxic?) hallucinogen the administration of which is reputed in underground circles to ‘cure’ opiate addiction, about which I’ve previously written. The difference between this and the rapid naloxone withdrawal the Times discusses is that ibogaine, according to published accounts, might precipitate a searching reappraisal of the self creating change in the psychological as well as the physiological grounds for the addiction-proneness. Here’s a Google search on ibogaine.

U.S. budget deficit projected until 2005. Grim economic reminder that not only was the government stolen from us but it’s proceeding to sell us down the river with glee: ‘Bush promised during the presidential campaign to avoid tapping Social Security except in cases of war, recession or a national emergency.

“Lucky me. I hit the trifecta,” Bush told Daniels shortly after the Sept. 11 attacks, according to the budget director.’ Miami Herald [with diolchgarwch — that’s gratitude in Welsh (grin) — to wood s lot for the link]

“So, will it (a.k.a Ginger and Segway) revolutionize urban life as the press-hype surrounding its initial disclosure dared predict? Probably not.

First off, it’s expensive. On top of that, it weighs 65 lbs, making it a real monster to drag home on an empty battery. But then again, it’s not so heavy that it can’t easily be grabbed and tossed into the back of someone else’s pickup truck.

And anyway, they’ll be banned from municipal sidewalks the split second some 18-month-old toddler gets crushed and paralyzed for life. Teenagers will re-jigger them, make them go very fast, and break their necks in Extreme Ginger exhibitions in front of admiring babes, leading to further restrictions by official killjoys. Small children will ride them down stairs, to very bad outcomes.” At least, The Register concludes, dogs will love them.

On the topic, someone on a mailing list I receive comments that they must not have had their acronym checker working the day they decided to call this the Segway Human Transporter.

Weekend Fireballs: “Pieces of a Proton rocket disintegrated in Earth’s atmosphere this weekend, startling sky watchers in western Europe and at least seven US states.” science@NASA

David Morris, v-p of the Institute for Local Self-Reliance: “Kenneth Lay is living proof that one person can change the world. His company, Enron, may be in shambles. In three months, it may no longer exist. But for the rest of our lives we will live in a world redesigned by Kenneth Lay.” The Man Who Screwed the World:

Why was Lay so successful? The Economist magazine described Enron as an “evangelical cult,” with Lay its “messiah.” It didn’t hurt that Lay was preaching the gospel of deregulation, a gospel widely shared by both political parties.

And this missionary had clout. Lay had worked for FERC and was Deputy Undersecretary for energy matters for the Department of Interior. In the 1980s he became a principal fund raiser for President Bush and later his son. His board of directors included Wendy Gramm, wife of Senator Philip Gramm of Texas. A month after they left office, Enron put former Secretary of State James Baker and former Secretary of Commerce Robert Mossbacher on the Enron payroll. Lay golfed with President Clinton.

AlterNet

Tamim Ansary: An Afghani Primer: “What journalists need to know in order to keep expectations in tune

with what’s likely to unfold in Afghanistan.” AlterNet

Tai Moses: Before and After: September 11 — ‘The events of September 11 divided our world into two radically different eras. We watch wistfully as the pre-9/11 world drifts away on its raft of memory, cast in Technicolor shades of nostalgia. We will remember that assassinated world as idyllic, secure (never mind that it was neither), we will speak of it in the reverent tones reserved for the dead.

Meanwhile, the post 9/11 era looms like an unmapped wilderness. As with other unclaimed territories throughout history, a fierce battle is being waged for its psychic, political and material capital. Former president Bill Clinton has called this conflict “the struggle for the soul of the 21st century,” and the spoils of war include some of our most cherished values and liberties. Leading the charge are the warriors of the Bush Administration, a battalion of securitycrats and generals who are attempting to colonize the future with their own repressive agenda.’

On the beautiful, glass-bright morning of September 11, a man — an ordinary, unremarkable American — called his wife on his cell phone. “We’re all going to die,” Thomas Burnett said as United Flight 93 careened over the Pennsylvania countryside, “but some of us are going to do something about it.” All we know of the rest of Tom Burnett’s narrative is that his life ended horribly. He and his fellow passengers did not let what must have been abject fear prevent them from acting — that is the true definition of courage.

What happened aboard Flight 93 was the country’s first real victory against terrorism, and it came out of the tradition of democracy. The passengers came up with a plan and they voted on it. Some of the men would rush the hijackers and force the airliner to crash, rather than allow it to be used in another suicide attack on Washington DC, where it was surely headed.

It’s a terrible irony that for a short time, while the condemned jet was aloft, the ideal of American democracy also reached its apex. The rest of us can only strive to do as well. Fortunately, Tom Burnett’s last communication to the world was an unintentional gift to us all, a battle cry for the age of anxiety. We are all going to die sooner or later. Let that consciousness not prevent us from acting in each other’s best interests, from trying to create a better, safer world.

AlterNet

Creating a CIA Poster Boy: “In releasing the name of Johnny Spann, ‘America’s first casualty’, the CIA is breaking tradition

and attempting to rehab its somewhat tarnished image.” tompaine.com