by Hadley Fitzgerald, MA, MFT

We need to sit on the rim of the well of darkness and fish for fallen light with patience – Pablo Neruda

One night some weeks back I dreamed that I had to leave, get out of somewhere, because a new person with a new army was taking over, running things. I was part of a protest movement, and we were all being forced to turn in our most precious possessions. After I turned in a radio I loved, I realized I’d just put new batteries in it. I wasn’t willing to surrender them, too, so I snuck into army headquarters to retrieve them. Someone had hidden the batteries in a cheap knock-off of my treasured radio. I removed them and vowed to get my real radio back somehow.

In spite of years of working with dreams, when I woke up, I just couldn’t get a handle on this one – until…

That morning in the mail I received an eight-page set of forms from a therapy client’s new insurance company. The letter began “Dear Mental Health Professional,” and went on to tell me that even though I was not on this HMO’s list of “preferred providers,” partial payment of my fee was possible if I provide evaluators with some information about my client’s “current level of functioning,” her degree of “suicidality, homicidality, impulse control,” and several other “risk factors.” I was to list my methods for achieving “measurable, behavioral goals”” and set the “target date” for resolution of her condition – i.e. how soon could I get this over with so that she would be “stabilized” and thence “discharged”?

“Mental health” professional is a necessary, handy rubric. But, after two decades in the field, the work itself relentlessly teaches me that humans are in need of something far deeper than what is often perceived as merely the flip side of “mental illness.” While various branches of the therapeutic community continuously engage in turf wars over who is entitled to call him/herself a “psychologist” vs. “psychotherapist” vs. “counselor,” etc., the unimaginably vast territory in question is, more than ever, that of the human soul. We forget that psychotherapy originated in the Greek words for “soul healing.”

We enter this era of managed (orig. “to-handle or train horses, to dominate”) care (orig. “anxiety, lament, grief, suffering”), with an understanding of the need to reduce costs, eliminate fraud, evaluate what we’re doing and why. Yet, when the term “acceptable number of deaths” is being factored into debates over cost-cutting measure for medical care, I cannot help but imagine that an equivalent term will slip into decisions about the already minimal coverage for psychotherapy.

A seasoned colleague was recently told that her anxiety-riddled client was “sufficiently stabilized: after six sessions; the therapist was “not to go for the molestation” disclosed along the way, since that would lead to “prolonged and unnecessary treatments.” There is no way to predict the ramifications of such a dictum. The client has been through several emotional deaths already, and we have no empirical proof that current failure to intervene further will ultimately lead to extended illness or premature death from heart dis/ease, cancer, or despair. Yet it seems to me that such considerations must be factored in if we are to bring any wisdom at all, let alone compassion, to this new management of care.

Staring at my client’s insurance forms, I was initially repulsed by the requirements that her hard-won trust in me be surrendered to a computer. Then, as I thought of ways to be as protective as possible yet still help her get much-needed financial support for therapy, I became surprisingly inarticulate.

How could I summarize the pain of her life? Convey the impact of a father raping her childhood, of the invalid mother who repeatedly let it happen? How would I assign “severity” and “duration” ratings to her grinding struggle to honor her prodigious musical talent, a gift co-opted by her relentless doubt that she’s worth anything at all? How would I predict for this HMO when she “should” be “over” all that? I know how amazingly far she’s come already. But I can’t know – and why should I? – how much, farther she has to go. What rating do I give my belief that what she can eventually offer the world, her husband, her children, will make her continued treatment “cost effective”?

The HMO is looking for a product, and “all” I can offer is a process. All I can offer is my reverence for the vast and mysterious ways the soul goes about its business, which is often to sit on the rim of that well of darkness and fish, oh-so-patiently, for fallen light. I’ve been participating in this process for nearly twenty years, and I believe we mess with it – codify and “manage” it – at our personal and collective peril.

I am warned that I can’t survive as a therapist if I don’t get on board the HMO Express. No one mentions the consequences for my soul if I do, though I already know what they would be. So, in pursuit of my own mental health, I will link arms and walk on down the road with George Orwell, who said: “There is truth and there is untruth, and if you cling to the truth, you are not mad.” We’re going to go and get my radio back.

This essay was originally published in The World Times.