I am continuing my journey through Doing the Right Thing, and Chapter Two addresses the moral issues of choosing “treatment plans.” When I entered the mental health field in midlife, there was a general acceptance of taking billable time to get to know a patient, both in terms of establishing rapport and getting a sense of the personal issues and problems of a new patient. However, when I started in the public health system with Medicaid, I would have to submit an evaluation and a treatment plan in a 50-minute window before getting a penny. This is general third-party practice today, to the degree that by the time I closed my office in 2014 my software would only let me perform a 90801 on first visit—diagnostic and treatment planning.
For mental health providers, treatment planning, perhaps surprisingly, was one of the hardest things to do. Medicaid, for example, gave me templates that read something like this: Johnny will reduce his incidence of impulsive interruption of his class room by 25% over four sessions. Treatment plans are geared to concrete outcomes, and more and more to quantifiable outcomes. Some of my third party payers, like United Health Care, required an admissions symptoms test that I would administer during first visit. The test would be repeated after the fourth or sixth session and also sent to the insurance company. Patients typically and understandably underreported or even failed to report symptoms at the first visit, not wishing to make a bad impression on me (or maybe fearful that I would order an involuntary hospitalization.) And thus, after a few weeks and a few billings, I would get a reasonably friendly letter from the company, commending me on my success and wondering if further treatment was necessary.
But on the other hand there is a moral imperative here, too, to cut to the chase and address the need of the patient, since his or her comfort, health, and safety depend upon both symptom and causal understanding and treatment intervention. As church workers we might not be accustomed to think of our interactions with our public in such ways, but the skill of identifying both need and best intervention is of immense help to the suffering, many of whom are attracted to the church—at our invitation. Moreover, given the shortages of personnel—not just priests, I might add—it is an appropriate stewardship of ministerial time to develop analytical skills of “ministerial” or service planning.
In the book I cited above, John Peteet, M.D., cites a moral dilemma of counselors who address patient treatment planning from their own preferences: some counselors focus on self-determination, others on medication, some on child compliance to parents in all situations, no matter how dysfunctional the household. The textbooks recommend collaboration between the patient and the provider in treatment planning options, though as Peteet observes, there is no hard and fast guideline about how this collaboration takes place. If all patients knew how to collaborate on treatment plans, they wouldn’t need me in the first place and I’d have to do out and get an honest job. State laws recognize an inherent imbalance of insight between patient and provider—hence the prohibition against sexual contact, as “informed consent” is deemed impossible in relationships of power. I might add here that many a first session in my office began with a patient declaration that “I’m not taking drugs.”
I think what Peteet may be driving at is that one size does not fit all, and that counselors may not be totally honest with themselves in addressing the patient’s need. Two reasons come immediately to mind: (1) we tend to work from the information and algorithms we know; and (2) there is a good chance that therapists themselves have sought psychological treatment, and perhaps tend to fall in love with the treatment style that made them better. So a counselor may very well have predilections toward therapy modes that will dominate most treatment encounters.
Let’s be frank here and admit that dispositions and predilections influence so much of our church work—personal work, team work, and planning. The great danger with church work is the subtle—and many, many times not so subtle—way we have of representing our gestalt of religion as God’s, or the universal Church’s. This, too, is a power imbalance that church ministers must constantly examine themselves for.
I could point out a number of examples, but one that keeps coming across my desk is the unrest of some Catholic bloggers regarding Pope Francis’ recent encyclical on marriage and the family. Among the complaints is an alleged absence of clarity on Church doctrine regarding marriage and the reception of the Eucharist. The line of thinking, as I understand it, is that pastoral variance for individual couples will destroy the certainty and clarity of Church doctrine and “confuse the faithful.”
There is a part of me that wants to ask if the denial of pastoral flexibility is any less confusing. But more to the point, I also wonder if part of the unrest is due to a genuine fear of disorder in general. The Church, in some ways similar to a therapist, becomes the object of “transference” in which the patient (or the Catholic) projects upon it what he or she needs it to be. I am not venturing into a sacramental debate here, but I think it is difficult for many to conceive of a Church like a field hospital among the wounded, where experience and Spirit-filled instincts carry weight alongside of established principles.
Thus, in my teaching, when I encounter students who feels it necessary to speak “for the Church,” (usually wrongly, as it turns out, cloaking themselves in their understanding of orthodoxy) I have to wonder, too, if such a person is prepared to take responsibility of his “treatment plan.” It may never occur to some individuals that their public statements may be discouraging other Catholics from seeking pastoral care in second marriage situations.
I just looked at my clock and I am scheduled to teach catechists in one hour. But we will continue the discussion.