Days from her 80th birthday, “Nancy” (not her real name) is doing well. She’s active, exercises, drives, travels, and lives alone in a multi-story apartment building without an elevator. Her busy schedule of weekly activities includes several appointments with physicians. Nancy’s medical needs are covered by Medicare.
Nancy’s been in psychotherapy for a half-century. She’s seen me, her psychotherapist, for the past three years. Nancy reports difficulty developing meaningful relationships over the course of her adult life. On a fixed income funded by Social Security, like many older adults, Nancy’s mental health care is also secured by Medicare.
To be eligible for insurance coverage, Nancy needs a presenting problem—a reason to be seen for care. In psychiatry, a patient receives a five-axial diagnosis, largely for reasons of insurance. The presenting problem, or complaint, is categorized as Axis I– the focus of treatment. Insurance companies only pay for these diagnoses. Continual psychotherapy through a span of decades is a strong indicator there’s something else going on with Nancy.
Many around Nancy use the word “difficult” to describe her. In psychiatry, this implies the next level of the five-axial diagnosis, Axis II: personality disorders. To simplify, Axis I is “what you have”, Axis II is “what you are”. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the bible of psychiatric diagnoses, describes personality disorders as enduring patterns of thinking and feeling that are maladaptive, inflexible and pervasive across a broad range of personal and social situations. Examples of the ten personality disorders are Dependent Personality Disorder, Narcissistic Personality Disorder, Paranoid Personality Disorder, and the emotionally labile Borderline Personality Disorder. Estimates suggest as many as 10% of older adults have diagnosable personality disorders.
Typical of personality disorders, in young adulthood and middle age, Nancy’s impacted her work and social relationships. Her career consisted of a series of short-term positions. Her personal life meandered through a few short-lived, tempestuous romantic relationships, none culminating in marriage. Through middle age, in our youth-oriented culture, there were always social opportunities, even if for Nancy their eventual result was loneliness.
As we age our social circle usually decreases. Friends and family may die or move away. Others may finally lose their patience or ability to tolerate an individual’s unnerving “quirks”, or the exasperating demands of a long-standing personality disorder. Family members are often literally ex-communicated from one another.
Nancy freely admits family members and acquaintances eventually tired of her chronic abrasiveness. Humans have a natural inclination for social contact– Nancy’s solution, as with many older adults, was to satisfy her dependency needs with physicians.
At a time when an estimated 10,800 people per day qualify for Medicare (four million baby boomers per year since 2010), utilization of this social entitlement program for socialization, as in Nancy’s case, is a symptom that will hasten Medicare’s eventual insolvency. Prices for medical services continue to rise, with increasing reliance on new, more expensive medical technologies for our growing aging adult population. Physicians have no incentive to hold down the number of tests ordered. Nancy is regularly assessed in her mental health care for signs of dementia, nevertheless her primary care physician curiously suggested an MRI of her brain, which she anxiously endorsed despite lack of any evidence necessitating the expensive procedure. As a number of regularly-administered screening instruments might have predicted, no abnormalities were found.
In their defense, physicians are not mind-readers. They usually will not deny care to a patient who asserts a need for it. It’s a complicated arena—many older individuals are not comfortable or able to communicate emotional pain but instead translate those feelings into physical pain, called somatization. It’s easier for some to say, “My back hurts” than “I’m feeling sad and lonely”. Part of the work of psychotherapy with older adults is to give them the facility to talk about their emotional distress rather than re-direct it into physical complaints.
We tend to perpetuate behaviors that are rewarding and discontinue those for which we receive punishment. Nancy will continue her weekly physician visits as long as doctors appear to listen, and Medicare pays the bills. She’ll remain in psychotherapy—perhaps it’s just another doctor. We’ll continue to address her issues, but she’ll likely continue to reinforce the status quo, as she has for decades in therapy with a long line of clinicians. As long as all the services are paid for, the patterns will be rewarded– until the reinforcement, in the case of Medicare, is eventually extinguished.
Henry Kimmel, PsyD, is a psychologist in Encino, CA, working mostly with older adults. He wrote this essay when completing his post-doctoral fellowship at WISE & Healthy Aging, a local community clinic for older adults (age 55 and above) in Santa Monica, CA. The post was originally published on the Costs of Care blog.
Comments from Jim Sabin: From the perspective of psychiatry: If I had been consulting to Nancy’s therapist at any point in her 50 years of therapy, I would have explored whether there were opportunities for group psychotherapy available to her. Group treatment is often more effective than individual treatment for folks with personality disorders of the kind Nancy has. And at this point in her life, being part of a group could also offset some of her loneliness.
From the policy perspective: The detail about the MRI is an excellent example of the dynamics of overtreatment. The story doesn’t give any details of whether Dr. Kimmel or his predecessors interacted with Nancy’s PCP. The right kind of integration between mental health clinicians and medical-surgical clinicians can improve care and contribute to decreased costs for patients like Nancy. Doing test after test for emotionally driven physical symptoms a) risks turning up meaningless findings that lead to further tests and, sometimes, associated injuries, b) distracts Nancy from addressing the existential problems of loneliness and sadness, and c) drives up Medicare costs without yielding corresponding benefits. The Accountable Care Organization format, in which the ACO is responsible for the cost of care as well as the quality, encourages integration of mind and body and has the potential to serve patients like Nancy better!