There is an affinity between Labor organizing and psychoanalysis in the deep skepticism each holds towards the myth of spontaneity. Work goes towards whatever you see in front of you. Work builds the systems people come together to change in psychotherapy or an organizing drive and any progress made toward greater freedom in either setting is built on work, and stands on a foundation laid earlier. The idea that change will come spontaneously in either mental life or in an economic situation is a myth that often inhibits groups of people from analyzing their circumstances and assessing the most effective ways to actualize needed changes.
Psychoanalytic psychotherapists and our institutions have the potential to improve the systems of mental health care provision in the US. Unfortunately, our mode of trying to address problems in mental health care with one another focuses almost exclusively on debates about psychoanalytic theory and how it informs clinical practice with specific populations, e.g. whether a given psychoanalytic approach is potentially liberatory or potentially oppressive when working with LGBT populations, non-white people, or women. These are useful questions for us to ask ourselves, but we often operate as if getting our theory and practice right will spontaneously result in a more diverse population coming to psychotherapy. It won’t. The flaws in our theoretical approaches to working with diverse patient populations, as significant as they are, are not what keep the mass of people from accessing high quality psychoanalytic therapy. What keeps most people from accessing psychoanalysis and psychodynamic psychotherapies are cost and availability.
The principal factor limiting the diversity of our practices is the economics of providing and paying for therapy. If we are going to improve the state of mental health care access in the US, we need an analysis of the economics of the field and we need to commit energy and resources strategically based on that analysis.
I am interested in how a “grubbing analysis,” a term coined by labor Historian John Womack, of the state of our field might advance the struggle for universal access to high quality mental health care.
In his analysis of the AFL-CIO Womack argues that the successes of labor organizing in the US in the thirties were predicated on a careful mapping of the industries being organized, identification of choke points in the industrial chain—specifically those areas of the production process where a few workers stopping their labor could grind a large system to a halt. Once these points were identified, resources were channeled strategically towards organization and the development of bonds of solidarity in those sectors in order to move from strategic actions towards a goal of mass labor power.
Womack sees organization of strategic sectors as allowing the labor movement to mobilize comparatively few resources to do something that has a big impact. Let’s say there is, for example, a small group of workers responsible for daily maintenance of a conveyor belt. Without daily skilled tuning of certain cranks and gears the conveyor belt jams. The maintenance workers are highly trained and hard to replace. If the conveyor belt maintenance workers could be organized to go on strike with a solidaristic demand that all workers in that factory receive overtime pay, their action could not only shut down the factory, but create the conditions for other workers to see the power of their work, the power of withholding labor, and the power of solidarity.
This organizing strategy pays dividends as compared with focusing first on organizing the conditions for a strike by less skilled assembly line workers who are easier for the boss to replace. Mass mobilization that includes all of the assembly line workers remains the goal—a focus on organizing the strategic choke points in the industrial chain is the strategy for building power and momentum, for jumpstarting a mass organizing drive. The strategy also depends on a practice of making solidaristic demands that enable mass organization and does not just privilege gains for the more elite workers.
As analytic clinicians we understand the value of prioritizing targets of intervention in our clinical work, and know that clinically it makes little sense to intervene on every front. In Bion’s framing, we wait and listen for a selected fact to emerge in a session and it is toward that selected fact that we turn the energy of our interventions, be they interpretive or containing or something else.
A grubbing analysis could be understood as a research process aimed at finding the selected fact within the economic chain that drives and supports our work, the place where it makes sense to make an intervention that builds towards a change in the balance of power in the sector we work in.
It is through really looking at the fine details of how goods and products move through a production chain and what kind of work is done at each point in that chain that labor organizers, having far fewer resources than the holders of the capital they are trying to redistribute, can hope to make an impact that a) demonstrates the importance of work as fundamental to keeping things going, and b) builds a sense of the common interests and political potential held by all who work for a wage or a salary.
For psychoanalytic psychotherapy to be able to help the mass of US residents who would benefit from it requires, as far as I can see, two goals:
- That psychoanalytic listening, formulation and technique re-emerge as fundamental tools in the care and treatment of psychological distress in all populations seeking care and,
- That the labor of providing psychoanalytic care be well remunerated regardless of what population is being served and regardless of the licensed degree of the practitioner.
Psychoanalytic work offers freedom from psychological pain and repetition that isn’t achievable through competing models of care, and this work is hard. To do it sustainably one needs to make enough money to be able to maintain a vibrant and healthy life outside of one’s clinical setting.
So what kind of analysis and action can help move the needle towards these goals? Unfortunately, while psychoanalytic clinicians have a lot of training and are hard to replace, the place we occupy in the larger system of mental health care in the US is niche, and the power of those of us providing care as private practice clinicians have to collectively bargain is constrained by anti-trust law.
The major institutional payers for mental health care nationally are prisons, schools, private insurers and public insurance. None of these payers remunerate psychoanalytic psychotherapy at rates that make practice as an in-network, school, prison, or public service analytic clinician sustainable. Most of the mental health workers depending on payment from these systems are underpaid and overworked, pressured to carry impossibly large caseloads and paid at rates that make student debt repayment near impossible—severely limiting the diversity of the mental health professions, and driving many licensed clinicians towards cash-only private practice work.
As a group, even if we were politically organized, psychoanalytic clinicians in the US do not occupy a choke point in the system of mental health care, whereby withholding our labor would create any considerable impact on the working of the US mental health care system. Given our lack of strategic position within the larger system, there are two important points where collective action on the part of organized psychoanalytic clinicians could support the movement towards a better and more equitable mental health system. These are the rate of reimbursement for therapy and assessment services paid for by Medicare and vociferous and psychoanalytically informed support for the labor struggles of current unionized mental health workers in hospital systems.
If we want psychoanalytic clinical work to venture outside of its current bastions in the wealthy enclaves of full-fee private pay patients, we’d do well to make certain that work with other populations pays well. This won’t happen without a significant increase in what Medicare pays for outpatient psychotherapy and a pegging of that increase to inflation. An increase in Medicare payments would pressure other insurers to raise their rates and would make it economically viable for psychoanalytically informed clinicians and psychoanalysts to take on insurance supported cases. This would pressure our field to re-examine the class biases in our practical applications of psychoanalytic theory. Currently our livelihoods depend largely on supporting the mental health and social reproduction needs of the Professional Managerial Class and the very wealthy. If as a field our own livelihoods were tied to supporting the mental health and social reproduction of the working class there would be pressure on our theory and practice to be examined seriously for class bias and other biases.
One group that is engaged in strategic work both in relationship to collective bargaining rights for independent practice clinicians and in organizing mental health workers in clinics and hospital systems is the National Union of Healthcare Workers, which has recently developed an associate membership category for behavioral health clinicians in private practice. NUHW, which represents health care workers across the country but is especially strong in California, is attempting through organizing and legislative efforts to challenge the prohibition on private practice therapists’ right to collectively bargain while also actively organizing therapists in hospital systems including California’s largest private employer, Kaiser Permanente. Associate membership is open to independent therapists nationwide who are not employing or managing other therapists. Joining and/or supporting the work that NUHW members are doing is an act of solidarity that would demonstrate psychoanalytic clinicians’ commitment to more equitable care.
As psychoanalytic clinicians we are also uniquely well positioned to use our understanding of the psychotherapeutic frame to argue for the potential harm to patients that comes with specific employer practices that unionized mental health care workers are fighting against. In a recent conversation with a union organizer, I learned of a hospital chain that has no cap on the number of clients their mental health clinicians are expected to see and a policy of adding eight new intakes per week to every mental health worker’s caseload. In addition, the hospital chain has a policy that new therapy appointments can only be made after a completed or missed therapy appointment: no patient can have a designated time in a clinician’s calendar. This means that as the worker’s schedule fills up, the time between appointments for any given patient increases. As psychoanalytic clinicians we can see the high likelihood of harm here, both to patients, and workers. It will be clear to us how this set-up amounts to an attack on the frame, creating none of the needed consistency that patients require, and preventing clinicians from doing clinical work that can be effective and rewarding. There is potential power in our ability to share this concerns in letters to policy makers and newspapers in concert with worker drives to organize for better conditions.
We are only going to be able to improve the state of mental health care in this country through collective and strategic actions. Unions like NUHW offer us one pathway towards that, organizing at the state level with other clinicians and patients for better pay for Medicare funded work offers another. There is a lot of potential for isolation in clinical practice; nonetheless, it is a worthwhile project, despite all that mitigates against strategic thinking, to figure out how to act both collectively and strategically.
