My father recently told me a story from a friend of his, an agent who represents ghostwriters. She recently encountered, for the first time in her career, a celebrity who had a gender preference for his ghostwriter. This celebrity, planning to write a biography in partnership with a ghostwriter, insisted that the ghostwriter be female. My father was shocked by this request and couldn’t understand it.
It made intuitive sense to me. It’s not unusual for therapy patients to have a strong preference about the gender of their therapist. I think what I do as a therapist has a lot in common with what a ghostwriter does: my job is to sit with someone, talk with them, listen to them, draw out their story, and make meaning of it in a way that is comprehensible and legible.
Many of my colleagues feel strongly that we are healthcare providers. Our livelihood partly depends on this conceit/construction/claim. Insurance pays some of us directly, and others indirectly, through our clients’ or patients’ benefits.
I’ve never liked this. It always feels wrong to me. I don’t like filling in a form saying that I have performed a “procedure” on my patients after a 45-minute session. The insurance companies require this if my patient is to receive any reimbursement, so, reluctantly, I comply. I have software that generates statements that say that at the end of a 45-minute session, I have provided a “45-minute psychotherapy session, CPT code 90834.” If the patient arrives too late or doesn’t show up, I can’t use this code, regardless of my cancellation or billing policies. To do so represents fraud.
To my mind, this is lunacy. The therapy I provide takes place not in 45-minute increments but over weeks, months, and even years. The relationship is the procedure, not the session. We all know this intuitively, yet when we fill in our forms, we agree to conspire with our insurance companies to pretend that what’s happened isn’t a relationship but a procedure.
Back to the question of ghostwriting, thought: in extreme cases, what I do feels a bit like healthcare. With a suicidal patient, I may make interventions to head off a suicide attempt. With a patient contemplating self-harm or harming another, the same thing happens. I might suggest that a patient consult with a psychiatrist for a medication prescription to ease certain symptoms.
But 99% of the time, I listen. I think. And I talk. I say back to my patients words they’ve said to me, or words they haven’t said but might have thought. I point out elements of their story that don’t make sense. In short, I edit. In some cases, it’s more active than editing, and feels more like collaborating. Maybe that’s true in all cases. The collaboration is in meaning construction, in narrative.
Yes, my patients hope that their work with me will bring about change, and often it does, but the mechanism by which that change arrives has more in common, to my mind, with literature than with medicine. I don’t make prescriptions. My patients don’t take pills (or if they do, they’re not pills they get from me). Together, we reshape old stories into new ones. We reconfigure distortions in perception or understanding. We work collaboratively to arrive at a shared understanding of what happens, of what people do to my patients, of what my patients do to and with others. The act is profoundly creative and not even slightly pharmacological, medicinal, or medical.
My dad seemed surprised to hear me talk this way. Many of my colleagues take offense when I say things like this, when I reveal that I think of my work as primarily literary rather than medical. Maybe they’re threatened? If this view were accepted more broadly, insurance companies, which pay a substantial proportion of our incomes, would no longer be implicated, and by extension, our incomes would presumably dissipate.
I’m not particularly concerned by any of this, not so much because of the financial realities of my life but because I know that my conception is so far from the mainstream as to pose no threat to my income. There’s no danger my conception will take hold more broadly.
And, in the meantime, I don’t mind collecting dollars my patients pay me in reliance on their insurance companies’ honoring the (to my mind, fraudulent) representation that what we’re doing is medicine. That seems to me just fine. Everyone has conspired together to create this situation, and like a married couple with unspoken secrets, all our continued happiness depends on the secrets remaining unspoken.
I’m speaking it here because I have no audience, because no one’s listening, and because the danger, therefore, is non-existent. But at least in my mind, the therapy I conduct has much more in common with writing and editing than with medicine.
