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Tele-Mental-Health: a glimpse of the affordable care act



This weeks blog is a summary of a what the health markets will look like in the next few years to come.  The information presented here is a snippet of the massive amounts of “BIG” data that was reflected upon at the workshops and in the convention hall.

I was a bit of a fish out of water.  The participants were generally executives of multi-million dollar super agencies that spent as much administrative time on acquisition and merger as they did on the health and mental health of their customers, clients and patients.

Having said that, my belief in the macro/micro theories led me to deciphering the noise from the meaningful data.  I came away from the conference having had a great time with an old friend attending from the west coast and carving out some innovative ideas that will help me to pull my psychoanalytic practice at the forefront of the 21st century thinking and technology.

This conference summary is about the big picture.  I will write a follow up article on how Mindfulness in Psychoanalysis will make changes in service delivery.  But for today below is a glimpse of the world after Obama-Care is implemented.

With the arrival of the Affordable Care Act (obama-care) we are entering a new era for medicine and public health in America.  It is an era powered, driven and managed by “BIG” data, meaning that technology, the internet, iPads and smartphones will be as integrated into medical practice as is the blood-pressure cuff and the thermometer.  And all of this new technology will not only impact how and when we see our physicians, but in what will be expected from the consumer in the providing of health and mental health services.  With the changes that we will see in medicine and in insurance coverage it is yet another brave new world that we are entering.  Both the doctors and the consumers will be new at this game-plan.  It will be wise to begin to prepare ourselves for a new form of service delivery where we are not only the consumer, but a partner in health care coverage.

Medical Homes

The best way to describe a medical home is to think about it as a cyber place rather than a brick and mortar place, although, there will be many physical locations that will be used as the hub for medical homes, the practice of interactive health care will begin with a primary care worker.  From this central point of entry into the new medical world, we can expect to see partnerships with the YMCA to be as focal as partnership with specialist.  The specialist will be for the high end user.  The healthier we are the more we will be encouraged to follow public health policies–no smoking, take meds on time, do a blood pressure reading twice a day, avoid sugar, avoid too many starches, eat greens, avoid caffeine, brush, rinse, floss…………

The Big Data that has been collected on Americans point to particular guide posts that appear to be generic or central to most healthy humans…lack of adherence to the know quality of health factors will be treated (as they should) not as forms of acute illness, but rather as a form of chronic illness.  In the old medical model a distinction was NOT made between a chronic condition and an acute condition.  Patients walked into their doctors offices expecting to be taken care of.  The new paradigm is walking into a coordinated medical home where all of your data exist, and we the consumers, along with the physician strolling through our options.  We become partners in health.  This is not yet a reality, but it is rapidly coming down the pike.

Coordinated Care

This coordinated care is expected to be a gateway to quality of health, but we have all seen what happened when managed care was suppose to do that in the 1980’s.  Everyone fell through some crack or some loop-hold and managed care became the biggest obstacle to receiving care.  The old managed care model placed private practice fees as the basis of delivery of care. Essentially some of the biggest providers either did it right and declared bankruptcy, or did it wrong and survived by saving the insurance companies lots of money.  Managed care became GATE-KEEPERS, rather than Gate-ways to health care.

It seems to me that the largest component of the affordable care act will take place behind the curtain of OZ.  The federal government has stepped in and made one huge sweeping motion that will change the game entirely.  Insurance companies, under the new act to take effect in 2014 are mandated to spend a formula driven amount on money on the provision of services.  It will no longer be un-regulated.  An insurance company will have to spend X % of its subscription fees on paying providers.  This is a huge change from the companies choosing to keep as large a percent of profit for shareholders as they deem fit.

Also in this changing retail market there is one more provision that will change the face of health and public health.  Insurance companies are moving from a fee for service model to a cost-effectiveness or value based model.  Medical practices will not be paid for a broken bone, but will be paid for a “repaired” broken bone.  It does not sound like such a big change, but moving from fee for service to a goal driven out come model may change everything.

What we saw happen in Mental Health in the 1970 and the 1980’s was a shift from the analytic model of therapy being provided, to a behavioral mental health model where only cognitive behavioral therapy was considered reimbursable, based on goals achieved.  I do not think that the mental health care act passed 50 years ago was effective in recognizing the best care, they became experts in a new language.  Out-come oriented psychotherapy and short term counseling replace sound theory about the relationship building that was necessary to facilitate major changes in depressive and anxiety driven conditions, which by the way we now know for sure accompany every chronic illness.

Fifty years later we are moving our physician based health care system to a public health, population driven paradigm that will require proven out-comes before the insurance companies pay for the service.   The reducing of cost for our health care is the driving force in the new medical homes model of care.  I am convinced that we will not spend less on health care, but a new distribution of assets will arrive with the new care act.  It is yet to be seen, but considering the strength of the insurance lobbies, I doubt that they will make less money.  There is a good chance that the losers in this new market driven, big data driven world will be both the providers and the consumers.  What bankers are to our economy, insurance companies are to the health and public health of Americans.

The markets are driven by profit margins not quality service provision or even consumer (patient) outcomes.  It is yet to be seen, but there are indictors that the healthier you are, the more favorable will be the new health systems for you.  The place where we will continue to be stuck is the work needed to be done for the most recalcitrant aspects of society–the unmotivated, depressed patient who can not become compliant because of subjective, unexplainable conditions that have yet to identify the genetic source for the condition.

There is a glimmer of hope based on the acknowledgment that all chronic disease are also psychosomatic conditions.  This is where mental health is going to have a newer and perhaps more forceful voice in holistic patient care….

Thank You for Reading,


Dr. A.L. Dussault





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A Note from a Colleague: CLAUDIA LUIS


Claudia Luiz
Author, “Where’s My Sanity?” Is available on Amazon
 Below is a recent note that I received from a dear colleague.  She recently authored a  book that will be of interest to many of you.  By way of introduction here is her note.

To my psychotherapy colleagues:

It never ceases to amaze me how — when people hear the word “psychoanalysis” — they still think of Freud. I mean yes, of course he’s the father of psychoanalysis. But really, if you stop to think about it, his first introductory lectures in the US were delivered at Clark University in 1903. That is over a hundred years ago!

Just forty years ago, my mother started studying psychoanalysis. And after that, my whole world changed. We went from being a family that loved each other but didn’t talk, to being a family that had a lot of anger that got talked about. And amazingly, all that anger being expressed, and dealt with, and processed and healed, brought us all so close together, and each individually, to such a better place. And no cigars!

Now, I’m a psychoanalyst. So I know even more about how far therapy practices have come. About emotional communication, emotional experiences, how we use countertransference (to understand not only our patients, but ourselves!) – and how art and science come together to guide our interventions…this is where it’s at.

It has become my mission to educate the general public about what a rich emotional experience therapy should be, and to restore hope and vibrancy to it. Because it seems like even our greatest advances in clinical practice are mostly unrecognized by the general public. People still think of therapy with an element of dread. It shouldn’t be that way. 

Now — I did not write an academic treatise or even an expository non-fiction book to fulfill my mission. I thought, “who would want to read that?” Instead, I wrote a set of moving stories about people in treatment, suffering from our most common-day afflictions – anxiety, depression, being stuck, unhappily married or raising difficult children. I wanted the everyday reader to experience – not just know – how therapy today can work to create deep and lasting change.

I am very pleased to report that “Where’s My Sanity: Stories that Help,” is being endorsed by the National Association for the Advancement of Psychoanalysis, and by the Society of Modern Psychoanalysis. Chapter Four, about my experience in clinical field studies with a schizophrenic called “Anita,” has been included, to date, in the curriculums and reading lists of four leading psychoanalytic institutes in the Northeast. 

I am so happy that the book’s solid foundation in clinical theory is being recognized, but what makes me even happier is when readers tell me that they couldn’t put the book down. People need faith that programs of change will help them, and I hope my book will help to stoke that faith, and that you will be interested in reading it and using it to help draw positive energy to your practice.

The book is available on Amazon (I can’t put a link to it in this letter) but if you go to and put in “Where’s My Sanity?” you will see all five-star reviews, and be able to take a look yourself. Please feel free to request a copy of the chapter that is currently being used in classrooms – I will be very happy to send it to you myself via e-mail.

Very best,

Claudia Luiz, PsyaD





Libido: the psychoanalytic law of attraction

 erotic dance
Libido–in short, it is a type of energy associated with both the mental and the biological drives.  It is one of the two drives
upon which psychoanalysis was founded and continues to this day, as the foundational mechanisms that are responsible
for piloting sentient beings forward.  It operates in tandem with the aggressive drive also known as the death drive.
Life is busy holding itself up until it can no longer hold it self up and the decompensation process sets in.  In biology and
physics the terms anabolism and catabolism are the words that most reflect what Freud and subsequent drive theorists had in mind
when proposing the dual drive theory.
For our purposes in this essay my concentration will be on the libidinal drive.  Not only was it the first drive to be identified
by Freud, but it is essentially the kernel of his thinking that led to his seminal work, “Beyond the Pleasure Principle”.  In beyond
the pleasure principle, Freud maps out the metaphor of the mind that we all recognize, the ego, the id and the super-ego.
In many ways we are seeing neurobiology catch up with what Freud induced from his observations of his early patients.  He had
earlier, in his writings said:  we will have to content ourselves with these subjective findings until chemistry gives us a more definitive
O.K. enough of the back ground….libido is the central concept on which psychoanalysis applies its concepts in research, philosophy
and clinical work.
Libido is desire.
Desire is also a foundational concept in new age philosophies. The most recognized of these theories is The Law of Attraction.  In the Law of Attraction
we are told that allowing ourselves to want what we want guides us to that wish.  It says, or implies, that there is a kind of personality
to “The Universe”.  This Universe is said to listen to our desires if we are sincere and we have the capacity to stay focused on what we want.
This is both similar and different from the analytic view of libido.  It is similar in as much as it requires the desire to be the focus
of the mind field; but it is different in as much as analysis does not claim that there is a Universe listening.  Instead psychoanalysis
is a theory of the mind that is and remains contained in the mind.  When we emotionally “cathex” with an object of desire, it is the
representation of that object of desire in the mind that is the object or the aim of the mental energy.  By infusing desire onto something
that is “Other” than us, we begin a process of aiming for that object.  Depending on the strength of the cathexis, another words on the
importance of the object, we begin a process by which we come to obtain the desired object.
To an alligator it might be the the lazy brown fox crouched among ferns, to a modern human it might be a new granite countertop.  We
want, we aim, and we go for it.
A cathexis is not to be confused with the other Freudian concept “catharsis.”  A catharsis is an expelling of energy that had been attached
to an idea or an emotion.  The catharsis happens when the object is no longer infused with emotional content.  We could almost use the word “relief”
as a substitute for catharsis.  An important insight that changes how we perceive something can be said to be a catharsis.  For example, a year after
a loved one has died, one can reasonably presume that the death of that person will not be as occupying or as charged a thought as it was when
the death first occurred.   Catharsis has to do with the amount or quality of affect that was released. Cathexis has to to with the amount of mental
and emotional energy that was infused into the event.
There is speculation about what Freud meant.  In fact when Freud could use a common word rather than a scientific term to describe
something he was witnessing he generally would use that word.  When we want something our mind is usually occupied or charged
with that desire.  Some Freud scholars seem to think that the word occupy or charge would have been closer to the idea he was conveying.
One of the things that has seriously changed in the last one-hundred years has to do with psychotherapies becoming less invested in the
disease model of neurosis, and instead has become occupied with a wellness model.  That is, most people today see a therapist with the
idea that some thinking need to be adjusted or some emotions need to be examined and understood.  At the time that Freud was writing
neurosis was seen as a mental disease that needed amelioration rather than remediation.
Nonetheless, Freud’s writings at the turn of the 20th century were seminal in the manner in which they came about.  Freud never said
do psychoanalysis like this.  Freud said that every psychoanalysis was unique in as much as the discoveries made by the patient and the doctor
were unique to that patient in that setting.  What was being looked at–the patient, was as likely to be seen from as many perspectives as
their were doctors doing the examining.  Each psychoanalysis was a new research project undertaken with a fresh new look because
no two individuals presented their problems with the same amount of emotional cathexis.  Single case study rather than statistical studies
remains the underpinning of modern psychoanalytic research.
It does not follow that if your house burned down when you were a child that therefore you would develop a “my-house-burned-down” syndrome.
Each child brought their own emotional charge or content to the event.  For one child a scaring trauma might happen and for another
it might not even register as an important event.
Central to Freudian thinking and central to The Law of Attraction is this concept of emotional cathexis.  This process of desiring is the
process of becoming invested in a particular outcome that we are wanting to attract.  It is not so far removed from [John 15:7],
“ask what ye will and it shall be done”.  We are looking at a convergence, a convergence of thought from more than one perspective pointing
to the same outcome.
When we pray, when we infuse libido or when we allow the universe to give us what we need we are following some kind of prescription
for truth.  We might hear this concept in a more Americanized way, “you have to work hard to be successful,” or in mindful way, “breath,
listen to your inner breath, breath with your heart.”  There are a multitude of methods and “secrets” and miracles that might get us
to this desired outcome.
In the end we are looking western civilization in the face and going against the grain of social civility.  Because regardless of what
method, secret or theory is employed you will need to selfishly put yourself in the number one position in order to accomplish getting
what you want.  Libido will have to infuse your wishes so that they can be aggressively pursued.  But for those of you reading who are
saying, “but selfishness is a bad thing, isn’t it?”  I want to say, “No, It is not a bad thing.”  The art and science of a a successful life
begins with the centrality of your own soul, your own self.  There, in the inner-sanctum, in the temple that is the manifestation that
is your mind, is where you will find the capacity to have the strength to place yourself in the number one position.  And you will
be able to do this because when you there in the depth of your inner world you are in the presence of truth and wisdom and knowledge–your own..
From that humanistically special place, you want what is best for you and you have no competition with the fact that your
neighbor wants what is best for himself/herself.  To Place oneself in the primary position only means that you are placing
your energy into your own vitality.  What we manifest from our own vitalities is always for the greater good.  Creativity is not an
act of aggression on someone else’s person.
In conclusion libido that perverted, sexually oriented concept is the seed of our humanity.  It is the drive that elevates pleasure and
comfort as a welcomed and desired state of being.  The wildness and primitive nature of our sexual urges are the first genuine sensations
that move us forward.  Like in the manner that a newborn infant placed on its mothers belly will navigate its mouth toward the breast,
the new born awakening that desire is nature’s way of guiding us to vitality, will navigate our wishes into manifested realities.  This
is the psychoanalytic law of attraction.


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…of thee I sing…..a non-partisan moment

…..of the i sing

46 million people are on food stamps.

14 million are unemployed, and millions more are under-employed.

2.9 million homeowners in 2010. were drawn into foreclosure.

48 million Americans live in poverty – almost 10 million more than before the recession hit.

Once upon a time, America was a wilderness.  It was home to man and beast.  It was the most precious, the most open and the most beautiful continent in the world.  Then in the late 17th century the europeans began to flock like geese to the new promised land.  From sea to shining sea evolved into a culture of the working class.  Nothing prevented the early americans from setting up and building communities and homes that were free from the monarchies of western europe.

Most of us know the story.  It is the story of the American Dream, a location in the universe where a shining city on the hill brought possibilities and promises; resources were plentiful and justice for all was the new call of the wild.  No one said that it was going to be easy. There was famine and pestilence and broken relationships with the Native American people.  There was to be war with England and France and the Mexicans and the Spanish.  There was to be war among ourselves in the Civil War where the ideology of equality would eventually be extended to the negro, and eventually to women.

Most recently the destructive power of mankind would be seen not only in the Great World Wars, but in how the war ended…millions of charred bodies would suffer under atomic explosions.  That moment called the worlds attention onto the era of the deluxe american life–cars in the drive way, children, well dressed and in school, mothers carrying a message of virtue and ethics into the families.  An idyllic memory, if not for all for most of america, captured the attention of the world.  New York was the capital of the world in fashion and commerce and industry. Chicago the white city, Hollywood, the film capital of the world, Miami, the playground for the rich and famous to get away from the cold winters of the northeast.

Throughout America more and more people were settling into an American Dream.  Eisenhower finished the interstate roadways that Harry Truman had begun in Kansas and Independence, Missouri a full century before as the first commissioner to be charged with paving the trails that were born out of the American migration west.

My God, we even made it to the moon…..Kennedy, Kennedy & Kennedy along with Martin Luther and the Great Society were to push forward the agenda of an America where more and more people could begin to grow and cultivate a life of moderation.  Back yards, picket fences, mowed lawns, garages and grilling along with vacationing and the automobile, the mountains and the sea shore and the national parks of America all converged to give us the illusion that we were a civilized nation that had arrived at all that it had at the hands of hard work, Thomas Edison, the Slater Cotton Mill, General Electric and Westinghouse–to name only a few.

America was cultivating and manufacturing itself into a greatness never before seen on earth.  We were harnessing nature; and with the good intentions of the hard working men and women of america we became the envy of the world and the most important player on the international stage of world politics.  The end of the twentieth-century arrived with hardly a glitch–not even a hint of the Y2K crisis predicted by the eccentric few who warned of an apocalyptic digital catastrophe.

We had been around for some 350 years and never were our shores touched by a foreign mercenary.  America remained some kind of a pristine label.  Whatever was wrong in the underbelly of the nation had not yet been exposed.  The second millennium saw stocks rising, share holders happy, investors buying homes and inventors creating ever new digital toys for the Great Generation to amuse itself with.  We were each in our own way computing ourselves to becoming the greatest consumer nation on earth.  We ate more fuel and emitted more carbon than all other nations put together.  We were the fattest people on earth and there was pride in our gluttony.  We delighted in being the envy of the world–anger and lust powered our economy that was ever being greased by greed.

Here we were at the threshold of time careening along in our jets and carriages, content as hogs in mud, proclaiming in God we trust while living out the most deliberate and flagrant lives on a stage cast with the seven most deadly sins known to the universe.

Then came the call we never expected–the twin icons of western greed, the granite and steel structures that represented the Fountain Head of mighty and tall were crushed to piles of fallen rubble and sadness by a solitary man on camel back seeking revenge for every crusade ever launched in the name of God………

The world as we knew it began to change–the ship of state would begin its onslaught while ever so slowly turning and turning until it began to head straight into the headwinds that had blown it forward.  We were in reverse, returning to the oligarchies from whence we came.  Now the governing powers of wealth once again took the reigns of government and hitched them up to the corporate paradigm.

We will be rebuilding america on the backs of the poor and the working class.  New pyramids will be erected in praise of the Guards of homeland security that allegedly protect up from harm.

The new currency will read–In Guard We Trust!

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The Conflicted Child: ambivalently connected

The Conflicted Child

the conflicted child

The behavior of the difficult child has long been debated in the infamous “nature vs nurture” arguments—everyone chimes in with opinions; but fact and statistics do not

squarely fall on one or the other as having the answer.  We are a divided mind much in the same way that we possess divided cells.

Our cellular makeup can be measured as a wave or as a particle.  In a similar fashion our difficult children must be looked at as well from both perspectives.  Frequently our investment in one or the other comes from a personal interaction with the parents of the child and with the child itself.  But, when we view an insecurely attached child we are pretty sure that we are witnessing a cry for help, be that a cry that suggests help my parents to bring me up, or help me to be more attentive to the wishes of other.

Out of this simple paradigm we can see the conflict forming.  With a wild need on the part of the child or the parent to be accepted and to feel connected to something secure, we see fears conducting both sides of the equation.  It is difficult for us to conceive that a child of two or three years old can engage in a drama that is primarily reserved for adults.  It is hard to comprehend that the instincts of the child may be reacting not only to what is being done or not done to help the child to be conflict avoiding, but to how the parents themselves are reacting to each other.

In describing transference and the repetition compulsion Freud discovered that we humans tend to have an unconscious memory of early interactions and we will use those old patterns in regression (reverting to an earlier pattern of feeling or behavior)

in order to make sense out of our current world.

The addiction to old patterns is a well documented story, but nonetheless needs to be repeated for we adults of difficult kids to understand that the difficult behavior that we are witnessing is a survival mechanism that arose as a means of dealing with an early conflict.

Don’t we all wish it were that easy–”Oh, I know where my last “asshole” behavior came from, so now I am cured.”

No!  It will not work like that.  A behavior that has its antecedents in early childhood development will have consequences beyond our conscious mind.  The repetitions will emerge in a time of stress.  Stress in a young child can be as simple as the child not getting his or her way in the cocoa puff aisle of the supermarket.  The parents know it is  not a good source of food, but the child reacts as if it will not survive if it does not get what it wants.

In this scenario it is not the content (box of sugar cereal) that is the problem, it is the lack of understanding on the part of the parent that the cereal represents a perceived need that appears to the child as if it is life threatening.  This deeply seeded transference can emerge over nothing at all if the child is tired enough.  Children often do not appear as if they need more sleep, but in reality most children need a lot more sleep than they want to get.  And with our school schedules that meet the needs of the corporation first, children are not getting the sleep they need.  This is pretty much true across the board for children of any age.

Once again the parental ambivalence is at work if both parents are not on the same page with regard to helping the child to calmly learn how to sooth themselves and put themselves to sleep.

The child who does not experience a secure connection to the parents is often feeling that not because the parents are not trying to do what is best for the child, but rather they are negatively engaged with each other over any variety of things that a young couple can begin to have differences….money, how the house should look, free time, who has it and who does not, work, who does too much and who is perceived as having it cushy, sex, we are having too much or not enough….the list goes on, and on, and on.

The position of the child who is brought up within the context of an insecurely attached relationship, can adopt the behaviors that the parents have to each other rather that to what we are generally accustomed to seeing as a transference, that is, how the child is attached to the parent.

This “adopted transference” as I might like to call it is as prevalent and as decisively dysfunctional as a direct transference might be. If the parents are unhappy with themselves and by extension with each other the child being brought up by this bond will feel insecure about the bond because the bond that the child is attached to is, indeed, insecure.

Since the 1950’s we have been avalanched with advise from physicians, psychologists, talk show hosts, and new age realism.  In the process we hear at best confusing, if not conflicting messages about what is needed.  We hear a great deal about nature and nurture and as we listen to one side it sounds reasonable and then we listen to the other side and it too appears reasonable.

But most often we are hearing about the attachment to the child….The real hidden problem in our age of anxiety and multi-media bombardment is the lack of conversation that we are having about the impact of a dysfunctional marriage at the helm of the home ship.  If we are conducting our lives within conflict that conflict by contagion will impact the children.

Because every child possesses his or her own unique share of DNA and genetic history, we find it difficult to pose the question to parents.  “Is your dysfunctional marriage influencing the baby in such a way that he or she is picking up on conflict and descent

and using that conflict as a manner of relating to the world.

One of the methods of treating child hood mis-behaviors is called the child-guidance model. That model has the parents or parent being the object of the therapy.  The resistances to change are addressed in the parents and in the process of doing so, the parent is brought into a more direct attunement with the child.

The bulk of the problem for the discontent and disobeying child is in the lack of consistent boundaries.  It is frequently difficult for a parent to be as attuned as is needed to bring about a slow and steady sense of consistency.   We live in a world where the corporate mandate asks of us that if we want to keep our jobs we must make it the main priority in our lives.  That does not square with what a family needs and it certainly does not square with what a child needs.

Bed times are a major cause of protest from the child and if the parents are exhausted

by two long days at respective offices, the child’s  need for a boundary may be too exhausting to execute….In this example the child “winning” the boundary skirmish would have the effect of exacerbating the insecurity of the child.  Further if one parent gives in and the other becomes angry, that will further increase the anxiety and boundary attachment.

The one answer that remains consistent is the need for a couple with a dysfunctional child to get family help.  Once a family is taken hostage by an unattached or a ambivalently attached child, the road is a slippery slope.  As the child ages the consequences become more and more dire to the child’s well-being.

If we want to teach well-being to our children we need to be in a state of well-being ourselves.  If the marriage or coupling relationship we are in is one of negativity, the child risks the chance of becoming not like either parent, but like the relationship that the parents have and are displaying in front of the child…..

If this article resonates, find a way to become engaged with a professional who is able to see this paradigm as a possible cause and therefore a possible solution to the problems of a conflicted child..