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Psychotherapy and Advocacy

Four Freedoms as Fundamental Patient Rights


Journal of Psychiatric Practice®: March 2019 - Volume 25 - Issue 2 - p 128–131
doi: 10.1097/PRA.0000000000000366

This column differentiates the role of psychotherapist from the role of advocate for our patients. It introduces and provides an overview of areas worthy of advocacy efforts that are encapsulated as Four Freedoms that are inalienable rights of those struggling with the burden of mental disorders: freedom from stigma, freedom from dehumanizing treatment, freedom to pursue recovery, and freedom of access to effective, medically necessary treatment.

PLAKUN: Medical Director and Chief Executive Officer, Austen Riggs Center, Stockbridge, MA; and Founder, American Psychiatric Association Psychotherapy Caucus, Washington, DC

The author declares no conflicts of interest.

Please send correspondence to: Eric M. Plakun, MD, Austen Riggs Center, 25 Main Street, Stockbridge, MA 01262 (email:

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The role of psychotherapist demands commitment to the task of psychotherapy. When we meet with individual patients to negotiate a frame for and the terms of psychotherapeutic treatment, we ask them to join us in a commitment to the shared task of the work. This important step in negotiating the therapeutic alliance conceptualizes the work of psychotherapy as a “third.”1 That is, in addition to the 2 members of the therapeutic pair of individual psychotherapy present in the consulting room (ie, patient and therapist), there is also in the room and in the relationship the “third” of the psychotherapeutic task. This task is a serious one to which both therapist and patient are expected to be committed and subservient. For example, as noted in a previous column, should a patient introduce thoughts about suicide, one component of a sensible clinical discussion of this worrisome development will inevitably be exploration of what has happened to the patient’s previously negotiated commitment to the work.2

The dictionary definition of advocacy is “the act or process of supporting a cause or proposal.”3 With the exception of therapies limited to a supportive focus, psychotherapy is distinct from advocacy for our patient. In psychotherapy we may advocate for the “third” of the shared task of therapy, as when we explain to a utilization reviewer how a patient meets criteria for a kind of treatment or level of care, and this may be of use to the patient. Here we are not strictly advocating for the patient as much as for the work.

However, psychotherapists also have roles outside the consulting room. This may be as educators, supervisors, students, supervisees, members of a professional organization, and even as citizens. It is in these roles that those who identify as psychotherapists have an advocacy function that looks beyond individual patients to the greater good of those struggling with the burden of mental disorders. Advocacy for access to psychotherapy and other treatment for mental disorders is consistent with if separate from the provision of psychotherapy when framed in this way. In fact, there is a long list of potential areas of advocacy relevant to psychotherapists. Arguably, the list begins with fighting stigma or with advocacy for implementation of the 2008 Mental Health Parity and Addiction Equity Act (mental health parity law), but there is much more. This column offers an organizing structure for thinking about areas of advocacy by psychotherapists, but also for other clinicians, patients, their families, citizens, and legislators—indeed, anyone who is concerned about the civil rights of those struggling with the burden of mental disorders.

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In his January 1941 state of the union address on the eve of World War II, with war clouds gathering in Europe, President Franklin Roosevelt spoke of Four Freedoms that were pillars of liberty and democracy: freedom of speech, freedom of religion, freedom from want, and freedom from fear. Roosevelt’s “Four Freedoms” speech proposed a “second bill of rights,” among which he listed “The right to adequate medical care and the opportunity to achieve and enjoy good health.”4

In 1943, illustrator Norman Rockwell painted 4 iconic illustrations of these freedoms as part of a campaign to sell war bonds. Currently these paintings are the centerpiece exhibit of his work at the Norman Rockwell Museum in Stockbridge, MA, the town where I live and where the organization where I work, the Austen Riggs Center, is located. We find ourselves living in an America that is much more diverse than in Roosevelt’s and Rockwell’s time, while also struggling mightily with tribal fragmentation, xenophobic fear, and a broken mental health system. Reference to Roosevelt’s and Rockwell’s versions of American identity may at first seem quaint and old fashioned, but the Four Freedoms as representing core American values are needed now more than ever. This may be why the Smithsonian Magazine recently elected to reimagine the Four Freedoms from a 21st century perspective.5

This year marks the 100th anniversary of the founding of the Austen Riggs Center, the 175th anniversary of the founding of the American Psychiatric Association, and the 50th anniversary of the founding of the Norman Rockwell Museum in Stockbridge. At this moment, following Roosevelt, Rockwell, and those artists who recently reimagined Rockwell’s Four Freedoms for 21st century America, and with advocacy for patients in mind, we would be wise to hold in mind a new bill of rights for those struggling with mental disorders. This column offers a new version of the “Four Freedoms” relevant to advocates for the rights of those struggling with mental disorders:

  • Freedom from stigma.
  • Freedom from dehumanizing treatment.
  • Freedom to pursue “recovery.”
  • Freedom of access to effective, medically necessary treatment.
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Stigma takes many forms. Unless there is clear evidence that safety is at risk, our patients deserve to be treated as competent human beings with all associated rights, privileges, and responsibilities. Of the many forms stigma may take, among the most pernicious is the view of mental disorders as in some way less significant than medical or surgical disorders. Here, psychotherapists and others have no better goal for our advocacy efforts than to support full implementation of the mental health parity law. This law requires that obstacles to accessing care for mental health and substance use disorders be substantially no more stringent than those for accessing medical-surgical care. The mental health parity law specifies that this applies both to quantitative limits (QTLs) and non-QTLs (NQTLs) to access to care. QTLs are numerical limits, like restriction in lifetime or annual dollars or numbers of outpatient sessions for mental but not medical disorders. NQTLs often take the form of higher utilization review barriers to access treatment for mental than for medical-surgical disorders.

Another insidious and subtle example of stigma in the form of an NQTL is lower compensation to psychiatrists than other physicians. A 2017 Milliman report found that psychiatrists were paid on average 20% less than when the same service code or procedure code was provided by an internist or other nonpsychiatric physician—and in many states the difference was much higher—up to 70%.6 The study suggests that the impact of this form of stigma is not just on psychiatrists’ pocket books. The economic pressures force psychiatrists out of network and contribute to the shortage of in-network providers to whom patients have access. The same forces affect payment and in-network availability for other mental health clinicians.

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Needless use of seclusion and restraint are obvious examples of dehumanizing treatment, but dehumanizing treatment can take more subtle forms than failing to offer treatment in the “least restrictive environment.” Our patients bring us their human suffering. They deserve to be met with our human compassion and attunement. This means engaging our patients genuinely as people with a story, and not reducing them to symptom checklist respondents, diagnostic entities, or receptor sites for molecules. The importance of patients having the opportunity to tell their stories is recognized as part of the healing process. We must advocate for listening to their narratives as a central part of treatment—indeed perhaps this is the heart of “personalized” or “precision” medicine in psychiatry.

Psychiatrists caught up in systems of care that provide dehumanizing treatment are at risk for burnout. Without evidence that it is an effective treatment, some systems of care shift the role of psychiatrist to prescriber in days full of 4-per-hour 15-minute medication checks. This is an example of how advocacy for better care for our patients can result in taking better care of ourselves!

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The generally accepted goal of treatment is more than symptom remission and crisis stabilization.7 The appropriate long-term goal of treatment of mental disorders is best captured by the term “recovery,” which the Substance Abuse and Mental Health Services Administration (SAMHSA) defines as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”8 Achievement of recovery is a process that unfolds over time and offers patients hope of finding their lives meaningful and worth living. Finding meaning in life matters to all of us, and it is often facilitated by attention to the meaning of our patients’ suffering.

Advancement of the pursuit of recovery requires advocacy for access to treatment that includes both biological and psychosocial interventions, the latter including psychoeducation and psychotherapy. Psychoeducation offers patients the opportunity to put their suffering into context by learning about their disorders, while psychotherapy, whether psychodynamic, cognitive behavioral, individual, group, or another form of therapy, offers patients the hope of grappling with the meaning of their symptoms and suffering so that it becomes possible to acknowledge, bear, and put them into perspective in the service of improved functioning.

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Patients often have difficulty gaining access to needed, desired, and clinically recommended care from insurance or managed care entities. It is worth noting that the SAMHSA definition of recovery notes that “Recovery is built on access to evidence-based clinical treatment and recovery support services for all populations”8 (italics added). A previous column reviewed this problem in some detail.7

Difficulty gaining access to effective, medically necessary mental health care is a predictable feature of work in a managed care environment. It is often difficult to gain approval from gatekeepers who determine the need for access to care, whether this is at an outpatient, inpatient, or intermediate (eg, intensive outpatient, partial hospital or residential treatment) level of care, when their criteria focus on crisis stabilization rather than recovery. Managed care access to care practices that impose NQTLs that restrict patients from ready access to effective and medically necessary care (1) are at variance with requirements of the mental health parity law, (2) are inconsistent with the intent of SAMHSA to support recovery in patients, (3) contribute to treatment failure, chronicity, and recurrence in patients, and (4) contribute to clinician burnout.

Patients seeking access to treatment at intermediate levels of care are sometimes denied care through the cynical argument that it is better for them to receive care in the “least restrictive setting,” where any level of care higher than outpatient is seen as “restrictive,” even if it is desperately sought by a patient and family and recommended by treating clinicians.

It is worth stopping to consider what “least restrictive” refers to. As Richard Lovelace wrote in his 1642 poem, “To Althea, from Prison,” “Stone walls do not a prison make, nor iron bars a cage.” It is clear that outpatient treatment is less restrictive than a locked inpatient setting, but, as the poet knew, restriction does not refer only to limitations in freedom to move about. Restriction also includes limitation of the right to access to medically necessary and effective care.

It is far more “restrictive” to leave someone suffering with overwhelming symptoms and recurrent crises in a lower level of care than to offer adequate treatment in an unrestrictive higher level of care, like an intensive outpatient program or residential treatment center. Restriction of a patient’s civil rights is a spurious concern in voluntarily sought outpatient treatment, or in an intensive outpatient program level of care, or in a patient’s actively sought immersion in voluntary residential treatment.

This is not to suggest that every patient has a right to psychoanalysis several times a week or to residential treatment. It does mean, however, that patients who, for example, meet widely accepted criteria for residential treatment, such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) criteria, have a right to access to the residential treatment that is warranted.9

Insisting on freedom of access to effective, medically necessary care is a worthy area of advocacy for clinicians and patients. Recently this kind of advocacy has been happening through class action lawsuits that target insurance entities for their flawed stances that restrict access to care by conceptualizing the goal of treatment to be crisis stabilization rather than achievement of recovery. Another step we can all participate in is joining the efforts of organizations that pursue implementation of parity such as “Parity at 10.”10

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The problems captured by the Four Freedoms—stigma, dehumanization, focusing treatment on crisis stabilization rather than on recovery, and imposition of cynical and disingenuous managed care obstacles to access to care—are major burdens for our patients. Many of these problems also contribute to psychiatrist or clinician burnout. Advocacy for the Four Freedoms as basic and inalienable rights of patients struggling with mental disorders—as individual clinicians, through our professional societies, and in the courts—is distinct from the role of providing psychotherapy to patients, but it is a role that is closely and properly linked to our patients’ interests.

Advocacy for the Four Freedoms sometimes involves advocacy for cultural change—as in fighting stigma. Sometimes advocacy for the Four Freedoms is advocacy to broaden a narrow biomedical perspective that may contribute to dehumanization of patients by viewing them through the narrow lenses of biochemistry and brain imaging while neglecting the lens of their personal stories. Sometimes advocacy for the Four Freedoms is insistence on following best practices (as in pursuit of recovery rather than crisis stabilization as the goal of treatment). Sometimes advocacy for the Four Freedoms involves insisting that those who fund treatment be held to the terms of the insurance contracts they enter with subscribers, and to the requirements of the mental health parity law. These are all goals worthy of our advocacy efforts that are encapsulated by the Four Freedoms.

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1. Muller JPPlakun EM. Why the pair needs the third. Treatment Resistance and Patient Authority: The Austen Riggs Reader. New York: Norton Professional Books; 2011:97–120.
2. Plakun EM. Psychotherapy with suicidal patients part 2: an alliance-based intervention for suicide. J Psychiatr Pract. 2019;25:41–45.
3. Definition of “advocacy.” Available at: Accessed December 8, 2018.
4. Second Bill of Rights. Wikipedia article. Available at: Accessed December 8, 2018.
5. Tucker A. A 21st-Century Reimagining of Norman Rockwell’s “Four Freedoms.” Smithsonian Magazine, March 2018. Available at: Accessed December 12, 2018.
6. Melek SP, Perlman D, Davenport S. Addiction and mental health vs. physical health: aalyzing disparities in network use and provider reimbursement rates. Milliman Research Report; December 2017. Available at: Accessed December 8, 2018.
7. Plakun EM. Clinical and insurance perspectives on intermediate levels of care in psychiatry. J Psychiatr Pract. 2018;24:111–116.
8. Substance Abuse and Mental Health Services Administration (SAMHSA). Recovery and recovery support. Rockvlle, MD; SAMHSA; 2012. Available at: Accessed December 8, 2018.
9. Sowers W. Chair of task force on level of care determinations of the American Association of Community Psychiatrists (AACP). Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS), Adult version 20. Dallas, TX: AACP; December 2016. Available at: Accessed January 28, 2018.
10. Website for Parity at 10. Available at: Accessed December 11, 2018.

psychotherapy; advocacy; recovery; mental health parity law

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