Cutting the Healing

The emotional triage performed by therapists for the severely disabled is being eliminated by budget cutbacks

That, in fact, is the reason "there's no one in the state like Ellen Savits," in Glickman's words. According to Barbara Cox, a graduate student in psychology at California State University who is studying the links between depression and disability (and who has cerebral palsy herself), there are few psychotherapists like Savits in the entire country.

The largest reason is also the simplest; disabled clients don't pay well. "Look, when you're talking about the disabled, you're talking about the poor," says Savits' husband, Mike, who heads the music department at Florida Atlantic University. "The two words are practically interchangeable."

That's why Cox, who says she'd like to devote her career to treating the disabled poor, probably won't. She could never afford to. "As a rule of thumb, a third of a practicing psychologist's income goes to overhead. If you're only bringing in what Medicare pays, something like $30 an hour, it's really like you're losing money."

Treatment of someone with a severe physical disability is time-consuming and arduous. "In order to get anything done, you're going to have to commit two hours for every hour you charge," Savits says.

Few of Savits' clients can speak clearly enough to be understood without frequent repetition and a lot of patience on the part of the listener. Many drool and twitch uncontrollably. Few can hold a pencil well enough to write.

Consider McClain. Indeed, he is one of Savits' more verbally adept patients. It took her only a week or so to become accustomed to his speech patterns so that she could readily understand him. With other clients she still has to keep a communication board handy during therapy. This is a device that looks a lot like a Ouija board, with letters and numbers painted on top so that a person who cannot speak can physically spell out what he or she is trying to say by pointing to the letters.

Then there's the appearance problem. "These folks are in wheelchairs and will never get out of them," says Savits. "They can barely talk, they're spastic, they can't control their body movements. Face it, these are not pretty people that many psychologists would want hanging around in their waiting rooms."

Agrees Cox: "A lot of people are put off or scared by someone with a severe speech impediment. They're not really prepared to handle a client who needs communication boards or who has to raise their eyebrows to say yes. I've even had problems finding research assistants." The result: "There's not really a network of providers" of therapy for the severely disabled, says Cox.

Meanwhile, the preferred treatment for the emotional problems of the severely disabled is medication. "I'd say 90 percent of our clients are on psychotropic medication," says Merle Bloomberg, executive director of Advocates For Opportunity, a nonprofit service group for the disabled. "Normally there would be some therapeutic element to this form of treatment, but with these people, the feeling is, give them a pill and they'll be OK."

In the '70s, Cox says, some psychologists argued that a severe physical disability by its very nature caused such damage to the ego over the course of growing up that the resulting emotional problems were as incurable as the physical problems.

That view has since diminished. But it has been replaced by a debate over the connection between severe physical disability such as cerebral palsy and mental retardation.

Most of the clients Savits sees have cerebral palsy, a little-understood disease that has no cure and can spring from many causes. There are three types of cerebral palsy: spastic, athetoid, and ataxic. By far the most common of these is spastic, in which body movement is stiff and difficult. This is the type of cerebral palsy afflicting David McClain. Athetoid cerebral palsy is characterized by uncontrollable movement and twitching, ataxic cerebral palsy by impaired balance and depth perception.

Some of Savits' clients have been diagnosed as being mildly mentally retarded, a label they universally reject. Paul McCarthy, for instance, refuses to go to workshops at one particular group home because, he says, "they want to put me down as an MR (a person with a diagnosis of mental retardation) on their paperwork." In McCarthy's case it's not difficult to see where the assumption would come from. His is an especially spastic case of cerebral palsy that causes him to twitch and writhe so rapidly and violently that he must be strapped into his chair or he'll jerk himself onto the floor. And most diagnostic tests for mental retardation require physical dexterity.

Given that so few psychotherapists devote their full practice to serving the poor, the impact of the law's provision was bound to be slight from a wide-angle view.

But here in David McClain's last counseling session, the law's impact is somewhat more weighty. "As you know, I'm going to have to give up this office space next week, so this will be our last session for a while, David. But you have my beeper number, and I want you to feel free to call me anytime you want to talk."

McClain knew this was coming, but he's still forlorn at the prospect of having to give up his weekly counseling sessions. He'll manage without them, he says. He has no choice. And anyway, "I'm used to losing people."

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