Can This Relationship Be Saved?
Once there was a time when whatever you said to your therapist was held in strict confidence. Then came managed care.This initiated a radical redefinition of psychotherapy, with disastrous consequences, many of them hidden, for clients and therapists alike. The working relationship between psychotherapist and client is being eroded, if not destroyed, by incompatibilities among the financial aims of health maintenance organizations (HMOs), the concerns of providers and the needs of clients.That's why we, psychotherapists with a combined 30 years of clinical experience, have begun a new practice, Independent Psychology Alliance. We and our colleague, Barbara VerKuilen, charge a reasonable flat fee and do not accept insurance payments. While this might exclude some from seeking our services, we believe a divorce of psychotherapy from insurance coverage is essential to protect confidentiality and individualized treatment.We view our clients' courageous decisions to seek change in their lives as a sign of mental health. Before insurance companies will pay for therapy, however, clients must be assigned a psychiatric diagnosis of mental illness. This diagnosis, as well as the reasons an individual is seeking therapy, must be available to anonymous reviewers. Unbeknownst to many people currently in therapy, this information may show up in computer data banks of future employers and insurance providers. This undermines the most basic tenet of psychotherapy: confidentiality.The following stories, drawn from our experience, use fictional characters--two clients and a psychologist-- who encounter very real problems as they navigate the present mental-health-care system. They throw light on repercussions of "managed care," an oxymoron if ever there was one. Our stories begin with Sarah and Ed, both of whom have decided to seek psychotherapy within the managed-care system. Each has been interviewed over the phone by an anonymous case manager, who has approved an initial session with a therapist from the HMO's list of providers.Sarah enters the waiting room nervously. She has left her two daughters home with a vague excuse about a meeting and a request to clean the kitchen in her absence. Several people are sitting in chairs looking at magazines or absorbed in thought, and Sarah feels almost invisible as she steps up to the reception desk. The woman sitting at the computer asks for her name, assigned therapist and insurance card. She gives Sarah a clipboard of forms, then reaches for a ringing phone, gesturing for her to go back into the waiting room.The first form requests her name, address and a signature granting the office permission to release information to her insurance company. That done, Sarah starts on the second form. Age: 45. Sex: female. Marital status: married 20 years. History of psychiatric treatment: none. Place of employment: unemployed. Reason for seeking treatment.... This one is not so easy. She considers various answers, and settles on "just can't cope." She returns the clipboard to the receptionist, who accepts it with a nod, continuing to enter data into her computer. Vaguely, Sarah wonders who will be looking at her forms, and what they must be thinking of her, a grown woman, mother of two, a formerly successful professional, who apparently is unable to deal with her own life.The therapist who comes to greet her looks kindly enough, and once in his office, Sarah finds herself dissolving into tears. Somehow, by the end of the session, she has managed to tell Dr. Hardie about how hard it is for her to get up in the morning, how she finds herself fighting tears at unexpected moments, and about how when she isn't crying, she worries all the time. Worries about the children, worries about her husband's health, worries about "stupid things" like being late and getting all the laundry done. Mostly she worries about money--wondering how they are going to make ends meet, with college tuitions around the corner, the mortgage on the house and their accumulated debts from careless financial management. She tells Dr. Hardie that she often can't complete a task because the worry catches up with her, and she just freezes.In response to his questions, Sarah replies that sometimes her heart races, and she gets nauseous and sweaty. Sarah says that although she has had these problems before, things got really bad three months ago, when she suddenly lost her position as an account executive in the telecommunications firm where she had worked for 10 years.When Ed comes into the waiting room, he notices no one. Head tilted customarily toward the floor, shoulders hunched, he glances at people only briefly, eyes slipping off to the side uneasily. He receives the same forms as Sarah, and responds to the questions quickly and automatically: Age: 30. Sex: male. Marital status: single. Employment: research chemist employed by the same lab for seven years. Reason for seeking treatment: referred by doctor. He then places the clipboard by the reception desk without waiting for the woman to take it from him.Ed haltingly tells Dr. Hardie of his chronic insomnia, made worse by the feeling that he has go to the bathroom several times a night. He mentions the digestive complaints and the recent heart palpitations that sent him to his primary-care physician, problems for which no physical explanation could be found.While talking, Ed, who has not taken off his coat, keeps his eyes directed toward the floor, and several times he appears to lose the thread of conversation, lapsing into painful silence. When asked to describe how he feels most of the time, Ed struggles to answer, and says "kind of down, I guess." He is unable to pinpoint when these problems began, saying that he has felt this way a long time, but that it seems to be getting worse.He mentions that he had a serious conflict with a coworker right before the heart palpitations started, and that it has been very hard to go to work since then. Ed talks about his work, referring to the speed with which he was promoted, despite his impression that no one likes him. He doesn't have much of a social life, and although there is one woman whom he has admired from a distance, he has never had the courage to ask her out. He wishes for a family and friends, but is sure he will never have either, although he can't say why. It's not that he thinks there is really anything wrong with him, he just can't seem to get close to anyone.Both Ed and Sarah have come to Dr. Hardie as new clients. Both have insurance for psychotherapy with a local HMO, so the procedures he must follow to obtain authorization for them are the same. Dr. Hardie fills out a form that calls for a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM- IV) for each individual. (The DSM-IV, based on a medical model, designates emotional disturbances as illnesses with specific diagnostic labels.) This will go to a case reviewer, who may not have much clinical experience.Ed and Sarah are presenting a mixture of anxiety and depression. It is difficult at this point to determine the degree to which these symptoms stem from their present situations as opposed to longstanding problems. Although it is impossible to assign an accurate diagnosis with confidence after only one meeting, this is required in order to obtain authorization for further sessions. Treatment must be deemed by the reviewer to be "medically necessary." This means that the problem must be defined as an illness meeting a certain level of severity. However, Dr. Hardie is acutely aware, although his clients may not be, that their diagnoses will become a permanent part of their records, potentially creating significant difficulties for them in the future. His challenge is to find an appropriate diagnosis--serious enough to merit treatment, but with as few repercussions as possible.As it happens, both of these clients could qualify for an "adjustment disorder with mixed anxiety and depressed mood." This is considered one of the milder diagnoses, and, in the case of Sarah, is clearly appropriate to the material she has presented thus far. Although Ed's complaints are also consistent with this diagnosis, Dr. Hardie has the feeling, due in part to Ed's unusually guarded style, that there may be more here than meets the eye. Dr. Hardie is required to detail each problem presented by the client, indicating its duration and severity; develop a treatment plan; define outcome goals behaviorally; and specify the number and frequency of sessions he is requesting.He knows from experience that he has to be conservative in his request. The short-term-treatment model compatible with the HMO's financial interests dictates that unless a patient is suicidal or severely impaired at work or in social situations, a maximum of six to eight sessions is usually imposed. He is also aware that in the absence of rapid progress, there will be pressure for him to refer the patient for medication.Neither Sarah nor Ed came into Dr. Hardie's office knowing that their insurance coverage for psychotherapy involves the participation of a series of uninvited and invisible guests. But in obtaining their insurance policies they authorized disclosure of full information. In addition, the intake form each signed reaffirmed this permission, without spelling out the scope of this release.The reviewer's response is usually forthcoming within 10 days. Since there is uncertainty that sessions will be approved, both clients elect to wait until they are sure that coverage has been granted. In both instances, six sessions of problem-focused therapy are allotted. In Ed's case, there is a disapproving note indicating that Dr. Hardie has not been clear enough in delineating the problem. It is recommended that he give serious consideration to the possibility of a medical evaluation.Dr. Hardie tells each client what has been authorized as "medically necessary." It is likely that additional sessions will be hard to obtain.In the course of the six sessions approved for her, Sarah begins to move from a position of paralysis to an active search for new employment. In treatment, her habit of regarding herself as a hapless victim is challenged, and she regains a measure of self-respect. Additionally, Sarah finds a support group for others cut by corporate downsizing. By the end of six sessions, she has improved significantly. While she has not yet found new employment, she has several good possibilities, and feels more confident and optimistic about her future. She decides to accept the limits placed on her treatment, and to continue with the support group. She does schedule a follow-up session in one month, although it may not be covered by insurance.Ed, however, continues to experience his physical and emotional symptoms unabated. He is still very guarded with Dr. Hardie, although there is sufficient meeting of heart and mind to keep him in therapy. At the end of the fifth session, Ed expresses interest in requesting additional time. He asks about the approval process, fearful that his privacy will be breached. He visibly cringes when Dr. Hardie informs him that he will have to reveal details about his problems and his progress in order to obtain further sessions. Reluctantly, Ed takes the path of least resistance financially, and asks Dr. Hardie to file the request.Dr. Hardie is aware that in the eyes of the HMO company, this will reflect badly on him. The number of sessions requested by each therapist is kept in a computer, and periodically comparison printouts are circulated to each practitioner on the HMO's panel. This is a thinly veiled warning, financially influenced, to restrict length of treatment. He feels torn between his own professional security and Ed's need for more time.With trepidation, Dr. Hardie uses his best clinical judgment, and asks for additional sessions. The reviewer grudgingly approves two to conclude therapy, and recommends a medical consultation, noting that progress has been minimal. Ed is adamantly opposed to the idea of taking drugs, and refuses the consultation outright. He balks at the idea of two more sessions, feeling that would be woefully inadequate.Dr. Hardie offers to continue to see Ed at a reduced fee, which he will have to pay out-of-pocket. Ed elects to continue treatment. He again raises the question of who will have access to his records, and Dr. Hardie assures him that if he is paying for his own treatment, his file is not subject to review by the insurance company or anyone else. The only exception would be if it were court ordered, or Dr. Hardie deemed him to be an imminent threat to himself or others, a remote contingency in his case.At her one-month follow-up session, Sarah is radiant. She has landed a good job, and is elated by its potential. Her depression and anxiety have abated. She still worries, but no longer feels paralyzed by her thoughts. She is hopeful about the future, feels confident that she does not need to continue in therapy, and leaves on an upbeat note.Several weeks later, Dr. Hardie receives an urgent message from Sarah to call as soon as possible. When he reaches her, she is distressed. She tells him that while filling out forms for health, disability and life insurance coverage through her new employer, she honestly answered "yes" to a question about prior mental- health treatment. Due to this information, Sarah has been denied coverage. Distraught, Sarah says she had worried about preexisting medical conditions, but it never occurred to her that six sessions of psychotherapy could cost her future insurance."Why didn't you tell me," she complains bitterly. "What am I going to do?" Dr. Hardie says he will call her company to emphasize the normalcy of her reaction to sudden job loss, but is aware that his influence in this matter is limited.Ed continues to see Dr. Hardie weekly for the duration of the year. No dramatic change in his situation or feelings is evident, but he is gradually becoming more trusting and expressive. One day, Ed comes in with an air that feels palpably different. He is extremely agitated and anxious. Dr. Hardie senses that he is determined to say something important. "I have to tell you something I have never told anyone in my life," says Ed. He is sweating, and his fists are clenched. Dr. Hardie remains quiet, hoping the familiarity of his presence will be encouraging.Struggling to speak, Ed tells him that between the ages of 6 and 10, his family had housed a male student who sometimes baby-sat for him. This young man at first fondled his genitals, then forced him to perform oral sex. Often. For four years. The man had threatened to kill Ed if he ever told anyone.For the first time in their year of working together, Ed looks Dr. Hardie straight in the eye, and after holding his gaze for a moment, begins to cry, deep wrenching sobs.This breakthrough marks the start of slow but unmistakable progress. Ed and Dr. Hardie discuss in depth these early traumatic experiences, and Ed begins to understand how they have profoundly influenced his life. During this crucial time, now in a new calendar year, the question of insurance benefits resurfaces.Dr. Hardie has reduced his fees significantly, but overhead costs keep them relatively high. Ed asks if additional details would have to be revealed in order to obtain more sessions from his HMO. Mindful of his experience with Sarah, Dr. Hardie informs Ed of the damage that may already be done. Insurance companies have the right to request copies of everything, including session notes, in order to determine whether treatment is "medically necessary." Ed is horrified, and quickly concludes that he would prefer to maintain the current arrangement.During this year, Dr. Hardie, along with many other psychologists, is informed without explanation that his contract with the HMO will not be renewed. Since his clinical skills have never been questioned, he suspects he fell into disfavor because of the number of sessions he has requested for clients. Still, he worries that his professional reputation has been tarnished because clients seeking his services will never be given a reason for his dismissal from the panel.His fears are borne out a few months later when Sarah calls to ask if she and her husband could come in for a few sessions of marriage therapy. (Unable to get insurance under her current job, Sarah opted to pay for federally mandated COBRA insurance, which allows her to stay on her old plan for up to 18 months.) She is dismayed to learn that Dr. Hardie is no longer on the panel. "What did you do wrong?" she asks.Dr. Hardie tells her what he knows and explains that marriage counseling is not a covered benefit anyway. Sarah has two choices at this juncture: start over with a new therapist or find a way to pay for therapy herself.The stories of Sarah and Ed illustrate many central problems.Medical necessity, a prerequisite for insurance coverage, imposes the stamp of "illness" on individuals who are struggling to improve the quality of their lives. Confidentiality of the therapy relationship is compromised. Accurate diagnoses are rendered difficult, if not impossible, because they have to be made so quickly. Medication is often substituted for psychotherapy because the masking of symptoms is faster and cheaper than a deeper resolution.We know from our own private lives and research that to develop a trusting relationship takes time. Without such a relationship, treatment cannot be effective.A victim of early sexual trauma, like Ed, becomes a member of the walking wounded who must rely on antidepressant drugs, rather than having the opportunity to resolve his emotional pain. Epidemics of "biochemical disorders," such as attention-deficit and hyperactivity disorder (ADHD), suddenly emerge, requiring amphetamine treatment, a quicker fix than evaluation of whether the distracted child is manifesting familial problems. This is particularly ironic in a country that is currently espousing a commitment to family values, and has launched a massive and costly campaign against the use of drugs and alcohol.An additional irony of cost-containment efforts is that effective psychotherapy can be the most economical treatment for individuals such as Ed, whose complicated physical complaints emanate from psychological trauma, and are unresponsive to expensive medical interventions.And what of the healers, the psychotherapists? The caretakers labor fearfully, and with increasing cynicism, as employees of the bureaucratic institutions upon which they have come to rely. Therapists, too, are in need of a cure.