Employers and insurance companies don't like to pay for treatment over which they have little control, particularly psychotherapy. So when medical costs rose in the 1970s and '80s (very little of the rise actually was attributable to outpatient psychotherapy), the insurance system lashed back. The managed-care/HMO system was created as the great savior, the David who would slay the spiraling health-care cost Goliath. In the mental-health field, HMOs reduced costs by scrutinizing all aspects of the therapy process, and structuring and formalizing the very individualized art of psychotherapy.
They designed endless reams of paperwork, treatment plans, requests for authorization of sessions, update forms, termination forms, provider-credentialing questionnaires, checklists, surveys, newsletters and contracts. The average practitioner working in a small office with limited office staff was suddenly bombarded with a cascade of bureaucratic froufrou, which even experienced support staff could not fathom or surmount. Therapists were frequently told that they could no longer see this or that patient because they were not in the right provider network (and couldn't gain access to these networks because they were "closed"). Or they were denied payment for services because their treatment had been deemed "not medically necessary" by some overworked case manager sitting behind a computer terminal. Demands were made on therapists to share intimate details of their patients' lives with these case managers in order to justify treatment. The individual patient became a "unit of service," an "insured life," a digit, a widget.
Therapists found themselves attempting to fit patient progress into terms that were easily countable and quantifiable because that was the only language spoken by managed care. We used to joke that a suitable managed-care therapy goal was that the patient would move from using 10 tissues per session to three or four. In the words of Hans Strupp, the great psychotherapy researcher, "If you can't count it, it's not there, and if you can count it, that ain't it!" One colleague told me that she spent half the day, at a managed care workshop, learning different ways to say "Wow," in order to convince the patient that they'd made such splendid progress in so short a time that now it was time to terminate treatment. Wow.
Now the people who staff managed-care companies are not demons or greedy autocrats. Like the rest of us, they enter the work with good and hopeful intentions. But when they become engaged in a system that is too profit-driven to consider the nuances of caring for people, they end up in a bureaucratic dance of death with the therapists and patients on the other end of the phone line. And we, myself and my brothers and sisters in managed-care companies, end up in angry phone consultations, forced, by corporate policy, to see each other as the enemy. This hardly contributes to the spirit of care and healing that we'd all like to create.
In short, the field that sought to help people move beyond compulsive, neurotic symptoms has itself been straitjacketed, ironically, into the most compulsive, oppressive system imaginable.
And so, when someone sits in my office considering with utmost sincerity whether to end their life, I have to struggle to set aside all the nonsense about benefits limitations and treatment authorizations. This person doesn't need a paper-driven compulsive to help them find their life spark; they need a human being who cares and is willing to take the time, however long or difficult, to help. Psychotherapy is a confusing, uncertain craft which, nevertheless, actually helps the majority of patients. It's not predictable. It is an art that flows in the strange and spontaneous movement of the patient-therapist interaction. It is practiced by people who don't typically gravitate towards business, but rather towards human connectedness and empathy. We are no match for the profit-driven, bottom-line machine of the managed care industry and it is grinding us into mincemeat.
Allowing giant monopolistic corporate control of therapists and the treatment environment is a dangerous abdication of our moral responsibility to care for one another. Unless we decide to take an active stand in how we provide care, our hearts and souls may soon be warehoused in the industrialized factory of "Managed Behavioral Health Care." Wow. S
Jesse Rabinowitz, Ph.D. is a clinical psychologist who directs the counseling program at Jewish Family Services in Richmond, Va.
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