Psychotherapy and insurance: the double bind

USA Today (Society for the Advancement of Education), May, 2004 by Dolores Puterbaugh

Many "therapists feel frustrated, threatened, and trapped in an unhealthy alliance" with insurance companies.

WHEN THE PHONE RINGS in a therapist's office, prospective clients invariably ask the same questions: "Are you accepting new patients?"; "My problem is my (job/stress/ spouse/teenager). Do you work with this issue?": and "Do you take my insurance?"

The first question determines the necessity of ally further conversation. The second and related queries to establish the therapist's personal style, approach, training, and background would seem of critical importance. The final one, however--"Do you take my insurance?"--is the real deal-maker or -breaker in the delicate task of selecting a psychotherapist. Clients shopping for a usually show little interest in whether I am a barely functioning hack or a highly respected professional. They do not seem to care if I am the kind of person whom they would not want rummaging about in their head, heart, and soul. What matters most is whether or not I accept insurance.

I do not accept insurance for counseling services. Since the situation described is almost always a life issue, rather than a psychiatric emergency, there are almost no insurance plans that would cover the client's claim. Health insurance as we know it is illness and accident insurance, meaning there must be a diagnosis. It is the absence of health that is billable. For counseling professionals, a bill able problem would be a mental disorder. This is why I have elected not to apply to insurance panels and have the resultant small practice,

There are three distinct ethical dilemmas in the use, or abuse, of mental disorder diagnoses and health insurance for life problems:

* Diagnoses are generally subjective sometimes political, and always inadequate to the task of describing the human condition.

* The health insurance system was instituted to pool resources mad risk in the high-stakes world of health care cost management. It is an abuse of this trust to manipulate diagnoses to save someone money on a personal issue.

* Clients are almost always unaware of how insurance companies operate. They seldom understand what the paperwork being filed tells others about them. For this reason, few comprehend that the immediate benefit of insurance may be far outweighed by future damage to their quality of life.

These are powerful reasons to shun insurance companies' interference with the counseling profession, but a double bind markedly similar to codependence has arisen. Over the last two decades, as insurance companies became bigger and more powerful, they began to provide referrals for therapists who, in turn, sought to try to please those insurance companies. Professional practices evolved to meet the companies' demands. These included the increasing use of diagnoses, different kinds of forms kept on file, and utilization of a specific billing format. At present, most therapists believe they could not possibly survive without the insurance companies. Where would they go, and what would they do? Like a spouse whose soul and body have been badly battered, therapists feel frustrated, threatened, and trapped in an unhealthy alliance. A successful counseling practice without the insurance companies seems impossible, even as the demands become more intrusive and fees smaller.

Diagnostic roulette

To be consistent with their origins as physical health underwriters, insurance companies require a diagnosis in order to cover a mental disorder. These diagnoses are drawn from the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, now in its fourth edition. The DSM comprises hundreds of diagnoses and subcategories, with criteria in the form of lists. It is important to note several things about the manual.

The DSM began as a means of abbreviated communication between professionals for the purpose of case review, supervision, consulting, and related quality-control procedures. Rather than listing every specific complaint of a client, two professionals can exchange one or two words and, with knowledge of the DSM, have a working mutual understanding of the client's general troubles. Thus, appropriate treatment alternatives can be discussed without weeding through unnecessary options.

In supervision, while respecting the client's anonymity, I can say I am preliminarily working with mild to moderate seasonal affective disorder (SAD), but want to rule out dysthymia. My colleague will understand, with those few words, that I am discussing a situation where the client's low-level, persistent depressed mood, appetite changes, sleep pattern disruption, etc. are probably due to the seasonal changes in daylight, but I am not yet completely sure that this is not a case of low-level depression persistent over time. We can immediately explore the recommended interventions for SAD without wasting time discussing irrelevant treatment modalities.

The criteria in the DSM are subjective and, except for a few neurological disorders, not measurable by scientific tests. Experts cannot agree even on those well-known diagnoses that many therapists blithely, and illegally, may toss out to frustrated parents. Attention-deficit disorder (ADD) and attention-deficit/hyperactivity disorder (ADHD) criteria, causes, and treatment were the subjects of. the National Institutes of Health's Consensus Forum in 1998. The only consensus the leading professionals reached was that ADD/AD-HD could not be clearly defined, reliably diagnosed, or predictably treated given the current research.