Can Insurance be Good for Psychotherapy?

What a Week!

This has not been a good week. Not the worst, but definitely challenging to my composure as a psychotherapist. I spent a difficult half hour on the telephone in second-level case review with the mysterious “Dr. S.,” who kept repeating (after pregnant pauses, perhaps timed perfectly to chip away at my ever-diminishing self-esteem): “I just don’t understand!” What was so hard to understand? My client came to me in crisis, and after we worked toward a new state of normal for her, we moved naturally into the mysterious, rewarding, often time-consuming phase of therapy that I love and that keeps me riveted to this work: psychodynamic deep therapy, exploring the way childhood traumas, big and small, keep impacting a person’s self-concept, thoughts, behavior, attachment style, and relationships. My client is a natural at therapy and has made magnificent progress in our work. I look forward to her hour, and, of course, I care tremendously about her. So, when “Dr. S” called back later that day to inform me that I was only allowed three more sessions to “terminate” with her, I was deeply upset (shocked and angry, mostly), and I wondered how long I can with good conscience continue to provide the quality and type of psychotherapy I think most benefits my clients if they are using insurance to pay for my services.

Insurance: To Use or Not to Use?

As a newly-minted licensed Marriage Family Therapist, I (pessimistically) applied to eight (yes, EIGHT!) insurance panels, thinking that my relative inexperience would make most companies reject my application. To my surprise, I was accepted by seven (yes SEVEN!) panels. I was quickly flooded with insurance private practice clients while working a 30-hour-a-week job as a group home therapist for severely emotionally disturbed kids: clearly not a sustainable situation! I soon had 18 private practice clients and took the happy plunge into self-employment. Over time, I have slowly whittled down to three insurance panels, which have provided me with a steady stream of wonderful clients. For the most part this has been a success: I’ve been able to connect and work well with the majority of clients sent my way, and I have had minimal interaction with and interference from the insurance companies. Granted, conversations with insurance personnel have required the obligatory mention of Cognitive Behavioral Therapy (pretty much the only type of therapy in which they seem to believe, and, I admit, useful in certain instances; though psychodynamic psychotherapy is beginning to be officially recognized as an evidence-based practice: https://www.apsa.org/portals/1/docs/news/JonathanShedlerStudy20100202.pdf; http://jama.jamanetwork.com/article.aspx?articleid=1028649; http://www.tandfonline.com/doi/abs/10.1080/00107530.2014.880312#.U8w5GbHb4k4), but for the most part, I have found insurance review personnel to be respectful and accepting of my eclectic, client-specific approach to psychotherapy, including justifications for deep, attachment-focused work. Hence my lack of preparation for the conclusions of the axe-wielding “Dr. S.”

The first reaction of my humorous husband (who used to work as an auditor himself, in a different field) was a text that read: “Auditors eat their young.” The ensuing chuckle broke my funk, and refocused me on my intention to fight the insurance company’s decision regarding my client with everything I’ve got. But “Dr. S.” has me thinking: how much am I willing to compromise my work as a psychotherapist to fit the insurance companies’ mold of an ideal therapist (i.e., providing brief Cognitive Behavioral treatment focused solely on symptoms and behaviors as delineated in the DSM)? I think perhaps it’s a question my clients should ask themselves as well: do they want insurance companies to have access to details of their personal lives and to dictate what should be happening between us in my office? Do they want one-size-fits-all psychotherapy? And if psychotherapy will only to be sanctioned by insurance companies when a client is in crisis, this needs to be made very clear in their policies. My client pays premiums in order to access psychotherapy through her insurance, which I believe means she should have some say in the type of service she receives.

Conclusion?

I’m not quite ready to see only private pay clients: I believe in affordable access to psychotherapy, and like most middle-class folks, I understand the sacrifice in paying for weekly out-of-pocket psychotherapy. But the fact that an insurance reviewer has such power and can pull the plug on successful therapy without even meeting or speaking with the client seems wrong to me, and it makes me wary of taking on the responsibility of becoming the therapist to anyone with that particular insurance: we might work hard to get to the point of diving off into the juicy, most meaningful, change-inducing part of therapy, only to be abruptly told we have to “terminate.” Isn’t the principal ethic of medicine and psychotherapy “Do no harm?”

Comments

  1. admin says

    Touche, Rory. I’m wondering about the ethics of the last few reviewers that I’ve spoken with: they certainly don’t aspire to “do no harm” to me, the clinician ;). This is a difficult issue, and I’m not sure how we as clinicians should respond. Many clinicians I know are just getting off panels in order to be able to practice therapy ethically and with no Big Brother effect, but what about middle-class folks who can’t afford $120-140/hr for therapy?

  2. Rory Osborne says

    Yes, you’re right, the principal ethic for medicine and psychotherapy is: “Do no harm.” However, an insurance company’s principal concern is, as you have said, to make money, and that might or might not have a relationship to the therapist’s principal ethic. Most of the concern they have for doing no harm has to do with potential liability issues that might arise for them which, again, relates to money. This, of course, is problem enough for those of us who have a differing focus. However, an additional irksome issue is that such organizations often take the position that they actually share our ethical principle at the same level and for the same reasons we do. And, frosting on that proverbial cake is that, seemingly, at times they actually believe that they are sincere (i.e., they have convinced themselves) at holding the no harm principle for the same reasons we do. Sad indeed.

    R

  3. Jacci O'Connor says

    Well said, Catherine. Thanks for articulating so well what many good clinicians (and their clients) have gone through and will continue to go through.

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