The article: “What Brand is Your Therapist” in the NY Times Sunday Magazine, November, 25, 2012, brings to mind a deeper dilemma facing serious psychotherapists today who believe in and practice long term treatment. As a psychoanalyst, having gone through eight years of post graduate training and having been in private practice for over 35 years, I have grown increasing alarmed over the current trends, including ‘Branding’, influencing the public’s belief in the value of long term, depth-oriented psychoanalytic treatment. It is paradoxical that while I grow more and more convinced of the value of my work with clients; seeing the long term benefits in improvement of quality in intimate relationships and a significant rise in successful achievement of career goals, (incidentally following Freud’s definition of mental health as “the ability to love and work”), there seems to be several powerful factors working against the public awareness of this belief. I have written extensively in previous posts about what I see as the hijacking of psychotherapy by the insurance industry, medical profession and the pharmaceutical lobby, as well as the value of long term psycho dynamic treatment.
(This may seem a bit long winded, but bear with me and I promise to get back to ‘Branding’ by the end of this post!)… Insurance companies have grown more and more self confident in their ability to control the quality and duration of psychotherapy, by defining strict guidelines for reimbursement, as they become larger and more powerful by buying out and absorbing smaller, previously competing companies. They set standards for treatment that, in my view as a clinician, often has very little to do with how people grow on an emotional level. Instead, they try to place psychological/emotional ‘wellness’ into a medical model based on diagnosing and then curing illness. While there are some severely damaged individuals who may fit into this type of categorization, i.e. chronically psychotic, there are many more seemingly healthy individuals who may simply want to improve the quality of their emotional life. This kind of work requires time and commitment. Are these people any less deserving of financial support for their attempts to improve personal, emotional issues simply because they are currently more functional than those in more dire, overt need? Insurance companies seem to offer reimbursement for drug addiction rehabilitation programs much more than for psychological treatment that might help reduce the potential for future addiction. It seems to me to be more logical to put their resources on preventative measures rather than treatment after the addiction has already manifested and created devastation in the lives of their policy holders. This irrational misdirection of funds seems to be the result of the medical lobbyists who advocate for expensive drug rehabilitation programs. Unfortunately the success rate of such programs seems much lower than the success rate of preventative treatment. Once someone is addicted, it becomes much more difficult to treat them because they have added an addictive substance that has physiological factors beyond the emotional factors that led to the original choice to use the substance, that now complicate the clinical treatment.
I have recently had several discussions with clinical consultants hired by insurance companies to review the status of the treatment of several of my clients who subscribe to these insurers, for approval of their additional ongoing treatment coverage. I first submit a written questionnaire via fax after every 6 sessions, describing the progress in behavioral goals. I then await a call from a reviewer who has basic training in behavioral model treatment, who then interviews me and reviews the form, typing the data into the companies data base for future use. If treatment is approved, I must once again go through this process after the next 6 sessions. This time consuming process seems to be mostly designed to wear down providers and subscribers in their effort to gain reimbursement for psychotherapy. In one case, continued coverage was denied because the client, who had a struggle with depression, had refused to comply with the insurance companies demand that she seek psychotropic medication. I tried to explain tho the interviewer that this client had parents who were both actively addicted to prescription medication and that it was a healthy decision for this client to not follow this path. In spite of my protestations continued coverage was denied. Another client had finally uncovered, after 2 years of intensive therapy, a repressed memory of as a young child, having observed a murder. My attempt to change the diagnosis to a more appropriate one, as a result of this new information, was denied by an insurance company employed ‘reviewer’ the client’s coverage was discontinued.
In another recent article in the New York Times on the struggle for reclassification of personality disorders, what the author doesn’t report is that the difficulty in classifying personality disorders has been complicated by the insurance industry lobby that does not want to have them included in mental problems that are reimbursable through insurance since they require long term treatment and don’t easily fit into their preferred formula for short term, medication driven treatment.
These decisions need to be taken out of the hands of corporations that have as their goal, the accumulation of profit and shift the focus onto the welfare of the public. Mitt Romney was right when he said “corporations are people too“, but unfortunately they are sociopaths and have no social conscience or remorse for the damage they may do in seeking their tightly focused goal.
As a clinical professional having the best interests of my clients at heart, I am seriously conflicted about engaging with a system that may be putting my clients at risk by having their most intimate personal information placed in the hands of such unscrupulous entities. I much prefer setting an individual fee for service that the client can afford to pay without the intrusion of insurance companies. Unfortunately today, most new clients come into treatment with their insurance forms in hand and expect to have their treatment at least partially covered.
So while we as psychoanalysts may be struggling as a profession for survival among these powerfully influential forces, and competing with each other for clients, I hope that our attempt to identify ourselves as having a service of value, does not get lost behind the current trend of ‘Branding’. The connotation of having a particular area of expertise that identifies you as unique may imply an oversimplification of the complex work that we actually do and the training that we have undergone to arrive at this point in our careers. Finding your ‘Brand’ or ‘niche’, while it may be practical in terms of differentiating yourself from other clinicians and initially securing new clients, should not divert attention from the importance of a serious, deeply committed course of training and experience that provides the foundation of any serious clinical practice. This will, in the long run, be what keeps your clients with you long enough to enable them to grow in ways that are not supported by their mental health insurance. It will help them to learn the value of a deeply rooted personal commitment to grow and change that can only be taught by the provision of an experience that promotes deep personal insight. This often takes time. Often more time than insurance carriers may provide coverage for. Many of my clients choose to remain in therapy for years, as they learn about themselves, improve their interpersonal relationships and successfully progress in their career paths. I plan to write another post, in the near future, on the value of ongoing group therapy for clients who decide to end their personal individual therapy but want to have some way to maintain an ongoing support system that helps them to validate authentic aspects of themselves as they continue to navigate through the complexities of their lives.