USA Today (Society for the Advancement of Education): Psychotherapy and insurance: the double bind

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.

Another issue with the diagnoses in the DSM is the politicization of the process. Disorders are decided upon, then withdrawn or changed as social currents demand. Homosexuality, for example, was a diagnosable sexual disorder well into the 1960s. It was subsequently removed from the DSM, and later replaced with a diagnosis for gay people who wished they were not gay.

Homosexuality is not the only unusual citation for a mental disorder. Physiological problems caused by fluctuations in body chemistry, such as premenstrual syndrome, are categorized as diagnosable mental disorders, too. In the case of premenstrual syndrome, this is despite the fact that the symptoms of this "mental problem" are often very physically apparent. Blood hormone levels, for instance, are not typical signs of emotional distress. In an interesting contrast, the depressed mood accompanying another hormonal imbalance--hypothyroidism--has not led to it being categorized as a mental disorder. Paula Kaplan, a psychologist who was on a DSM panel, explored the political process of diagnostic development in her book, They Say You're Crazy, which is a useful resource for anyone interested in knowing more about the machinations of guidelines for mental disorders.

There have even been pressures in some quarters to reinstate previously withdrawn diagnoses, as a mental disorder may qualify one for protection under the Americans with Disabilities Act. Thus, many disorder diagnoses are as malleable as social pressures mandate.

In addition to defined illnesses, the DSM has a section covering the problems that drive most people to counseling: relationships, bereavement, parenting, job difficulties, and other life events. These are described as "V Codes" and are not billable under insurance. They may even include specifications advising the psychotherapist when to use a V-Code and when to use a mental disorder diagnosis. For example, bereavement is just supposed to be used as a diagnosis for the first two months after a death. Any trained hospice professional will state that, until two or three months go by, the bereaved is still in too much shock for any real counseling. Only support is appropriate up until that time. According to the DSM, a long-married person should be pretty much back to normal two months after the death of a spouse. Otherwise, by American Psychiatric Association standards, he or she is mentally ill. This expectation says far more about the professionals behind the development of the DSM than the mental state of grieving family and friends.

Health insurance is a managed risk instrument. In exchange for a premium, I accept a range of services. I select the policy I want with the benefits I believe will be most useful for me. Among many choices, I may opt to have a higher copayment, but more flexibility in selecting my providers, or I may choose to pay for my own day-to-day costs completely and only access insurance for major medical expenses. These are my choices and determine the expectations I should have for the insurance company.

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The insurance company negotiates for bulk purchases of services, such as physician appointments, prescriptions, and blood tests. These providers apply to be on the "panel," the group of providers who will be paid out of the insurance pool. In practical terms, then, the prospective client's real question should be, "Does my insurance company take you?" Fees are established, as are practice criteria--for instance, whether a mental health patient qualifies for six counseling sessions or 10. Being on the panel means accepting these set tees and the practice criteria.

The insurance company also monitors bills submitted to be sure that no one is exploiting the system. If I am pooling my money with other people, I do not want my funds to go towards frivolous or unnecessary services. This is a drain on the pool and will result in higher insurance premiums for all members of it later. I do not want to pay for unnecessary visits for lonely people or massages disguised as a health treatment. I do not want to pay, as health care, for premarital counseling, blended family counseling, someone's finding himself or herself, or any other personal need that may quality as psychotherapy, but not as treatment of an injury or disease.

It my insurance company, when presenting my options, offered limited coverage for life issues, I not only would sign up for it, but expeditiously apply to be a provider for those services. This would be an honest exchange of pooled risk, fees, and services. The trouble is that this is rarely, if ever, the case. More often, marital, family, or personal counseling is provided under the guise of a person's treatment for some mental disorder or another. The ethical dilemma here can be a tenuous one. There may be a certain validity to a diagnosis, but it is not always the rationale for treatment. The diagnosis may be ancillary to the real problem or may be simply a stretch of the criteria. A person having marital troubles might legitimately feel depressed, but that depression is not the issue being directly treated, nor is it necessarily a physical aliment requiring coverage under the client's physical health insurance plan.

When I take my car to be repaired, the mechanic provides a specific diagnostic report and estimate, after careful investigation requiting considerable knowledge, experience, and skill. When my physician orders blood tests, he or she completes a lab requisition listing my diagnosis by code number and the tests correlating to that diagnosis. A physician will not order a cholesterol/blood lipid panel it, for example, preliminarily diagnosing anemia. The provision of expert medical care requires careful observation, the application of knowledge, experience, curiosity, and then the selection of the appropriate scientific instruments and processes to verify the problem and affect a cure.

Diagnostic codes

Provision of mental health services can also include appropriate diagnostics. When research, informed application of it, agreed-upon standards, and compassion meet, good treatment and sound use of diagnostic categories can occur.

When I worked in community mental health with severely disturbed clients, we used diagnostic codes to summarize their symptoms. The diagnosis of the paranoid type of schizophrenia would be utilized to characterize the experience of a client whose complaints included persistent, troubling, and very real-seeming (but not real) threats from the exterior world. The doctors, nurses, case managers, and residential staff could then work to develop a compassionate treatment plan and environment for this client's needs.

When I moved into a children and family-focused agency, we were treating passing behavior problems, blended family issues, and similar life events that impact youngsters and their attending grownups. The diagnostic codes we used to communicate with the physicians, nurses, and case managers reflected the passing nature of the families' dilemmas. The diagnostic codes were never intended to tell the whole story. Instead, they were shorthand among professionals.

Psychotherapists in private practice frequently treat the "worried well"--basically healthy people who may be working through issues from their past, overhauling a relationship, or otherwise undergoing a period of personal growth, rather than experiencing a mental or emotional crisis. Similarly, they may see people who are struggling with a difficult event or a life passage, such as empty nests, bereavement, retirement, and marriage.

Many people believe that, since their health insurance provides mental health benefits and that it is usual to see a mental health professional for such personal growth or life passage processes, these services should be covered under insurance. There are, in fact, a few insurance policies that cover life events. More often, though, clients search for a therapist until they successfully find someone to play the game with them. The professional may clarify that "we will bill this under your/her/his/insurance," and that identifies the patient. The holder of the coverage becomes the person who will be diagnosed with some mental disorder or another, perhaps just for the sake of saving some money in the short term.

Here is where the buyer should beware. When your insurance form is sent in for billing, it includes an ICD code that tells your insurance company what your mental disorder is. ICD stands for International Classification of Diseases. Although there is not a disease called "turning 40 and the kids just left for college" or "we're getting married, but our children hate each other," people seeking assistance for such matters expect to use insurance. They almost never understand that insurance companies require that someone be diagnosed--officially and forever documented--as mentally disturbed.

The ramifications of being diagnosed with an unwarranted mental disorder are many, and the long-term impact on people's lives only will really be understood in the next several decades. Confidentiality sounds good, but read the fine print. Your insurance company may be able to share that information with other providers, employers, or researchers without your permission.

Have you ever read a newspaper report that an accused criminal or politician was previously "treated for depression"? This may come as news to the subject of the story, who accepted an antidepressant without comprehending that a diagnosis of depression was made to justify that prescription. Someday, a future employer, bureaucrat, or insurance agent may explain that your history of mental illness means you are unfit for a position, sportsman's license, or favorable premium. What mental illness, you may wonder, only to discover that a preliminary misdiagnosis of depression on the way to a scientific diagnosis of Graves' disease or short-term counseling for bereavement after the death of a family member is behind this history of alleged mental illness.

This is not meant to create a vast undercurrent of paranoia about the misuse of diagnostic codes mad confidential records. The clients of mental health professionals deserve to know, however, how third-party payers are billed and the true requirements for using health insurance.

These issues--the nature or psychiatric diagnoses, the ethics of pooled risk within health insurance, and the future risks to uninformed clients posed by misuse of diagnoses--are powerful arguments against using, or accepting, typical health insurance policies for most counseling services. The dilemma is clear, as is the solution. Therapists can break out of this double bind, but only if willing to bear considerable financial losses. Referrals will drop, since few clients are willing to pay for services.

This is not so radical a step as it may sound. Breaking free of the insurance double bind is simply a return to the way therapy was handled for most of its first 100 years. This independent, rather than codependent, posture has, within 20 years, become a revolutionary stance in mental health. Like leaving an addicted spouse or ceasing a futile attempt to appease an abusive employer, therapists should break free, meet with like-minded professionals, and return psychotherapy to the health of its youth.

Dolores Puterbaugh, a psychotherapist in private practice in Largo, Fla., is a member of the Advisory. Board of the International Center for the Study of Psychiatry and Psychology.