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PROTECTING PSYCHOTHERAPY:  MANAGED CARE AND BEYOND

by Karen Shore, Ph.D.  Founder and Past President of The National Coalition of Mental Health Professionals and Consumers, Inc.

             This article is being written to provide both a summary of the Rescue Health Care Day (RHCD) effort against managed care and to bring your attention to what we see as the next set of battles beyond managed care itself.  There are several threats to psychotherapy, some from within our own field and from health care policy makers in general.  The threats most immediately concern psychoanalysis and psychoanalytic therapy.  As we all know, however, if one of us is threatened, controlled, and pushed to the sidelines or nearly out of existence, then we are all threatened and face a similar fate.

RESCUE HEALTH CARE DAY (RHCD)

             More cities than I was aware of held marches, rallies or teach-ins, and it seems that everyone had a great time on April 1st, 2000.  In all, 37 cities were involved, from Portland ME to Portland OR and Seattle, five cities in California from Fresno to San Diego, from New Haven CT to eight locations in New York State, down the East Coast to Washington, West Virginia, to seven sites in North Carolina, and down to Atlanta and Orlando.  In the middle of the country, RHCD rallies were held in Madison WI, Denver, two cities in Ohio, Pittsburgh, and Austin.  Attendance ranged from 50 to 300 people at the rallies.

The purposes of RHCD were to declare a national vote of "No Confidence" in managed care, raise awareness of the problem and state clearly that managed care must be replaced, and to initiate a national dialogue on alternatives to managed care.  A theme used by many of the rallies, "Blow the Whistle on Managed Care," made for wonderfully noisy and invigorating demonstrations.

            Most of the organizing and attendance at the rallies involved a combination of consumer and professional groups. Some were heavily clinician-driven. Others, like New York City, had heavy support from both professional and consumer groups, and the Washington DC rally was fully organized by consumer groups. Most of the rallies had speakers who were patients who have been harmed by managed care and health care professionals from a variety of fields addressing the crowds.  At some, several legislators came down to speak, too.

            All political points of view were invited to participate in RHCD and use it to promote their own ideas.  Most rallies remained focused on exposing the problems of managed care and calling for its end.  Some rallies added discussion of ideas that could be used to replace managed care.  Both the single-payer folks and the anti-single-payer folks were suspicious at first and avoided RHCD.  Eventually, the single-payer supporters climbed on board and used RHCD more than those who favor the private market and ideas like medical savings accounts.  It seems to me that those who support government/single payer plans are organizing strongly and including consumer organizations in their efforts, whereas those who are opposed to government plans did not use RHCD as a platform as much as they could have and do not seem to be joining with consumer groups as much.  My sense is that consumer backing is needed for any plan to be accepted on any large scale as an alternative to managed care.  My personal opinion (not necessarily the opinion of the Board and not any official Coalition policy) is that there are important ideas from both the left and the right, and I have some concerns about ideas on both sides of the spectrum.  Thus, I still would like to see all perspectives being discussed openly so that each point of view can have some influence. 

             There were two chief accomplishments. One was the excellent press coverage. RHCD made television and newspaper news all over the country, increasing public awareness of the problem of HMOs and other forms of managed care and clearly stating our desire to replace the system. The other major accomplishment was that the RHCD effort attracted about 250 consumer and professional organizations. These organizations can now continue to work together and expand the effort to overthrow the managed care system and replace it with something better.

            The biggest lack of success was that we did not get thousands at each rally. All those who want to see managed care end but who did not take two hours to attend have to ask themselves why they did not come down to add themselves to a show of strength and numbers.

            The greatest achievement is yet to come, though, and this is the creation of a pro-patient, pro-quality system of health insurance. One of the contacts we made was with an organization called U2K--Universal Coverage in 2000. U2K is an organization of organizations from the consumer, union, and faith communities who want to create a better system. They were very interested in working with us as representatives of the mental health community.  Many, though not all, of the groups in U2K lean left of center.  They seem truly open to hearing from all perspectives, though.  They are aware that there are points of view that are important but not familiar to them.  What is very good is that they seem more aware than policymakers that good mental health care is crucial to our society, including care for the seriously mentally ill (SMI) as well as for the non-SMI population who generally seeks only outpatient psychotherapy and/or medication.  They do not want policymakers to limit mental health services to crisis intervention and short-term therapies and they seem to know that mental health is more than a list of symptoms. 

            U2K was instrumental in organizing the Washington DC and the New York City RHCD rallies. They have a growing list of members of Congress who want to listen to them and work with them.

            The binding principles of the group are universal coverage and access, a comprehensive plan, affordability, quality, and public accountability. Others, such as the NYC groups, want to add the principle of the autonomy of the patient-practitioner dyad. The discussion is open to all who wish to take part. U2K is a politically savvy group of good people and I believe they will have a strong impact. Thus, the National Coalition of Mental Health Professionals and Consumers chose to work with them. We want to be at the table when ideas for a new system are discussed. Board members Patricia Dowds, Ph.D. and David Byrom, Ph.D. are our representatives to the U2K steering committee.  Do know, though, that we wish to work with a variety of groups in addition to those that join the U2K movement.  

       There are several groups that want to continue the RHCD effort and have started planning RHCD 2001. Activity is beginning in New York City, for example, and the U2K movement is in support of a continued Rescue Health Care effort.  For those who are interested in continuing with the RHC theme, we have set up a new listserve, called Rescue Health Care (rescuehc@egroups.com).  This listserve can be used by people from any political point of view who wish to join together to end to managed care and work on devising a better solution.  If you would like to consider organizing a RHCD 2001 event in your area, begin NOW! You need to work with consumer and professional groups and involve as many as possible right away. Consumers are the key. The date for a national RHCD 2001 event is open at this time. If you are interested, join the listserve through http://www.egroups.com/group/rescuehc. 

       Many people and organizations gave their money, time, and/or effort to RHCD.  Division 39 was on board from the beginning, and I want to publicly thank the Division for its warm and strong support (which included help with funding).  My heartfelt thanks to Rep. Ted Strickland, who was the very first individual to sign on to RHCD.  His trust in us and his willingness to put his name to the list of Supporters and Participants very likely helped bring in so much of organized psychology and other legislators.  Also, his appearance and talk at the Columbus, OH rally was greatly appreciated and warmly received.  Thanks also to the other Divisions (17, 35, 42, & 29), and to the 21 State Associations (AZ, CA, CO, CT, DC, FL, MD, MA, MI, MN, MO, NH, NJ, NY, NC, OH, OR, PA, RI, SC, TX) and the many regional and county associations that signed on.  A very large "Thank you" also to CAPP for its financial support, and to APA's Council for their unanimous vote of support in signing on and to all the individuals and organizations who gave time, effort, ideas, and/or money toward Rescue Health Care Day 2000.

THE YEARS TO COME

         We in the Coalition have identified a few major threats to high quality psychotherapy and mental health care in addition to the continuing problems with managed care.  We take pride in our role in the exposure of the unconscionable harm done to patients, clinicians, and the field through the use of the media.  We wanted to make a real difference and could not tolerate the thought of leaving managed care in place.  We believed that we saw the damage it could and would do before most others and we were determined to keep saying what I believed and foresaw.  Pretty much everything we said would happen did happen and now our views, once considered radical, are fairly mainstream.  Managed care is now hated across the land and it is sinking, but not yet dead.  Our work-and YOUR work--is not done.  Below, I briefly discuss a few other very real threats to psychotherapy.  We hope that APA and its Divisions will join in the efforts to correct these problems.

ATTACK ON THE PHRASE "THE WORRIED WELL"

             The phrase, "the worried well," has always infuriated me.  It seems demeaning, insulting, and dismissive of people who are truly in pain.  I have never had a "worried well" person walk into my office.  The Coalition continues its full support for generous benefits for the seriously mentally ill, and I am delighted to see what I feel is a beginning awareness amongst policy-makers that the SMI population must be included in health care reform.  We are all familiar with the abominable situation in which our jails end up being the only place that many of our seriously mentally ill citizens can receive treatment because they were not able to get adequate treatment when they needed it.   

        At the same time, it is becoming clear that policy-makers still fear what they perceive as "runaway costs" for the non-SMI population who largely seek psychotherapy and/or medication.  The notion that policy-makers are buying is that those who are not seriously mentally ill are merely the "worried well"--people who are basically fine but who whine and worry about little things that only require a brief therapy.   

            We intend to publicly declare and inform policy-makers that there is no such thing as the worried well.  The people who are not seriously mentally ill but who need and seek care, including long-term psychotherapy, are people in pain-often a great deal of pain.  Most are able to work or go to school, but this should not be used to minimize their need for treatment. 

           The costs to our nation because of the emotional problems in the general population are enormous.  People with emotional problems have an impact on their families, schools, workplaces, communities, and on the nation as a whole.  Problems such as alcohol and drug abuse, absenteeism, workplace accidents, under-productivity, white-collar crime, bad divorces that hurt children, domestic violence and other forms of violence, vandalism, theft, runaway teens, child abuse, teen pregnancies, smoking and overeating, and families in pain that raise children who hurt and go on to raise another generation of hurt children are more often than not, the result of emotional problems of people who are not seriously mentally ill. When we do not provide access to needed treatment to the non-SMI population, the costs of their problems get displaced onto our families, communities, government service agencies, schools, employers, police, courts, and sometimes our jails, probation, and parole systems.  These problems cost our nation dearly and the people involved need and deserve high-quality care, often long-term psychotherapy and/or medication.  They do not deserve to disparagingly or dismissively be referred to as the "worried well." 

HEALTH INSURANCE PROPOSALS THAT EXCLUDE OR LIMIT PSYCHOTHERAPY FOR THE NON-SMI POPULATION

           One of the consequences of the spreading of the notion of the "worried well" is that major policy-makers think that the non-SMI population should have little or no coverage for mental health benefits.  Many of the parity laws approved by State governments apply only to the diagnoses deemed to represent serious mental illness (major depression, bipolar disorder, schizophrenia, borderline personality disorder, obsessive-compulsive disorder; substance abuse).  Excluded would be dysthymia and anxiety and the host of other diagnoses that fit many of our patients. There are many well-meaning groups whose proposals suggest little coverage for the non-SMI.  

PROPOSALS TO ONLY ALLOW INSURANCE COVERAGE FOR "EMPIRICALLY VALIDATED TREATMENTS"

            There is a major threat both from within and outside our field from many people with influence who strongly believe that there should only be insurance coverage for psychotherapies that are "empirically validated" and conform to research protocols applicable to cognitive-behavioral therapies (manualized treatment, randomized clinical trials, symptom-focused).  This threat includes influential psychologists as well as influential non-mental health policymakers.  They recommend that psychodynamic therapy and psychoanalysis not be covered because it does not meet their kind of science and the research protocols so suited to cognitive-behavioral therapy.   I have seen health care reform proposals that specifically preclude psychodynamic therapy and psychoanalysis from coverage, stating that only "empirically validated treatments" would be included.  (Worse yet, and a different fight, some influential psychologists believe that it should be considered malpractice to do psychoanalysis or psychodynamic therapy with people with conditions shown to improve quickly through cognitive-behavioral therapy.  I would assume that dysthymia, anxiety, panic attacks, etc. are included). 

          Restricting coverage to symptom-focused, brief therapies would prevent experimentation and theory-building and cause pain, unnecessary suffering, and even death.  There is no doubt that a very large number of people have been able to pull out of a suicidal depression, out of an inability to work, out of what we see as dysfunctional family dynamics only through a long  relationship with an psychoanalytic therapist, the feeling that they are understood, the increasing insight into themselves and others in their life, and the freedom and time in therapy to learn to trust and gradually say whatever it is they need to talk about to heal. 

          It is important to let anyone who proposes that psychodynamic therapy and psychoanalysis be excluded from coverage know that doing so will cause unnecessary pain and death.  Rather than argue about whether one form of therapy is better than another, it is important to argue that all people are different and patients need to be free to find what works best for them. All major forms of therapy that are widely accepted by the patient and professional communities must be supported.

         My experience is that some of those who believe only cognitive-behavioral treatments should be used or that psychoanalytic therapies should conform to their favored research protocols are impossible to influence.  Please take heed, because this could be a bitter fight if policymakers turn to some of these people for recommendations regarding health care reform and insurance matters.  Beware of those with power who are well-meaning but would force their standards and opinions on others, denying many of what they need. 

          For our country to be a mentally and physically healthy nation, the seriously mentally ill and those with emotional problems need high quality care that will treat the causes as well as the symptoms of their problems so that all Americans may live as productively, safely, and peacefully as possible. 

             Coalition Board members, Patricia Dowds, Ph.D., David Byrom, Ph.D. and I will be working on developing literature aimed at dispelling the myth of the "worried well,"  advocating for coverage for the non-SMI population, and substantiating the costs to our nation when emotional problems go untreated.   

DESTRUCTION OF PSYCHODYNAMIC TRAINING IN GRADUATE SCHOOLS

            Sadly, there are almost no doctoral-level clinical psychology programs left in the United States that are strongly psychoanalytic.  For several decades, all major theoretical orientations were well represented, with many programs leaning toward one theory or another.  In the past decade or two, programs that were psychodynamic have been diluted or changed to cognitive-behavioral programs.  Students will be hard-pressed to find a program in which their faculty and supervisors are almost all psychoanalysts, though several such programs used to exist. 

          There are a few forces responsible for this situation.  One, certainly, is managed care. Almost all graduate schools in our nation have stopped or severely cut down the teaching of psychodynamics, believing that they must "prepare students for the marketplace" rather than for the problems of all the people who will seek their help.  The emphasis on "empirically validated therapies" is another force.  A related problem is that few university programs hire full-time faculty members who spend the bulk of their non-teaching time doing clinical work rather than research.  Value is not placed on a prospective faculty member's theoretical and clinical writing nor on their ability to teach clinical theory and practice.  In part, this is because many programs' decisions are influenced by the university at large, with few committee members who understand clinical preparation, especially psychodynamic training.  However, I do believe that this is also due to those within our field who wish to marginalize training in psychodynamics as well as to the lack of protest and involvement from the psychoanalytic community itself.    

          Despite knowing that I will likely receive a roar of protest, many of us believe that-with very rare exception--it is simply not possible to teach, do research and be as great a psychodynamic therapist and supervisor as students need.  I can only say that my own experience at Adelphi University, attending at a time when all supervisors and almost all clinical faculty were psychoanalysts, was superior.  The training was unsurpassed, our graduates received the best internships because the internship programs knew the worth of these students.  As a supervisor of psychology interns, I was able to see the difference in the abilities of students with strong grounding in psychodynamics and those without it.  No doubt, with respect to well-trained cognitive-behaviorists, some interns I've met have been great at cognitive-behavioral interventions, are sorely needed, and could do things I and those of us from analytic programs are not trained to do.  But they were adrift when patients needed more than 15 sessions of therapy.  We need both students with strong cognitive-behavioral backgrounds and we need students with strong psychoanalytic backgrounds.  We are no longer producing the latter and our citizenry will suffer.  Almost all graduate students today are deprived of the availability of tenure-track faculty and supervisors who are psychoanalysts. This situation needs to be confronted by our practice divisions and our training programs.

THE NATIONAL COALITION OF MENTAL HEALTH PROFESSIONALS AND CONSUMERS

             If the above concerns are important to you, the Coalition could use your support.  The Coalition is now eight years old.  We have been instrumental in exposing the problems of managed care through the media and other forums and in advocating for high-quality mental health treatment.  We have and will continue to work hard to be sure that a pro-patient, pro-quality health insurance system is created that includes appropriate and sufficient benefits for mental health care.  We have also been politically active within social work, psychology, psychiatry, and related fields so as to influence the professions. Over the years, a good working relationship has developed between the Coalition and many APA divisions and committees.  To continue our work, we need your help.  Political activity costs money and takes a great deal of volunteer effort.  Please give us your time, effort, and/or financial backing.  Join the Coalition by contacting us by phone (1-888-SAY-NO-MC), by e-mail (NCMHPC@aol.com) or through a visit to our websites (www.TheNationalCoalition.org, www.rescuehealthcareday.com).  Don't put it off - contact us today.  The Coalition needs you, and you need the Coalition.

Karen Shore, Ph.D., is President of the National Coalition of Mental Health Professionals and Consumers.

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