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
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
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.
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
In the middle of
the country, RHCD rallies were held in Madison WI, Denver, two cities in
Ohio, Pittsburgh, and Austin.
ranged from 50 to 300 people at the rallies.
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
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.
the single-payer folks and the anti-single-payer folks were suspicious
at first and avoided RHCD.
the single-payer supporters climbed on board and used RHCD more than
those who favor the private market and ideas like medical savings
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.
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.
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.
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 (email@example.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
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.
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
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
We hope that
APA and its Divisions will join in the efforts to correct these
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
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.
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
INSURANCE PROPOSALS THAT EXCLUDE OR LIMIT PSYCHOTHERAPY FOR THE NON-SMI
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
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.
TO ONLY ALLOW INSURANCE COVERAGE FOR "EMPIRICALLY VALIDATED
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.
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
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
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
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.
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
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.
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.
Shore, Ph.D., is President of the National Coalition of Mental Health
Professionals and Consumers.
|Back to the Coalition|
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or 1-(631) 979-5307
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We can build a better health care system!