Who's in Charge? Health Care in the 90's

Who's in Charge? Health Care in the 90's

Somewhere on the cusp of professional memoir and position paper, this article represents my perspective on the root wrangle over mental health service delivery in the nineties.

As the financing of health insurance comes more and more under the jurisdiction of plans guided by a Managed Care philosophy, everything about the social construction of psychotherapy is again undergoing redefinition: the role of mediation, power issues, affordability, the nature of pathology, profit, of the professional, the body/mind connection, the nature of what is healing.

The Age of Freedom is over...

Recently, at a professional conference I attended, the presenter declared "The Age of Freedom" in mental health delivery is over. No more choosing your own therapist. No more controlling your own work.

Once upon a time the western medical model was the only option. Soon, it may be the only one again. If we wish to reclaim a spectrum of service options, we will have to reach beyond what managed care offers, as well as dig deep.

In the 70's...

In 1974 I didn't believe in mental illness. Powerful anti-professional sentiment was the order of the day, so I began my career in mental health as a volunteer in a women's peer counseling center in Cambridge, MA. that offered an alternative to the traditional mental health system. I simplify only somewhat in writing that our most basic belief was in the deeply curative power of good listening, honest caring, and the sharing of concrete resources. While that philosophy of healing carries, even now, its own enduring, if partial, truth, I did eventually learn a deep respect for true mental illness, although not at the cost of pathologizing people in general.

I also worked as an abortion counselor in a women's health care clinic that opened shortly after Roe vs. Wade and purported to have the empowerment of women as at least one of its goals, though neither the administration nor the medical staff seemed especially interested in holistic health nor in the particular meaning individual women attached to the decision to terminate a pregnancy. As the profit-making function of the clinic became more and more apparent, counselors were expected to see more and more patients each day, take less and less time with each individual woman. When the clinic voted in a union, management refused to negotiate a contract. In 1976 a strike occurred in which I lost my job.

Into the 80's...

During the seventies and eighties I became part of a group of newly credentialed professionals who worked outside the system offering a viable alternative to the traditional mental health delivery system which saw people through the lens of the medical model as "sick". I learned about addictions and alternative "treatments" like gestalt, psychodrama, psychosynthesis, and trance work, and I co-founded a feminist counseling center in Cambridge, MA. When we began there were neither PhD psychologist or masters level social workers among us. Licensing laws did not yet exist, but the handwriting was certainly on the wall. Fearful that my work and livelihood were in jeopardy, I pursued a Masters Degree in Social Work, and thus became eligible for third party reimbursement. At first, reimbursement seemed not only harmless but serendipitous.

Three principles of our educational model...

We worked from an educational model which asserted that, given the right kind of support, people could unlearn dysfunctional habits of thought, feeling, and behavior that were originally adaptive responses for survival in dysfunctional families. Three principles informed our thinking.

The first was a strong belief that, regardless of the theoretical framework or therapeutic technique utilized by a therapist, the source of healing lay deep within oneself. The helping relationship was critical, the holding environment which facilitated the emergence of authentic healing.

The second principle was accountability. Sometimes the focus here was on the family of origin and whatever neglect, abuse, or dysfunction had caused the client's original suffering; sometimes the focus was on more institutionalized forces that perpetuate oppression-sexism, classism, racism, heterosexism, etc. Whatever the locus of external power, clients were encouraged to externalize anger rather than internalize self - hatred and blame.

The third principle was personal responsibility. While people might not be responsible for what they inherited from their families of origin, or from the larger society, they were certainly responsible for what they did with the raw ingredients of their own lives. Windows on choice and freedom did exist, though they might indeed be slim, and one's power lay in locating these windows and using them effectively.

The western model viewed women stereotypically; it saw minorities as "underprivileged," gays and lesbians as non-existent, alcoholics as hopeless, childhood sexual abuse as something women lied about. Hierarchical procedures reigned: somebody did something that made you better, at least you hoped so. In the process you got a "diagnosis," which labeled what was wrong with you.

The plot has thickended...

A lot has changed. The plot has thickened; there are difficult to untangle subplots, as well as dramatic and rapid action/reaction patterns. The cast of characters has expanded to include HMO's, PPO's, EAP's, case managers, and preferred providers, to name but a few. Nor is it easy any longer to distinguish the villains from the heroes and heroines. Indeed, much of the landscape in mental health today is filled with ambiguity.

It is no longer possible to characterize the mental health system in a unilateral manner. There are good people working in the field everywhere. At least until the recent and rapid transition to a managed care model with its emphasis on medication and brief treatment, one could receive relatively high quality psychotherapy in the public sector. There was, of course, no guarantee this would be the case, despite licensing requirements. The road to help-seeking, in both private and public sectors, has long been littered with the victims of incompetent professionals, false prophets, and unhealed healers of every conceivable variety.

The power of grass-roots movements...

Two powerful grass-roots movements weave in and out of this retrospective: twelve-step programs with all their great variety, and the organized efforts of adults who were sexually abused as children.

AA, with its emphasis on peer support, spirituality, and the surrender of one's will, surprised everyone with its success in treating alcoholism. Unlike the medical model, AA, in labeling alcoholism a disease, sought to render the alcoholic blameless rather than helpless. In emphasizing humility and service, 12-step programs may well have paved the way for a spiritual revival that provides welcome relief from the egotism and narcissism psychotherapy can sometimes foster. Twelve-step programs put a new spin on the concept of personal responsibility at the same time that they emphasize a force at work, both benevolent and transcendent, beyond what we can know either individually or collectively.

At the same time, and in the wake of a growing awareness of the prevalence of rape and battering, more and more women (soon to be followed by men) found the courage to tell their stories about childhood sexual abuse. Memories were uncovered, voices found, at least partly because some therapists believed their clients' stories. Post traumatic stress disorder now referred to survivors of sexual trauma as well as war. Therapy, no longer a tool of the elite, became a vehicle through which women confronted injustice and reclaimed personal and collective power. Of course, five hundred dollars never covered more than ten or twelve therapy sessions, but for many people it was a start. When benefits ran out, they paid out of pocket.

It is no longer possible, except for the truly uninformed, to think about the nuclear family as a necessarily benevolent institution. This victory for women and children, has not, however, come without its price tag. Women with health insurance, including trauma survivors, use their mental health benefit not because they believe they are sick, but because they suffer, and they do not wish to bear that suffering alone. Nevertheless, they have now won the dubious right to be "diagnosed" in greater numbers that ever before, as having mental illness: adjustment disorder, post traumatic stress disorder, multiple personality disorder, dysthymia, that require professional treatment.

Entering from the right is managed care...

Not surprisingly, many of the therapists they consult are no longer eligible for third party reimbursement. As the cost of medical insurance skyrocketed, the cost of delivering mental health services became more and more problematic for both the medical community and the insurance industry. Enter managed care, with its emphasis on cost containment, medication, and brief services.

The managed care train can not be stopped. And at the risk of sounding heretical, I must confess there are some things about its approach I find appealing. The emphasis on community, peer, and educational resources, the twelve-step friendliness, the use of cognitive and behavioral techniques that build on the human capacity to replace formerly adaptive but currently dysfunctional coping strategies with new ones. Brief treatment, including the possibility of medication, has surely earned its place in the spectrum of options. There are dangers inherent in the long term model, and over dependence on external resources, whether a therapist, a welfare or disability benefit, or an over-generous friend, is one of them. Even when problems of neglect, abuse, or systemic disempowerment are severe, well-intentioned help that extends over a long period of time, can become enabling. Therapy that goes on too long, especially with little progress, risks contributing more to the problem than to the solution.

Nevertheless, change is arduous; furthermore most persistent conflicts, especially those that stem from family violence or sexual abuse, will not be resolved by brief treatment. What took years to create will simply not be undone in a matter of months let alone weeks. The most brief therapy can offer symptomatic relief, at least for those who carry the least amounts of fear, resistance, and unconscious conflict.

The model has other shortcomings. It negates the significance of the helping relationship as the very foundation for healing, transcending both theoretical framework and technique. It erodes at the right to privacy and choice. (It's hard to tell a stranger handling telephone intakes you've just uncovered memories of childhood sexual abuse and want to see a therapist, then be told you must choose from a list of "approved providers," none of whom you may ever have heard of.) Horror stories abound. Recently, someone I know requested a lesbian therapist and was told, "Oh, we don't cover that..."

The tragic timing of managed care...

The timing of managed care's take over seems tragic at best and calculated at worst to undermine the organized efforts of adults who were sexually abused as children. Managed care plans discriminate against therapists who do trauma work by excluding them from approved provided lists. Most licensed therapists in private practice rely substantially on insurance reimbursement to support their work and have come to feel, like consumers, entitled to reimbursement. Current predictions suggest that eighty to ninety percent of them will soon be out of business.

For providers and consumers alike, a break from dependence on this system is in order. If the option of long term therapy is to remain viable, consumers will have to pay for it out of pocket. Providers, at least if they value their integrity and wish to retain control over their work, will have to forego reimbursement, adjust fees on a sliding scale, and consider returning to treatment in groups.

Many things, in addition to seeking professional assistance, help people change: nutrition, exercise, friends, relaxation, a sustaining spiritual life, creative work that renews, political work for social justice. Therapy, which is art more than science, is only a tool for helping us respond differently to stress, pain, or injustice. Regardless of the nature of our suffering or oppression, the task of sorting through our repertoires for those slim windows on freedom and choice falls to us alone. Restructuring the financing of therapy may on the long run restore a principle long-cherished by progressive therapies of all sorts-the principle of personal responsibility.

Illustration (Health care structures)

Copyright Off Our Backs, Inc. Jan 1995
Provided by ProQuest Information and Learning Company. All rights Reserved