An Assault on Safety:

February 27, 2008

The Central Problem of Managed Care

With paralytic passivity and frightened silence, psychologists have witnessed the all but total destruction of their ability to provide competent psychotherapy. Every issue of The California Psychologist reveals its occurrence. Conferences about how to get on managed care panels blossom. Managed care representatives foretell the death of private psychotherapy practice. Articles update psychologists’ rush to obtain prescription privileges, believing it will help them to survive in the managed care environment. Far too many psychologists have already surrendered, believing themselves in touch with the “wave of the future.” Yet, managed care, as far as provision of psychotherapy is concerned, is a true oxymoron. The central problem with managed mental health consists of one simple but incurably malignant defect: its violation of privacy.

This simple but crucial point is often overlooked because economic factors, and the need to increase public access to mental health treatment, has been so emphasized. These are important points. But certainly the public no longer worries that psychologists greedily keep patients in treatment to pad their own pockets. Now they have the much greater fear of supporting $1 million or greater salaries for managed care company directors, not to mention the support of extensive organizations which process paper, perform utilization reviews, have unnecessary telephone conferences with treatment providers, and so on. The concern with greedy providers has been replaced by concern about profit-hungry corporations, which bleed benefit dollars from providers and consumers of mental health services who in turn are left with fewer services. Managed care has failed to solve the problem regarding the equitable provision of mental health care services to those members of society in need of it. But these well-worn, yet important, issues pale in comparison to the far more compelling one which involves the destruction of the privacy of the psychotherapeutic relationship. No need exists to lessen the cost of, or increase access to, an intervention that has been rendered all but worthless.

The contamination of the psychotherapeutic process can be likened to performing surgery without a sterile field. Certainly some surgical procedures can be performed, and in certain emergency situations they indeed are, but the risks of infection and other complications are great. It would be ridiculous to perform surgery without preparing the surface of the skin, sterilizing instruments, covering the skin and mouth of the surgeon, and filtering the airflow through the operating room. It is similarly absurd to perform psychotherapy without absolute confidentiality and privacy. Regardless of whether the psychologist is behavioral, cognitive behavioral or psychoanalytic in orientation, the person seeking psychotherapeutic assistance will not truly open up to the process and, indeed, cannot in any meaningful way without such a basic sense of safety.

Those that have studied and understand the basis of the development of trust in human relationships, the exquisitely sensitive nature of the unconscious, and the volatility of psychotherapeutic relationship understand the absolute importance of establishing as much confidentiality and privacy as possible. Treatment status reports, discussions with utilization reviewers, provision of financial incentives for limiting care, and the like all violate the safety of the healing relationship. They are grossly antithetical to the art and science of psychotherapy.

The rebuttals of the managed care organizations, and those psychologists who either profit from their involvement in it or rationalize their participation (understandably because of financial necessity), may view this concern as unwarranted. Great efforts are taken to preserve the confidentiality of the material submitted, they say. In the better-run organizations, the material is only reviewed by similarly trained professionals. This is a necessary evil to save costs. These arguments, and others like them, miss the point.

As soon as one enters into psychotherapeutic treatment, for whatever length of time or for whatever problem, a basic sense of trust must exist for clients to safely introspect and address their problems. Many clients will deny that this matters to them, but how could it not matter to anyone? The sanctity of their relationship has been eliminated. Another party, a paper ghost if you will, enters the consulting room. The ghost’s involvement may range from passive to highly active, i.e., frequent requests for detailed reports. It’s simple common sense. Psychotherapy is not removing an appendix or providing a course of antibiotics; it heals solely within the context of a trusting interpersonal relationship which is necessarily thwarted by the intrusion of the third party. Any suggestion that the protection of such privacy and confidentiality is irrelevant, unnecessary, or unaccomplishable, is patently absurd.

Although it almost appears that the battle is over, and the possibility of providing competent psychotherapy dead, some hope remains for the reversal of this unethical trend. The alternative to managed care is as simple as its incurable defect. Insurance companies, should they still exist, should be required to offer a certain number of psychotherapy sessions per year, whether it be 15, 25, 30, or whatever. Depending upon the will of the people, the fee for provision of psychotherapy mayor may not be set, but the minimum amount per session covered by the insurance company, i.e., $40 per session, should be mandated. Just like the federal government sets standards for meat, it could set standards for what a minimum insurance package, whether it be an HMO or an indemnity policy, would cover. With the simple acknowledgment that a patient is in treatment, then this number of sessions would be allowed per year. Insurance companies would then be free to offer more extensive benefit packages, or possibly even offer more money per session, but all would be required to provide this minimal level of provision of services.

The system could be as simple as that. If necessary, some slightly more complicated modifications could be instituted, such as a means of extending the number of sessions in cases of severe disturbance. It would be preferable to keep the basic program simple, however, and allow market forces to compete. This system would allow greater, and more private, access to those members of the population that most need the help. Ironically, those people who would be most loathe to have their confidentiality violated – people who physically abuse or molest others, have been the victims of such abuse, abuse substances. etc. – would be more prone to use a system which protects their privacy.

By eliminating the current managed care bureaucracy, while at the same time providing some restriction on the number of sessions per year, costs could be controlled, consumer access to mental health care services increased, and, most importantly, privacy and confidentiality maintained. The struggle to achieve such changes in provision of mental health services can be eventually accomplished, with a little faith and time, by organizing around these concepts and then actively lobbying governmental representatives.

In the meantime, psychologists should consider not playing the managed health care game. To actively participate in managed care so violates the psychotherapy process as to render it worthless. To do so is to participate in a charade, one that potentially harms clients and compromises the ethics of the entire profession. By either refusing or limiting participation in managed care, psychologists will ultimately earn the reward of knowing that they are truly committed to psychotherapy as a method of healing, not conforming. Ultimately such dedication will lead to professional and personal rewards far exceeding those succumbing to the mores of the psycho-technicians of our age, whose reign will certainly be limited.

Published as:

Karbelnig, A. (1997). An assault on safety: The central problem of managed care. The California Psychologist, 30(1), 31-32.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)


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