Let's Talk Therapy
by Garry Cooper, LCSW
Well, John, I’m glad we agree that universal health care is the goal, and if you figure out how to do that without going to a single payer system, and be able to eliminate the highest administrative healthcare costs in the industrialized world, then you’d be eminently qualified to set up the program for the Bush administration (although the way this administration works, being eminently qualified to do something would automatically eliminate you from being considered for that position). The US spends 31 cents on the dollar for administrative healthcare costs, while Canada spends about 17 cents. I marvel at the way you often disguise your very real, deep humanity and morality with arguments that sound utilitarian and amoral. If the awful system of healthcare we have in this country seems to be spreading to other countries, that doesn't’t mean that our system is better; it just means that the fungi of greed, nurtured by international corporatism, is spreading faster these days.
I’m glad, however, to see that we agree that everyone ought to have convenient access to quality healthcare. It speaks well of you and prevents the forces of darkness from claiming you as one of their own.
But let’s talk therapy. No therapist I know likes to share his therapy notes with bean counters or with administrators. No therapist likes to have to seek authorization for additional sessions, or to discuss his clients or treatment decisions and options with anyone whose primary interest in the client is monetary. Most therapists I know went into the field to be able to do the best they could for people who need help, and we don’t like to make compromises on that. Years ago, I remember going into couples counseling with my eventual ex-wife. We went through a managed care network. After the first session, the therapist outlined an ambitious plan that included several individual sessions with one of us, along with an unspecified number of conjoint sessions, and it sounded like to me exactly like the right plan. The next time we showed up, he said he’d decided on 5 conjoint sessions instead, forget about the individual stuff.
“You’ve been talking to your case manager,” I said.
Those were the days of the infamous gag rule, when therapists were forbidden to tell their clients what treatment decisions had been mandated by their managed care case managers, but his rueful expression and evasive answer said it all. I suspect he was a damn good therapist who’d found himself in an untenable position, like an altar boy who’d accidentally sold his soul to the devil: every Sunday he still assisted in Mass, but he was kind of compromised.
If it’s the only way to make therapy available to whoever needs it, I’ll take the restrictions and idiocies and reduced income that would probably come with a single payer system. I won’t however do that if it makes me a pawn and enabler of a for-profit system that enriches people at the top at the expense of quality care for clients and reasonable payments for therapists. Hell, I already see some people for ridiculously low fees, and so do many therapists I know, though few therapists like to talk about it. Some therapists barter, and there really are ways to do it without violating boundaries (see my article in “The Clinician’s Digest” in the November/December 2003 Psychotherapy Networker. Ofer Zur also has some great stuff about bartering on his website www.drzur.com ). Other therapists lie to their case managers, presenting case notes and objectives, in approved format, that bear only a passing resemblance to what’s really happening in session. (While that’s clearly unethical and probably illegal, they justify it by saying they’re doing it not for personal gain but to help clients receive therapy who otherwise couldn’t afford it).
The bottom line: we’re here to help people, and the current healthcare system makes it really difficult to bring quality, timely care to people who can’t afford it, and we all need to do whatever we can to change the current system.
Garry Cooper, LCSW is a therapist and writing coach in private practice. His “Clinician’s Digest” column for the national magazine Psychotherapy Networker, covers the latest news and research in mental health and psychotherapy. Visit his website Psychology Trends. He can be contacted at garry@psychjourney.com
