Ethical Issues With Using Managed Care For Psychotherapy

In a prior article, I discussed why it has become so difficult to find a psychotherapist in New York City on managed care panels.

This is a problem not just in New York City but all over the country.  In the current article, I'm expanding this discussion to include ethical issues involved with using managed care for psychotherapy.

Ethical Issues With Using Managed Care For Psychotherapy

The purpose of this article is to provide information to clients who are considering using their managed care benefit to attend psychotherapy so that clients can be informed consumers.

Ethical Issues About Using Managed Care For Psychotherapy
Managed care companies' main focus is saving money.  Although most managed care companies would deny it, their allegiance is to their shareholders--not to their subscribers.  When saving money is the main focus, this inevitably leads to certain ethical problems, including:

• Problems With Client's Privacy/Confidentiality:  When a psychotherapist enters into a contractual agreement with a managed care company, she will, most likely, have to share your confidential information with managed care representatives because it is demanded by the managed care company.  In effect, not only is the confidential information shared with the representative on the phone (or sometimes by mail or on the insurance company's website), but the information also becomes available to hundreds of other employees at the managed care company.  This is becoming even more of a problem than when I wrote the about this before because in the last few years there have been breaches in confidentiality when insurance companies sites were hacked.  This exposed thousands of insurance subscribers to having their personal information used illegally, possibly including information about their psychotherapy sessions.

• Problems With the Intrusive Nature of Managed Care: Managed care representatives often contact in network psychotherapists to find out why clients are still in therapy; to make "suggestions" about how psychotherapists should change clients' treatment plans, including referring clients for medication, even when clients have made it clear that they're not interested in medication; and, possibly reducing the frequency of sessions from weekly to every other week or less.  Often, the managed care representatives demand that psychotherapists justify their clients' treatment in writing in order for clients to be able to continue in therapy.  This often involves the representatives asking for detailed personal information about the clients' problems; what else the clients have attempted to do, aside from going to therapy (e.g., joining support groups, seeing a psychiatrist, etc) and so on. 

• Potential Conflicts of Interest For Psychotherapists on Managed Care Panels: To save money, managed care companies prefer short term treatment, even, at times, when clients are in crisis or very depressed and they need longer term treatment.  Many psychotherapists who are on managed care panels are aware that they are more likely to get referrals from managed care if they do brief therapy--even when clients need more intensive therapy.  This often leads to psychotherapists, who are on managed care panels, making decisions based on their financial needs rather than the needs of their clients.  In other words, if a psychotherapist is aware that a managed care company prefers psychotherapists who do brief treatment, he will be placed in an ethical dilemma because he knows that the managed care companies will look at their records to see which therapists only keep clients for a short period of time before terminating treatment so, in the long term, it is in his financial interest to keep clients for only a few sessions so he can get more referrals from the managed care company.  This often leads to poor treatment because the psychotherapist might only be focused on "shoring up" clients rather than helping the client to make meaningful change.  Clients might "feeling better" for a short time and then, after a while, they need to go back several other times to the prior therapist or to a new therapist because their problems were not resolved in short term therapy.  It also discourages clients from seeking help in therapy because, after going through several cycles of short term therapy with poor results, clients will often conclude that "therapy doesn't work" rather than that their therapist might have been pressured by managed care to provide suboptimal care.  This is not to say that all psychotherapists on managed care will choose less than optimal care because many will do what is best for the client, but it is a potential ethical dilemma.

Ethical Issues With Using Managed Care For Psychotherapy

• Potential Problems With Quality of Care:  As mentioned above, when psychotherapists on managed care panels are pressured by the insurance company to provide short term therapy, even when the client needs longer term therapy, the quality of care often suffers.  In order to justify longer treatment, psychotherapists often must go through a lengthy and time consuming process of providing increasingly more detailed information as to why clients need more therapy sessions.  Not only is this time consuming for the therapist, it also compromises confidentiality, as mentioned above.

• Pressure From Managed Care Regarding Medication:  As mentioned above, managed care companies often pressure psychotherapists to refer clients to psychiatrists for medication, even if the clients do not want to take medication and, in many cases, do not need medication.  Often, the representatives making these clinical "recommendations" are Bachelor's level employees, if that, and far less qualified to make these clinical decisions than the psychotherapist treating the client.  Once again, the focus is on saving money rather than  providing quality of care for clients.  

• Restricted Choice of Psychotherapists:  In order to save money, most managed care panels are narrow with a restricted number of psychotherapists listed by zip code.  This saves the managed care company money because there are fewer psychotherapists to choose from and the ones who are on the panel, who are often are other managed care panels, are forced to take many clients in their private practice in order to make financial ends meet due to low managed care reimbursement.  This usually meets that it is very hard to find a psychotherapist in your area who has openings because therapists are all booked up.  Also, many of the therapists (although not all) are new therapists who are starting their private practice and willing to take managed care until they can build their practice.  

• Diagnosis and Stigma: Managed care for psychotherapy is usually based on medical necessity, which means that a client must have a diagnosis that the managed care company deems necessary to cover this client.  As a result, psychotherapists must provide a diagnosis to the managed care company for each client that the managed care company will accept.  Once again, this brings up issues around confidentiality and privacy because these diagnoses are on the managed care computer system.  Also, as mentioned above, when a managed care company's website is hacked, the client's confidential information, including diagnosis, could be exposed (see my article: see my article: Psychotherapy: You Are Not Defined By Your Diagnosis).

What to Do to Avoid or Mitigate These Problems With Managed Care
Obviously, there are many clients who must use their managed care plan because they cannot afford to self pay for therapy.  If this is the case for you, you should, at least, enter into this process knowing what is at stake.  If this is the only way that you can access mental health treatment, it's better to use your managed care insurance than not to go to therapy at all.

Steps To Take to Be An Informed Consumer

• Find Out If Your Company Has a Health Savings Plan:  This is an alternative to using your managed care benefit that many people use.  Your human resources or health benefits representative should be able to tell you if your company has a health savings plan, if you are eligible for the plan, and how to use it.  If your company does not have health savings plan, you and other employees can advocate for this benefit.  Express your concerns to your concerns about these issues and find out what steps the company can take to remedy them.

• Find Out If Your Insurance Allows Out of Network Psychotherapy: When you go out of network, your benefit is not managed by the managed care company, although there might be some restrictions with regard to the deductible and how much the insurance will reimburse you depending upon the plan that your company negotiated with the insurance company.  If your company does not offer out of network benefits, you and other employees can advocate for it.

• Discuss Your Concerns With Your Psychotherapist: If your company does not have a health savings plan, out of network benefits or if you really need to use your managed care benefit, speak with your therapist about your concerns regarding diagnosis, confidential/privacy and quality of care.  You have a right to know the diagnosis that your psychotherapist is submitting to the managed care company.  You also have a right to know what information your therapist is providing to the managed care company if the insurance representative indicates to your therapist that they must do a review of your case.  You can stipulate what you want/do not want shared.  However, be aware that if your therapist does not share information that the managed care company considers necessary to approve additional sessions, you might not be able to continue in therapy.  This is another ethical dilemma.

Ethical Issues With Using Managed Care For Psychotherapy

• Consider Your Priorities:  Only you know your financial situation.  There are times when you might be forced to use your managed care health benefit to access therapy because you cannot afford to pay out of pocket.  This is understandable.  But it is often worthwhile to look at your priorities and assess how your spending your money and how you want to spend your money.  Take a look at your budget and make decisions based on what is important to you.  At certain times, it might be worth it to you to forgo certain expenses, like buying packs of cigarettes or buying expensive coffee in order to have quality mental health treatment.  

• Consider Sliding Fee Scale Mental Health:  There are certain mental health centers that offer sliding scale therapy based on household income.  Most of them will request proof of household income in order to assess your fee.  Many of the psychoanalytic institutes have referral services to their candidates in training where you can see a licensed psychotherapist in their training program for a reduced fee.  These students are usually supervised by senior clinicians.

Getting Help in Therapy
Many people need to use their managed care health benefit in order to access psychotherapy.  However, many of those same people are unaware of the issues involved with using managed care benefits for psychotherapy.

No one who needs mental health services should ever go without treatment regardless of whether you use your managed care benefits or not.   At the same time, it is important to be an informed consumer.

If you have problems that you have been unable to resolve on your own, you could benefit from seeing a skilled psychotherapist who can help you to overcome your problems (see my article: The Benefits of Psychotherapy).

A licensed psychotherapist can help you to overcome the problems that are keeping you from maximizing your potential (see my article: How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Serious Medical Problems Can Change How You Feel About Yourself

When you're healthy and your life is going well, all other things being equal, it's easy to feel good about yourself.  But when you develop serious medical problems, it can change how you feel about yourself and about life in general.  When people develop serious medical problems, they often have a sudden sense of their physical and emotional vulnerabilities in ways they might not have experienced before.  

Serious Medical Problems Can Change the Way You Feel About Yourself

Reactions to Being Diagnosed with a Serious Medical Problem:  Shock, Fear, Anger, Sadness

If the medical problem is unexpected and potentially life threatening, people often experience shock at hearing the diagnosis.  Initially, a sense of disbelief can create a sense of emotional paralysis and confusion.  When the shock wears off, people often feel a combination of fear, anger and sadness about the "unfairness" of being diagnosed with the illness.  

Each person's experience is different.  These feelings don't occur in a linear way or, necessarily, in this order.  They can happen all at once or in any order.  However it happens, it usually takes people outside of their everyday experience and it can change their perception of themselves.

Being Treated as "a Sick Patient" 
A day before you received a diagnosis of a major medical illness, like cancer or heart problems, you probably thought of yourself as a husband, wife, mother, father, brother, sister, friend, an employee and all the other identifications that we all take on in life.

Suddenly, after you've been diagnosed with a major medical problem, your doctors identify you as a "sick patient," a "cancer patient," a "heart patient" or whatever diagnosis is applicable.  This isn't a criticism of the medical profession.  It's just the way it is in many medical settings, especially hospitals. When this happens, you can feel like you've been reduced to one identification-- your diagnosis.

You're More Than Your Medical Diagnosis
But each of us, no matter what our health issues might be, is more than any particular diagnosis.  We're whole people with relationships, histories and, hopefully, dreams for the future.  After a while, if you take on the identification of your diagnosis, it can change how you feel about yourself, reducing you to a list of symptoms.

Words Are Powerful
For the sake of maintaining a healthy emotional attitude, it is far better to be thought of as "a person with cancer" rather than "a cancer patient" (or whatever diagnosis applies).

You might think that this is just a matter of semantics, but it's not.  Words are powerful. When you're identified as "a cancer patient,"the implication is that this is your primary or, worse, your only identification.  But when you're identified as "a person with cancer," the implication is that there is a lot more to you than just your medical diagnosis--you're a whole person with a life that includes your medical diagnosis but also goes beyond your illness.  Rather than losing your sense of self to your illness, you maintain all the different aspects of yourself.

Research has shown that a positive attitude can have a significant effect on recovery.  So, maintaining a healthy sense of self can make the difference between having a good or a poor medical outcome.  So, how you think of yourself, including your sense of identity, is important.

Finding New Meaning in Life While Dealing With a Serious Medical Problem
I know there are exceptional individuals who are given serious medical diagnoses who find tremendous new meaning in life.  They appreciate every day, their relationships take on new meaning, and they might even find a renewed sense of spiritual connection.

While this is certainly impressive and something to aspire to when you've been diagnosed with a serious medical problem, a lot of people, through no fault of their own, find if very difficult to get to this place emotionally, and pointing to these exceptional people can make these other individuals feel blamed for not being able to reach such an enlightened state.

Your Internal and External Resources
If you're fortunate enough to be an individual who is resilient and who has a good emotional support system among family and friends, your chances for maintaining a healthy sense of self, despite the illness, are better.

As a resilient person, who has emotional support, you might have an awareness that, during the course of your life, you've overcome other challenges and you could see your medical problems as one more challenge to be overcome.

But not everyone is fortunate enough to be resilient and have a support system.  In addition, sometimes, prior emotional trauma can get triggered when you're diagnosed with a serious medical problem.  At that point, you're not only dealing with the current medical problem, but you're also dealing with the emotions that get triggered from prior trauma.

Under these circumstances, it's not unusual to feel powerless.  Feeling powerless, due to the current situation as well as feelings triggered from the past, can cause you to feel anxious or depressed.

Suddenly, your life looks a lot different from before your diagnosis.  People who have been diagnosed with a major medical problem, often talk in terms of "before the diagnosis" and "after the diagnosis" with the diagnosis serving a dividing line in their lives.

Getting Help in Therapy
Working with clients who have medical problems, I often find that a combination of clinical hypnosis and Somatic Experiencing (SE) can be very effective to help them overcome the emotional challenges and maintain a healthy sense of self.

If you're struggling emotionally due to a medical diagnosis, you owe it to yourself to seek the help of a licensed psychotherapist who practices clinical hypnosis and Somatic Experiencing.  

About Me

I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist. 

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Psychotherapy: You're Not Defined By Your Diagnosis

As a psychotherapist in New York City, I see many clients who have been in psychotherapy before. People who have a lot of experience with psychotherapy will often start their initial session by saying, "I'm depressed" or whatever they've been told their diagnosis might be. Whenever I hear this, I often have an internal experience where I feel the weight of this client carrying around this identification and self concept, in some cases, for many years.

You're Not Defined By Your Diagnosis

It's Useful to Know There's a Name for What You Feel

Now don't get me wrong: I'm not completely against diagnoses. If you're a person struggling with depression (or some other diagnosis), it's useful to know that. Knowing that there's a name for what you feel and thousands of other people have similar experiences can be comforting and indicates that you're not alone.

...But Your Diagnosis is Not Your Identity
But taking on a diagnosis as a permanent identity is a different story.  When you say, "I'm depressed" almost like you're saying, "I'm Mary" (if that's your name),it's almost as if you're claiming the symptoms of depression as part of your permanent identity as if it's never going to change. Now, we know that, depression, for instance, can be overcome with treatment, whether it's psychotherapy or the combination of psychotherapy and medication. It's not a permanent part of your identity that can't be changed like, possibly, your ethic background or some other unchangeable part of who you are as a person.

Your Diagnosis Isn't Your Identity

When you strongly identify with and embrace your diagnosis by saying "I'm depressed" as opposed to "I'm a person with depression," you're giving yourself a message that this is who you are and it's not going to change. And the more you say it, the more ingrained it becomes in your mind.

What I'm proposing in this blog post is NOT that people should be in denial about what they're experiencing. Instead, I'm proposing that your relationship to your diagnosis doesn't have to be a permanent one. If the reason you come to therapy is to change, if you're constantly giving yourself the message that you are your diagnosis, it's going to be that much harder to change because you've accepted that this is who you are on the most basic and core level. It's giving yourself the message that you're not going to change.

What I'm discussing, about how people label themselves with diagnoses, is more than semantics. it's a way of thinking and holding onto something that you say you want to change by coming to therapy. So, in a way, the internal message that you're giving yourself contradicts what you're trying to change, so you're at odds with yourself.

It's like the opposite of saying self affirmations. Instead of giving yourself positive messages, you're giving yourself a negative message--over and over, so it becomes part a habitual negative thinking.

This is all aside from the fact that, even though there are diagnostic categories, no two people with depression (or any other diagnosis) are the same. And, of course, you're a whole person who is much more than a diagnosis. So, to limit your self identification to your diagnosis is like putting yourself in a small box. What about all the other wonderful parts of you that aren't related to the diagnosis? It becomes easy to overlook all of those positive aspects when you become overly identified with your diagnosis.

It might take a while to develop this type of awareness about yourself but, in the long run, it's much more affirming to who you are as a complete person, beyond labels.

About Me

I am a licensed New York City psychotherapist with expertise in Somatic Experiencing, clinical hypnosis, EMDR, and psychodynamic psychotherapy.

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (917) 742-2624 during business hours or email me.