Does Cutting Costs Create Mental Illness?

By Kathy J. Marshack, Ph.D., P.S.

Recently I heard a well known Dale Carnegie graduate give a talk on how to attract new business. He used as an example, what attracted him to the family physician who had attended to him, his wife and children for years. The good doctor had given a similar talk at a public event and impressed the man with his expertise, solid reputation, and sincerity. For something as personal and life important as the health care of his family, the man wanted such an individual as this dedicated doctor. And for years his initial decision to choose this physician proved to be a good one. Yet in spite of the importance of choosing the “right” health care professional, this Carnegie graduate dropped the doctor like a “hot potato” when managed care rolled into town. Because his company chose a managed care plan that would not allow the doctor to join the panel, the dedicated patient who had so carefully chosen and developed a meaningful relationship with his health care provider, decided to follow the impersonal dictates of the managed care plan. Closer to my own area of practice, psychology, is another story that is even more disconcerting. A young teenage girl had been treated for depression by a psychologist. In actuality she was not seriously depressed but rather angry at her boyfriend for being somewhat shallow. The girl’s parents called the managed care company and were referred to the psychologist. After a few short sessions with the psychologist, the girl felt she had more control of the situation and would not allow the boyfriend’s manipulation to continue. Two weeks after terminating psychotherapy, the girl and her father had a fight that erupted into yelling and screaming between the two of them. The father in frustration called his managed care plan (an 800 number in southern California) and told them his daughter was suicidal. Without any psychiatric evaluation and without contacting the daughter’s psychotherapist, the clerk at the other end of the 800 number advised the father to take the girl to a psychiatric hospital. Although the girl was not suicidal and didn’t need hospitalization, she did learn to fear her father and to behave lest she be hospitalized again. Not a healthy outcome. By now you probably have the tone of this article. While managed care may save your company dollars, and while there is a need for health care reform, you might think twice about just what you are subjecting yourself, your employees and your family to. The mistakes made by the Carnegie graduate and the father of the teenager are not uncommon. There is a mystique about managed care. People have come to believe that the 800 number is like a parent, able to solve all of their woes. They believe that they will get the same personal service they received for years by a doctor who knows them. They are puzzled when the service they do receive is not sufficient to resolve the problem. Often they assume that there is nothing more that can be done, since their managed care company has not authorized additional services. It’s as if the managed care company has assumed the paternalistic mystique that the family doctor once held. But now the mystique has no concern about the individual, only cutting medical costs.

All right, I realize that I am biased on this subject, given that I am one of those doctors that is being pressed by the managed care industry. It may be hard for some of you to accept my complaints about managed care, even though others of you have your concerns too. So let me relate a few statistics to bring you up to date on the state of the art when it comes to psychotherapy. The following points come from recent published research. Ninety percent of emergency room visits are psychosomatic in origin. In a review of 58 studies, 85% of the studies found substantial reductions in the medical and surgical costs of patients who regularly used psychotherapy. In a review of 475 studies, the authors found that the average psychotherapy patient at the end of treatment was better off than 80% of those patients who need psychotherapy but remain untreated. Therapist competence relates more to client improvement than does the particular treatment modality. By 8 sessions of psychotherapy 50% of the patients are measurably improved. By 26 sessions or about six months of psychotherapy, 75% of patients are improved. Cognitive-Behavioral psychotherapy alone is as effective and efficient in treating depression as are drugs, or drugs and cognitive-behavioral therapy combined. Drugs have side effects. These are pretty impressive statistics. If as an employer you could improve the health of an employee, certainly you would see an improvement in your bottom line. Healthy employees produce. Most managed care companies, however, are not into improving employee health, but in cutting insurance and medical costs. If they were really interested in your bottom line, why are they not increasing mental health benefits? If psychotherapy works as well as or better than drugs; if psychotherapy reduces emergency room visits and medical and surgical costs; if psychotherapy works better than no psychotherapy; if competent experienced psychologists are part of the success, why then are benefits for psychotherapy being slashed and watered down so dramatically? You may question my findings, noting that your managed care plan includes mental health benefits. However, if you review your benefits in particular, you will find some serious flaws. Such flaws include the fact that your employee is entitled to five or ten employee assistance visits with a counselor. If the problem cannot be resolved in five or ten sessions, they get no more. Also the counselor they must see cannot be of their own choosing. Many of the psychotherapists contracted to managed care companies are inexperienced master’s level people. Another flaw is that all psychotherapy plans must be reviewed with the clerk at the managed care company. The treatment plan is not a confidential arrangement between the client and the psychologist. It is part of a computer record available not only to the insurance company, but to the managed care company who reviews and authorizes insurance claims.

There are some estimates that up to 12 people see your psychotherapy treatment plan. For things as personal as serious depression, or marital problems, this is hardly sensitive or confidential. Furthermore, do you really want an anonymous clerk to be making decisions about your personal mental health? A third flaw is that the managed care company makes decisions about what kind of treatment you should receive based upon actuarial tables. It is not based upon your unique situation, nor what you and the doctor feel would be best. There is no sensitivity to your needs, but what fits the budget. If psychologist competence is significant to treatment outcome, then why is a clerk making these decisions? I personally am willing to participate in only three managed care plans for the above reasons and more. I will work only with those plans that leave the treatment plan between myself and the client. I will work only with those plans that maintain client right to confidentiality. I will work only with those plans that pay me what I am worth as a seasoned professional. I will work only with those plans that authorize appropriate treatment and will not cut off therapy for short term gain, forgetting the long term health loss. If you are shopping for a new health plan and if you are considering a managed care plan, why would you be interested in my point of view? After all, as I said earlier, I am biased in favor of preserving my profession. But there are compelling reasons to take a good look at all sides of the situation. It’s like my CPA says about taxes. If you find a way to save some taxes in one area of your business, you ultimately pay more tax somewhere else. It’s the same with mental health. If you cut premiums and cut services to your employees when it comes to their mental health, you pay the price in increased medical and surgical costs, employee accidents, higher turnover rate and so on. In an ideal world, there would be enough to go around; enough dollars to pay for health care and the ability to choose any provider you wished. However, obviously employers have to strike a reasonable balance and health care has skyrocketed. But in the time that medical and surgical costs have skyrocketed, mental health costs have not grown. They are essentially at the same utilization rate and cost as they have been for decades. So psychotherapy is not the place to cut. It just doesn’t make financial sense, when the price you pay is increased health problems. So when you are shopping around for a health plan, I hope you consider just what you are buying when it comes to mental health benefits. ? Do you have ample psychotherapy benefits; at least 26 to 52 visits per year per employee? Do you have the right to choose the most experienced and competent psychologist? Is there true confidentiality guaranteed? Is the treatment plan dictated by actuarial tables or by the unique needs of the situation and the employee? Is the payment to the therapist worth the time of a competent professional, or are you forced to seek out an untrained, inexperienced person who will charge rock bottom prices?

Making the most out of psychological consultation



By Kathy J. Marshack, Ph.D., P.S.

The other day, a client came into my office and sat down in the rocking chair, she crossed her arms and asked, “Well, what do you want me to talk about today?”

Her response reminds me that many clients of professional consultation, particularly psychological consultation, do not know how to use the consultant’s time. Paula’s questions reveals her belief that the consultant is in complete charge of the relationship, can read her mind, and has ready advice for every contingency.

It is understandable that people put this much power into the hands of their consultants. If you have a problem that is overwhelming, it somehow feels safer to let someone else be in charge of the solution.

The problem is that you the client/business owner have to make the decisions about your life and work. As Harry Truman said, “The buck stops here.” No one other than yourself can ultimately decide your proper course of action.

Psychologists know from our research that people will take credit for their successes and blame someone else for their failures. What most people don’t realize is that if you are brave enough to take full responsibility for all of your decisions, whether or not they were guided by a consultant, you have much more of a chance of success.

Because you are noticing all of you little and big failures along the way, you stand a better chance of correcting the problems before a crisis erupts.

Too often I am confronted with clients who have waited until the top has blown off the project. They are desperate. They want immediate solutions. They often get disgruntled with the consultative process because we are taking time to repair damage before we can move to more proactive work. If as the client or business owner you are ready to face your weaknesses as well as your strengths, if you are ready to admit your ignorance, the consultant can step in sooner to help you.

If you view each failure as only feedback, you will be operated as the cybernetic system you were designed to be. Get your Ego out of the way. Admit your ignorance. Use skills creatively. Use your employees creatively. Be open to solutions that at first sound ridiculous. They may sound ridiculous because you haven’t had time to expand your consciousness to include new ideas.

The consultant’s job, if they are doing their job, is more process oriented than task oriented. While you may want the advice or labor of our consultant regarding tasks that you are not skilled to handle, the consultant can help you best by getting you to think and use your own talents toward the solution.

Your lawyer cannot writ up a will without knowing your wishes specifically. Your CPS cannot advise on investment of even tax planning without understanding your financial objectives. Your Organization Development Psychologist cannot guide you in those tricky interpersonal problems without knowing how you and your personnel fee.

Knowing that you are really the decision-maker makes it a lot easier to take charge of the consultative process and ask the questions that need asking. Don’t be afraid to ask a stupid question.

Slow your consultant down and ask for clear explanations and rationale for their recommendations. The psychologist is an expert in her field and may not realize that you don’t understand her jargon or thought process. You are paying the psychologist for her education, knowledge and expertise, and to help you make the best decision for yourself, your family and your company.

Finally, if you are going to benefit by the use of a consultant, be prepared to do some hard work. Change is not an easy process. Just as when you first learned to drive a car, you have to be aware of every little move if you are to change your behavior and business organization or strategies. Now, driving a car is so automatic that your rarely remember the time between putting the key into the ignition and arriving at your destination. But at one time it took every ounce of concentration you had to master the ignition, the clutch, the rearview mirror, the brakes, the accelerator, the odometer, and so on.

The psychologist/consultant assists and guides in the process of change, but it is up to you to do the work. It is also up to you to refine the advice of your consultant to fit your unique situation. Things may sound good on paper, but in practice may need a little modification.

Psychologists know from our research that if too much time lapses between the consultation and taking action, the person will not do the required work in order to change. Take the time to put into practice what your consultant and you have decided. Notice where it works and where it doesn’t. Then keep modifying until you have a system that fits you perfectly.

Process consultation is a valuable contribution to your business. The psychologist can open your thinking in directions you never thought of before.

For example, two brothers were arguing bitterly about how to manage their landscaping business. In terms of skills they were ideally suited to be partners. One was the landscape architect; the other had the sales skills and business management savvy.

They had also grown up with the business and inherited it when their father died. Nevertheless there were constant arguments about how to handle clients, employees, investments, and so on. The trust between the two brothers/business partners was shattered.

The brothers finally turned to a psychologist when their business consultant, attorney, and CPA failed to find a resolution. The psychologist helped the brothers recognize that while they loved each other as brothers, their lack of common interests and values make it difficult to be business partners. In other words if they had not been brothers, they may never have chosen each other as friends of business partners.

The psychologist also helped them to get over feeling guilty for breaking up the family and the family business that Dad had founded. Each was able to move on as an independent landscape contractor with his own business modeled after his own distinct personality. Now they can socialize as brothers, attend family functions and even refer each other business.

Psychological consultation is probably the most intricate form of consultation you will engage in. The focus is more on how you communicate and make decisions than on what you say or do. Many decisions and relationships can be much improved by changing the how or the process. If the two brothers had maintained their old method of relating they would have destroyed their relationship, the business or both. As a result of being willing to consider other methods of defining a family and a family/business, the brothers were able to transform themselves to amore productive and happier level of functioning.