One of the problems that health care reform is trying to address is curbing unnecessary medical procedures. I am not an expert on these things but I can offer my own informal snapshot view of what I have seen in the mental health field.
One of the problems that exists in mental health care has to do with what kind of treatment is being provided. Take a single case and give it to 5 mental health clinicians and you will have, more or less, an agreement on diagnosis. But what happens next depends on clinicians’ point of view or therapeutic orientation, depending on what kind of training they received. The disagreement can be quite profound because there are so many different schools of thought, each with their own tools and each requiring a different amount of time to deliver. And that, of course, determines how much needs to be paid for that treatment to happen.
I have seen hundreds of medical charts from residential treatment centers and inpatient hospitals. Great treatment is provided. Bad treatment is also provided. The usual “bad” treatments are those situations where people are kept in treatment much longer than they need to be. Clinicians, both in private practice and at facilities, will use their “clinical orientation” to justify why someone should continue treatment.
It’s quite possible they are right too. Sometimes people want to leave treatment because it is becoming too sensitive to them. They are beginning to look at uncomfortable issues in more detail and this raises their anxiety, fear, inhibitions and so forth.
Most therapies I know of do require some degree of relating to those demons that bring someone into treatment. Clinicians provide a “safe place” for clients to explore these things. But no matter how safe the relationship is, some clients find it too unnerving and leave “against medical advice” and then complain that treatment didn’t work.
Yet I have seen many instances where clients are kept in treatment because it does keep the money flow open. For example, there are quite a number of treatment facilities that work with adolescents. These are long term programs that can last months or even years. Typically they refuse to work with insurance companies because they know their services will not be reimbursed or because they do not want anyone looking over their shoulder and making decisions about the quality of care they are providing. They simply bill the parents and expect payment in full.
So what happens to that teenager who might not need to be there? Maybe he or she was told they needed to be there “for their own good” when, in fact, it is for the facility’s own good to keep that teenager and for the parents who just don’t want to deal with that child at home. Make it someone else’s problem and then blame them when it doesn’t work. Sound outlandish? Happens all the time. It all costs money too.
Consider a sixteen year old girl who was on an inpatient unit for four weeks because she was sad over the fact that she was not allowed to have a boyfriend. She was depressed, had the typical teenage heartbreak when you don’t get what you want, but she was not suicidal, was not hearing voices, was not out of control (yelling, throwing things, truant, running away from home) or a danger to anyone around her. She was just upset.
After a few days she became resentful about the fact that she had to be there. Um, hello? You know any teenager who wouldn’t? Yet she was told she needed to be there. You know how much a day costs in a hospital? She was finally released because she had to go to summer camp. Bad treatment. Bad fiscal consequences. Bad all round.
There are drug/alcohol treatment centers that provide the typical 30 day recovery program. Treatment is finished once you’ve done your 30 days. What happens if you finally “get it” after two weeks and decide you’ve had enough and want to continue with an outpatient therapist or AA/NA or both? If you leave, most of the time, you will be labeled as being “in denial” and that you haven’t finished the program yet. It’s 30, not 14.
Facilities will rationalize that typically hardcore patients don’t just “get it” after one or two or even six weeks. They need to stay in treatment to make improvement and maintain improvement (which begs the question because how much you improved you don’t know until you’re back in the saddle). Hence 30 days is a norm that becomes a one size fits all label. It completely contradicts how healing actually happens. Everyone is different. Some get it quickly, others more slowly, some not at all.
Without a doubt there are some people who do need a long term structured environment to “get it.” And then there are some who don’t. How do you know which is which? For better or worse, we rely on our health care providers to help us make those decisions. What if my primary care physician says I should get “into treatment” at such and such a facility, which is a 30 day program? Well he is the expert. He does have that state license hanging on the wall so he must know. Well he does. Or does he?
Sometimes therapists begin to feel helpless because they are not making inroads with their clients. To cope with their sense of failure they say maybe you just need an inpatient program. If my slingshot doesn’t work, let’s nuke it and ignore the fact that maybe I’m using the wrong tool to begin with. The unwitting client believes in the authority of their treating clinician and buys into the advice. Now the wallet has to be opened wider.
I have known several therapists who use an orientation whereby, once an initial crisis has been resolved or the client has gotten it together in some ways, they state now is the time you can “go deeper” in therapy and look at those underlying issues that caused the crisis to begin with.
Going deeper means more time invested and more money spent. There is something to be said for that too. Unless we come to terms with some of those inner demons, they will resurface later in some other situations and another crisis will ensue. But, and this is a big but, this kind of thinking lends itself to abuse too. It could be used to try and keep someone in treatment longer than they need to all in the name of “for your own good.”
However, most therapists I know work ethically and it goes against their grain to take advantage of their clients. When someone is ready to leave the nest, we let them fly. But I can’t speak for every therapist in the nation.
Although managed healthcare is given a bad name for making decisions from afar, decisions that have cost people lives when a procedure was not approved, it does provide a cost containing mechanism. With costs more under control, there is more opportunity for others to access medical care. This is good for all. Yet it seems to be a clumsy, improvised tool that doesn’t make everyone happy all the time. “May you live in interesting times” is a Chinese curse. So true.
