The Shrink Brigade


The therapists are not happy. Proceeding from a teach-in at the Methodist Church on West 4th Street to a rally in Washington Square Park on April Fool’s morning, they are throwing around terms like “profiteers” (as in “all we need to do is get the health care system out of the hands of the profiteers”) and “managed care-ization,” a process that, according to one speaker, “is squeezing practitioners and hurting patients everywhere.” Occasionally, the psychologists, social workers, and psychoanalysts participating in “Rescue Health Care Day” blow little plastic whistles for emphasis.

Thirty cities around the country staged events like this one to give a “nationwide vote of ‘no confidence’ in managed care,” according to organizers at The National Coalition of Mental Health Professionals and Consumers. The date was picked to highlight the idea that “Americans have been fooled by the promises of the managed care industry,” as the organizing materials explain, and many participants obligingly wore foolscaps to bring home that message.

But it takes more than felt hats with bells to get a hundred people out of bed and into the streets on a Saturday morning. And, indeed, many of those who showed up for the rousing speeches and folk songs (played by a flutist-psychoanalyst) were motivated at least in part by the impact that system has had on their own psychotherapy practices. Managed care, it turns out, is not a supportive environment for therapy.

“The HMO world has led to mounds of paperwork,” says Marcia Poston, a psychotherapist who works with substance abusers and is considering no longer accepting managed care payment. “If a patient has a certain insurance, you have to first call just to make sure what that benefit is. The initial call can sometimes take me up to two hours because I don’t have the right office, or I don’t even have the right plan. Then I’ve got an insurance company plus a managed care organization, so who do I call to get the certification? Where do I send the insurance? Then I have to fill out treatment plans. And then a lot of times I don’t get paid.”

For Helene Gould, a psychotherapist in private practice, such hassles simply aren’t worth the business they would allow her to keep. “I refuse to take managed care,” said a resolute Gould, as she made her way through the park. “I refuse to be told by somebody who knows nothing about the patient what is wrong with the patient and how many weeks I’m allowed to see the patient. I won’t be dictated to that way.” As a result of her no-managed-care policy, Gould says she’s lost about a quarter of her business.

That is just how insurers that manage mental health would like it, of course. In the past 10 years, as “managed behavioral health” companies have begun to oversee mental health care, coverage for those benefits has fallen a whopping 54 percent, according to a study by the Hay Group (which found that health benefits overall dropped a mere 7 percent in the same period). Those on the management side of the equation argue that such cost cutting is a step toward efficiency; some even make the case that open-ended talk therapy is harmful for patients—as well as the economy.

But according to the social workers and psychologists at Saturday’s protest, the cutbacks are downright dangerous. More than one clinician told of patients who were denied treatment only to end up attempting—and, in one case, committing—suicide. And many railed against the take-two-Ritalin-and-call-us-when-you’re-older approach of managed care, which increasingly authorizes less-expensive psychiatric medication instead of talk therapy.

For health care advocates who are already convinced that the American, profit-driven approach to health is fundamentally flawed, therapists are the canaries in the coal mine. “Since the early ’90s, managed care has been telling mental health practitioners what they could and couldn’t do in order to stay on panels of providers,” says Martha Livingston, a SUNY associate professor of health and society. “The powers that be didn’t take [the restrictions] seriously enough. Now we see managed care telling docs what they can do and that what they really need is not to have sick patients.” Livingston says that mental health care is especially vulnerable, but warns that further cuts in other types of health care are likely not far off.

As Livingston sees it, the solution to our health care ills—mental or physical—lies in a single-payer health system, like those in Canada and the United Kingdom. But these days, that seems about as likely as finding a good shrink who takes HIP.

In the meantime, therapists’ personal stake in preserving their businesses makes them perfect foot soldiers in the battle for health reform. Says Nick Unger, spokesman for the Universal Health Care 2000 Campaign and one of the event’s organizers: “These folks have been hit hard by managed care because of the particular historical bias against mental health. But when you strip away the details, it’s the same thing.”