Psychotherapy and insurance: the double bind.

• Author: Puterbaugh, Dolores
• Position: Psychology

Many "therapists feel frustrated, threatened, and trapped in an unhealthy alliance" with insurance companies.

WHEN THE PHONE RINGS in a therapist's office, prospective clients invariably ask the same questions: "Are you accepting new patients?"; "My problem is my (job/stress/ spouse/teenager). Do you work with this issue?": and "Do you take my insurance?"

The first question determines the necessity of ally further conversation. The second and related queries to establish the therapist's personal style, approach, training, and background would seem of critical importance. The final one, however--"Do you take my insurance?"--is the real deal-maker or -breaker in the delicate task of selecting a psychotherapist. Clients shopping for a usually show little interest in whether I am a barely functioning hack or a highly respected professional. They do not seem to care if I am the kind of person whom they would not want rummaging about in their head, heart, and soul. What matters most is whether or not I accept insurance.

I do not accept insurance for counseling services. Since the situation described is almost always a life issue, rather than a psychiatric emergency, there are almost no insurance plans that would cover the client's claim. Health insurance as we know it is illness and accident insurance, meaning there must be a diagnosis. It is the absence of health that is billable. For counseling professionals, a bill able problem would be a mental disorder. This is why I have elected not to apply to insurance panels and have the resultant small practice,

There are three distinct ethical dilemmas in the use, or abuse, of mental disorder diagnoses and health insurance for life problems:

* Diagnoses are generally subjective sometimes political, and always inadequate to the task of describing the human condition.

* The health insurance system was instituted to pool resources mad risk in the high-stakes world of health care cost management. It is an abuse of this trust to manipulate diagnoses to save someone money on a personal issue.

* Clients are almost always unaware of how insurance companies operate. They seldom understand what the paperwork being filed tells others about them. For this reason, few comprehend that the immediate benefit of insurance may be far outweighed by future damage to their quality of life.

These are powerful reasons to shun insurance companies' interference with the counseling profession, but a double bind markedly similar to codependence has arisen. Over the last two decades, as insurance companies became bigger and more powerful, they began to provide referrals for therapists who, in turn, sought to try to please those insurance companies. Professional practices evolved to meet the companies' demands. These included the increasing use of diagnoses, different kinds of forms kept on file, and utilization of a specific billing format. At present, most therapists believe they could not possibly survive without the insurance companies. Where would they go, and what would they do? Like a spouse whose soul and body have been badly battered, therapists feel frustrated, threatened, and trapped in an unhealthy alliance. A successful counseling practice without the insurance companies seems impossible, even as the demands become more intrusive and fees smaller.

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