The Therapy Shrink Health: Managed health companies increasingly dictate mental health treatment. Long-term therapy is less of an option.

October 31, 1995|By Patricia Meisol | Patricia Meisol,SUN STAFF

Your 14-year-old son refuses to go to school. Your wife says she's leaving -- maybe she'll be back when she finds herself. Your boss gives you a poor evaluation based on repeated late entrances and you know why -- alcohoism.

You need help. But chances are your insurance company will offer the following menu: group or family therapy. Brief therapy. No therapy.

While interest in psychotherapy has never been greater, families in need increasingly find their choice of therapists and the length and kind of treatment they get limited by managed care companies trying to help employers cut costs.

Even before they knock on the therapist's door, the patients' anxiety is heightened over the possibility that treatment will end before the problem is solved. As their autonomy shrivels up, therapists themselves are becoming fearful and depressed.

"Any major conference you go to, there are always workshops on how you can deal with anxieties of managed care or how insecure therapists feel," says Mary Beth Smith, a Baltimore social worker who no longer takes new managed care contracts. "They are working more hours, getting more patients, making less. It's depressing."

Indeed, more than a dozen sessions on managed care are being offered for 3,000 family therapists gathering in Baltimore this weekend for the annual conference of the American Association for Marriage and Family Therapy.

Family therapists are selling themselves as part of the solution to the managed care crunch, arguing that such therapy is more efficient and solution-oriented than more traditional one-on-one therapy. In fact, those who embrace family therapy could find their practices booming in the new world order.

The new mental health therapy is short-term, solution-oriented and inexpensive.

Directing people into care is often done for an employer by a specialty company that stands to profit from providing as little care as possible. Therapists who criticize the dictates of the managed care company risk being dumped.

But the quality of these companies varies greatly. Typically, many families in trouble find:

* Individual therapy is out, and group therapy or family therapy is in.

* Gone are the years of examining one's childhood on the psychiatrist's couch. Instead, patients are urged to forget the past and focus on the here-and-now. The goal is to develop a practical plan to get functioning again. The briefer, the better.

* Therapy is limited to an average of 10 sessions. Some companies allow only two or three.

While insurers say they follow the best clinical practices for managing illnesses such as depression, there is evidence that some companies have used incentives to deny care. In July, United Behavioral Systems of Minnesota paid more than $100,000 in fines to the state of Rhode Island after being accused of illegally paying bonuses to executives who kept 80 percent of outpatient therapy to 10 sessions.

* Choice of psychiatrists and psychologists is limited as insurers steer patients to lower-cost professionals, such as social workers, or set up their own networks of therapists who agree to follow their rules.

* Insurers are questioning whether help for problems once routinely covered is "medically necessary." Treatment for severely disruptive adolescents, for instance, is being denied by some companies on those grounds.

Whether managed care's approach to mental health works remains to be seen, many say, but in the past, people got unnecessary, costly care.

"We participated in the decade of greed and we are downsizing like everybody else," says William Doherty, director of the marriage and family therapy program at the University of Minnesota.

Eric E. Anderson, until recently an executive of MEDCO, one of the dozen large companies nationwide that manage most mental health care, calls the current system to manage mental health therapy "primitive."

"The focus has been -- and this is the argument by detractors -- on financial, cost reduction. It's a legitimate criticism," says Dr. Anderson, a New Jersey psychologist. "The focus should be on clinical intervention."

But change is in the air.

MCC Behavioral Care Inc., a Cigna subsidiary, takes the long view, paying for therapy for troubled teens to prevent more serious -- and more costly -- problems down the road.

GreenSpring Health Services Inc., of Columbia, which manages care for 11 million people nationwide, credentials therapists for only what they are trained to do.

"Unlike other companies, we don't assume that all providers provide brief therapy," says Clarissa C. Marques, senior vice president and chief clinical officer. "When you get a lot of long-term psychotherapists trying to do it, they get lost."

Therapists fall into four main categories -- psychiatrists, who are doctors and can prescribe drugs; psychologists, who are expert at testing for various disorders; social workers, who have a master's degree, and, in Maryland, people who have a master's degree in a counseling field.

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