A Brief Look at the Current State
of Mental Health Care

By Susan Chipman, Ph.D.

It's been a while since I dared survey my colleagues about their experiences in private practice, group practices and agencies (public and private). Unfortunately, nothing has improved, and, in many cases, the system is more broken than it had been a few years ago.

Private individual and group practice
What we used to know as psychotherapy is rarely practiced. At best, clinicians are often limited to cognitive behavioral therapy, or some attempt to reduce the acute symptoms of a person's pain. In most group practices and many public clinics that rely on fee-for-service reimbursement, 'productivity' is the guiding principle. Clinicians are encouraged to get as many people as they can in and out; spending much time justifying to insurance companies the need for more than the initial few sessions, completing endless forms, and making sure that billing meets the requirement of each insurance plan and "product" (the particular type of plan that patient has).

Gone are the days when the clinician and patient had the time to establish a working relationship that enabled them to then pursue the patient's problems - not just symptoms - over time. As one colleague told me, you quickly bolster the patient's self-esteem enough to stabilize him/her; "you don't want to stir anything up" in the few sessions you're allowed.

If you are working with somebody who is severely depressed or anxious, you can spend a good deal of your professional time going to bat for them with the insurance company. Another clinician noted that more of the people he is seeing in his private practice now are "relatively sick people".

Finally, many insurance companies will not put a clinician on their panel unless that person is part of a group practice. By working with a group, they can obtain various concessions that benefit the insurance company…but certainly not the patient.

Public and Private Agencies
It is the clinics, and the populations they serve, that are hurting the most. Here, many of the patients are at least fortunate enough to be covered by MassHealth, which, however, is managed through a couple of different private insurance plans. Patients can be shifted, without explanation, from one plan to another, disrupting the attempt to provide treatment. And, the insurance plans have unrealistic expectations of what can be accomplished in the limited number of sessions they are willing to dole out.

In some cases, the MassHealth Plans now require that 'outcome studies' be done as well, so that the data from them can be used in treatment planning. The final Catch 22 is that the agencies are reimbursed so inadequately that they are left without sufficient funds to hire licensed clinicians, a requirement by the Plans for insurance reimbursement of the agency. They can only hire inexperienced, even if dedicated, treatment teams.

Parity
Mental Health Parity came in, several years ago, in the form of a state law that was to equalize the availability of treatment for major mental disorders with the treatment of physical disorders. The hope was that this law would provide a basic number of mental health treatment sessions, allowing the patient and clinicians to do their work without having to justify each session with the insurance company.

Most clinicians I interviewed indicated that nothing changed with passage of the Parity Law and that the name was a cruel joke. In most instances, the same micro-management of sessions took place. The number of session 'automatically' given at the start of treatment is smaller than what parity should warrant; and this number is often reduced each year. In fairness, several clinicians told me that some of the Blue Cross/Blues Shield plans were the exception to this, remaining closer to the stated intention of the Parity Law.

Substance Abuse Treatment
If any form of treatment can be considered the 'step-child' of mental health, it is substance abuse. In recent years, there has been a nearly 50% cut in the number of beds for detox throughout the state, and long term treatment is rarely available to the severely addicted. Instead, many of these patients are being warehoused in our prisons. Contributing to this is the seemingly endless stream of hospitals that are closing and/or being sold by for-profit corporate owners. When looking at which units to close, in those instances where the entire hospital is not being closed or merged, the units considered first are usually the dual diagnosis psychiatric and detox wards.

In Conclusion
It is nothing new to mental health service providers to have to fight to get the needed resources to treat diagnoses that continue to carry a stigma. Now, with people increasingly losing their health insurance through job loss, unaffordable premiums, or not having health insurance to begin with, the mental health sector is but a part of an entire healthcare system in crisis.

The fate of mental health and health services as a whole are inextricably linked. As long as we allow a market based, for-profit driven system to control the services we provide, no area of healthcare can function optimally and peoples' needs cannot be served. In mental health, the number of clinicians who talk about leaving the field is staggering.

Susan Chipman, Ph.D. is a clinical psychologist