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Psychotherapy's Silent Crisis
Healthcare administration is undermining the effectiveness of therapy
Written by Tristan Maclean, PhD.
There is much controversy surrounding the field of psychology as a whole and much discourse separately and relatedly about therapy (“everyone needs to be in therapy” vs. “therapy is fake.”) However, there has been little discussion of a more practical issue: how the perverse incentives of healthcare organizations and administrators are forcing psychologists and other licensed therapists to provide a much lower quality of psychotherapy than is desirable, effective, or “evidence-based.”
I’m an early career clinical psychologist who took a somewhat non-traditional route to obtain my doctorate and now practice in a managed care organization. My doctoral program provided high-quality clinical training and ensured I gained experience in embedded healthcare settings with an intentional eye to the growth of this therapy delivery model. My non-traditional background, clinical and didactic training, and current experience within a managed care organization inform my perspective on issues in the field.
Psychiatrist Scott Alexander has written in some depth on whether therapy works, and I would direct the reader to his writings on the matter if interested. For this essay, it’s sufficient to note that research on different therapies shows a range of efficacy in reducing symptoms. Efficacy rates are typically no higher than 40%, with the effect sizes tending to reduce from medium to small the longer the therapy exists and is studied.
A variety of therapy modalities fall under the umbrella of “evidence-based treatment.” While these modalities often differ in their language and pacing, they all share some aspects as “evidenced-based” treatments: A record of research including randomized control trials; testing and validation for specific treatment manuals, with typical treatment based on some number of set weekly 60-90 minute sessions often 8-16 weeks in length; and some recommended way to monitor outcomes. Treatment will also include “homework” to accomplish in the intervening days between sessions. While this is what treatment is supposed to look like, it rarely does in practice for the reasons given below.
For this essay, I am referring to an “embedded” psychologist as one that does not have a private or group practice but instead practices within a larger healthcare organization. They exchange easy access to internal referrals for less autonomy in managing schedules and caseloads. My training program impressed on its students that this was the model of the future and that it benefited both clinical psychologists (access to referrals, fewer administrative hassles, more liability protection) and patients (less difficulty following through on referrals, more likely to be covered by insurance).
Managed Care Organizations
Most people obtaining healthcare in the US today do so through a managed care organization. Managed care organizations attempt to manage “cost, utilization, and quality” of care. What this means in practice is people with degrees in “healthcare administration” or other non-clinical fields are the ones actually directing your care. Their job is to cut costs by reducing your quality or quantity of care. Healthcare administrators treat clinical hours as fungible widgets in ways that are incompatible with the delivery of psychotherapy described earlier in this essay. In my managed care organization, I am simply not allowed to provide any psychotherapy modality as designed, researched, and manualized because I have next to no control over scheduling or caseload.
Follow-up times are incredibly important for delivering effective mental healthcare. It really matters that a patient struggling with, say, suicidal ideation can see his psychotherapist two days after a session as opposed to two weeks or two months after. However, the administrators in charge of managing specialty care, which includes mental healthcare, come from a background of managing primary care, in which follow-up times matter far less. In my experience and in talking with peers, these managers neither understand nor care about the unique scheduling needs of patients undergoing psychotherapy for serious mental health issues. Sessions which should last 60-90 minutes are limited to 45 minutes or less, crisis services are pushed to emergency rooms or a random provider assigned “triage” availability, and the exorbitant length of time it takes to receive a follow-up appointment leads to higher dropout rates as well as failure to follow through on treatment plans by both patient and therapist.
Of course, the trade-off for autonomy in practice is then needing to deal directly with insurance companies, referral sourcing, and other overhead costs, all of which have their own challenges and which I am not well qualified to speak on, never having operated in private practice myself. There are, in some cases, insurance coverage-related problems in accessing psychotherapy in a way that has full fidelity to treatment modalities, and again I cannot speak to the intricacies or details of this issue with my current experience. What is clear is that there are economic and bureaucratic pressures towards centralization of healthcare delivery, and it’s coming at a cost to your access to and quality of care. There is no incentive for managed care organizations or insurance companies to understand these problems and plenty of incentives for them to continue in ignorance or apathy.
What Does This Mean?
If you find yourself in need of psychotherapy and are one of the millions of people in the US accessing their care through a managed care organization or requiring insurance coverage for payment, you may think you are getting therapy, but what you are likely to get is something watered down and compromised. If you cannot see your therapist weekly because their caseload is too full, that’s a problem, and unless they are in private practice, it’s likely not their fault. You may still obtain a benefit, but your odds are worsened. This problem is likely to grow worse in the near future rather than better, as demand continues to outstrip the supply of licensed mental health professionals of any level of qualification, and persistent calls for single-payer healthcare push us further towards centralization under a bureaucracy equal parts blind as malign.
In summary, there are real problems rooted in healthcare management practices that greatly overshadow any imagined or real problem within the realm of psychotherapy, and potential or current clients of therapy services should keep this in mind.
Tristan Maclean is a clinical psychologist based in the United States.