Why I Hate Managed Care in General, and the Medical Model in Particular

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So this arrogant psychiatrist in another state, who has never met nor spoken to my patient, decides in less than 10 minutes on the phone* to deny coverage for depression and ADD because she's made only minor progress in 12 weeks of outpatient psychotherapy ("three months!" quoth he, obviously horrified).

Oh, yeah, and because she's not getting "standard" (read: "cheaper") treatment, to wit, psychotropics.

He actually asked me why I was asking for more sessions! Um, because she's still depressed? still has family issues? Still doesn't know what she wants to do with her life? After all, he says, it's not working, is it?

Yes, it is. It may be slow, but it is working. Her problems have been years in the making and we're not going to turn them around in three months. He seemed astounded by this concept.

He implied more than once that my treatment of her was substandard. She wants a non-drug solution and I'm not forcing the issue, partly because her depression is moderate, therefore not an emergency, and partly because most of it is environmental in origin, not endogenous. As for the ADD, well, it is definitely holding her back, but it's not going to kill her, and I see the decision whether to medicate or try adaptations and accommodations as a personal one. I respect patients' ability to make decisions like that for themselves, and support their right to do so.

And by the way, the standards of care are written by--wait for it--the American Psychiatric Association.

Not to mention, success with medication is hardly guaranteed. I have had dozens of patients who have not responded to medication after medication after medication. Do insurance companies then want to stop paying for any more drugs? No. This is about money, pure and simple, and it pisses me off. This, people, is why we need national health care.

So if your insurance company doesn't want to pay for ongoing psychotherapy, fine. If it doesn't fit within their definition of "medically necessary," fine. I get that, and I have no problem with it. But don't imply that my work is substandard, dude. Do not go there.

*actually, he'd clearly already made up his mind before he even picked up the phone, based on a one-page request form I'd faxed in. I suppose I should have claimed "moderate" progress on the form. Her role functioning has improved because she's learning to structure herself better ("yes, but is her concentration better?" the insurance company care manager wanted to know) and she's made one of the major life decisions she came here to make. But I really feel we're just getting started. "Moderate" to me implies that we're about halfway through. "Major" progress would be close to the end, right?

While I was writing this the care manager called to see if I wanted to appeal. You betcha! And she pointed out that this all happened because I didn't return their calls quickly enough to suit them. I got passed on for this "peer review" thingy (Do you really think he's my peer? Do you think he's got a doctoral degree in psychology and 30 years experience providing psychotherapy?) partly to punish me.

Anyways, if I had, she went on to say, she "might" have given me two more sessions!! to get the client to agree to a med consult.

Makes me want to set my head on fire. 

I can't believe I p***ed away the whole morning on this, or

OMG! Someone's wrong on the Internet!

I had other things to do this morning. Lots of other things to do. But this is a subject that absolutely gets my blood boiling, because I believe it is harmful to steer people away from AA and its sister programs. This is my entire response to yet another gross misinterpretation of 12-Step philosophy. Basically, the poster conceptualizes mental health treatment and addiction recovery as opposing forces, compares AA to Scientology, and calls 12-Step programs blaming, punitive, and  "dangerous". I am not giving a link or naming the poster, a professional who is at least in part touting her book with her post, as I have no wish to give her argument any more exposure than it already has. Since, unfortunately, she is a guest-poster to a site I used to have in my blog roll and some of you may have read her already*, I am posting my response, verbatim, here:

[Poster] claims that AA is anti-treatment. This is totally not my experience, not as a recovering alcoholic 24 years sober, not as a psychotherapy patient, and certainly not as a psychotherapist with 29 years in clinical practice.

Alcoholics Anonymous (the Big Book) states quite clearly that medical professionals and medications have their place. Other officially-sanctioned AA literature includes brochures and pamphlets on mental illness, medications, and recovery. What is discouraged is medication that merely replaces (by mimicking the effects of) the alcohol/drug of choice (e.g., Valium, Xanax). In meetings it's called 'taking your alcohol from a prescription bottle' or 'taking your alcohol in pill form'. It is the abuse of prescription drugs and the naïveté of physicians who keep handing them out that AA sponsors worry about, not appropriate treatment.

Alcoholics and addicts are experts at obtaining prescriptions that they don't need and which may interfere with recovery to the point of precipitating a relapse to the drug of choice. Old-timers recognize this drug-seeking behavior when they see it because they spent many years doing it themselves, and warning against it is not "bad advice". It may save a life.

My professional and personal experience is that very few groups will tolerate the handing out of advice. It's one form of "cross-talk" when it happens within the meeting itself, and is actively discouraged if not forbidden outright. Sharing in meetings is supposed to include our "experience, strength, and hope". When we tell our stories we share "what it was like, what happened, and what it is like now". This basic instruction is read aloud at the beginning of every meeting. It means that when a topic is introduced, we share how we use the Program to deal with a given issue--not how you should do it. "Take what you want and leave the rest" is an oft-repeated slogan in 12-Step groups.

In the context of fellowship outside the meeting, telling another member what she should or should not do is considered to be working the other party's Program instead of your own, a sign that you at a stuck point in your own recovery process, and is similarly discouraged. While we will point it out if we think a person we are sponsoring is engaging in (pre-)relapse behavior, rarely, if ever, would a member with good quality sobriety tell another member not to take their medication or not to see a given professional.

Even so, of course some members will dispense bad advice. We're only human! The Program offers a built-in protection against that, as members periodically remind themselves and each other that for successful recovery one must place "Principles before personalities". In other words, keep the big picture in mind. Don't let one person's bad attitude or general wrong-headedness get you off track.

[Poster] is right about one thing, though: Of course nobody wants to hear about your diagnosis at meetings--because that's not what meetings are for. AA members recognize that they are not professionals and are not equipped to treat mental illness. AA can be independent, primary, or supplementary, to mental health treatment, but is not in competition with it. Meetings are for getting clean and sober. They are for talking about the solution rather than living in the problem.

The whole point of working the Steps is to learn to live life on life's terms, which is to say, clean and sober regardless of what happens to you inside or outside of your body. Got a funeral to go to? A divorce to get through? The Steps teach you to handle it sober. Talking about how you can't handle it will not. (That, by the way, is a basic principle of Cognitive-Behavioral Therapy--not anti-scientific at all!) Depressed? Working a good Program will get you through this episode sober. Sitting around talking about your depression will not, and anyway, you can (and should) do that in therapy.

This may sound cold, but it is not. It is practical. Raise your issue in the meeting then take the cotton out of your ears, put it in your mouth, and listen to how people who are happily sober many years longer than you handle similar situations in their lives. You may learn something. Again, far from being anti-scientific (or even lacking in common sense), modeling is a basic principle of learning theory, intuited and put into practice by recovering alcoholics decades ago. AA is like dust-bowl empiricism: We use what works.

Old-timers hold newcomers accountable because they ARE accountable for their behaviors, as is everyone else trying to live life as a mature adult responsible member of family/society. Relapse is a behavior, a decision, a choice. Alcoholism is not. It is a disease. But now that you know you have this disease, you are responsible for your recovery. AA does not hold people responsible for their mental illnesses any more than they hold them responsible for being alcoholics.

"Think before your drink" and "the time to call your sponsor is before not after" are no different than our expectation as therapists that a cutter or suicidal patient be responsible for her recovery by picking up the phone to call us before she picks up a razor blade or a gun.

Nor does AA apply consequences for relapse. When your patient returns to his home group to pick up another white chip (think behavior therapy tokens) after a period of 'going back out to improve on his story', he will be greeted with a chorus of "Welcome back!" and hugs, not punishment. Relapse has its own natural consequences--another basic learning theory principle intuited by Bill W. and the other originators of the Program.

Most, if not all, AA members have struggled with symptoms of anxiety and depression at some time, if not chronically, and many may qualify for formal diagnoses. Child sexual abuse survivors, for example, are heavily represented in women's meetings. I believe you would be hard put to find a home group that has not lost at least one member to suicide. So the old-timers know exactly what it's like to suffer from emotional pain. The Big Book from the First Edition addressed the dual-diagnosis issue directly in the Promises, where it reads that even the severely mentally ill can achieve sobriety if they are capable of being honest. But old-timers also know that drinking when you are feeling blue or antsy not only will not help, it will inevitably make symptoms worse: Statistics show that alcohol is directly involved in a significant proportion of suicides, and AA members are more aware than most of this connection. The quip heard in meetings is that "I never had a problem that was made better by pouring liquor on it".

Because of AA's acute awareness of the consequences of untreated mental illness/addiction, "hitting bottom" does not mean abandoning a person to his own self-destruction. AA members fully appreciate the dangers therein. However, just as in therapy, the person needs a certain amount of motivation to succeed in recovery. All "hitting bottom" means is becoming sufficiently "sick and tired of being sick and tired". Members compare it to being on an elevator going down: You can get off on any floor. But sobriety is not something you can impose from the outside in: It's an inside job. AA members reach out to the suffering alcoholic as part of their 12th Step work, but at the same time recognize that the newcomer has to "want what we have and [be] willing to go to any lengths to get it" in order to resist the siren call of alcohol.

In short, AA as a whole--completely unlike Scientology--is hardly anti-treatment, never mind anti-science or lacking in common sense. C.J. Jung had a lot of input into the early development of the Program. As noted above, a lot of common-sense psychological principles are incorporated into it.

Many members come to the Program through treatment, because it's the rare addiction program that does not incorporate required attendance at AA meetings as part of the treatment plan. AA, NA, CA, and other groups meet on treatment-facility campuses. Off-campus groups send representatives to host meetings in hospital facilities, serve as temporary sponsors, or meet one-on-one with patients. Many, if not most, of the staffers in these facilities are recovering alcoholics/addicts.

I have personally seen a pair of old-timers bundle a newcomer into their own car and drive her directly from her first meeting to a treatment facility, recognizing as they did that she was in withdrawal and needed professional attention, STAT. Members routinely refer each other to their own psychotherapists and psychiatrists, many of whom are in recovery themselves.

Real world, then, the overlap between mental health and addiction "cultures" is nearly 100%. Setting up a false dichotomy like treatment-vs-recovery tears a great hole in the safety-net fabric for alcoholics/addicts to slip through, potentially falling to their deaths. It does this by providing them with an excuse not to participate in real recovery, to wit, "My therapist says it's a cult". Just going to psychotherapy alone is a softer, easier way, and if we enable people to do that, the choice is a no-brainer for the active alcoholic/addict. And it won't work. We can practice our empathic listening skills, pretending we are doing something to get them clean and sober and feeling good about ourselves, until we coddle our poor victims of mental illness right into the grave.

"Poor me, poor me, pour me a drink" is not just a slogan, it's a real and deadly phenomenon.

My professional experience over three decades is that I cannot get patients clean and sober without their active 12-Step involvement. In all that time I have never once found either the Program or its members to interfere with someone's mental health recovery. I have, of course, often had clients engage in splitting between the therapy and the Program, and I am reasonably certain they employ the same defense in reverse when they are at their meetings. Seasoned therapists in possession of a deep familiarity with personality structure, the dynamics of addiction, the process of good psychotherapy, and with how 12-Step programs work, however, will recognize that for what it is and work through it with the patient to the latter's ultimate benefit.

AA has succeeded in helping many people who were formerly considered hopeless causes, and they've done it in a completely transparent manner, from the publication of the Big Book (probably the original manualized treatment!) forward. Furthermore, they do it entirely through the efforts of volunteers who wish only to give of their time and energy to share what they have found with the still-suffering alcoholic. It is a gross insult (not to mention, a false analogy) to compare AA to a secretive cult that charges its members each hundreds of thousands of dollars over a lifetime for a completely bogus process. All AA asks of you is that you put a buck in the basket if you have it, and that you stick around to "pass it on". You do your patients a grave disservice when you compare individual A.A. members to a manic, over-paid actor who publicly insults people who seek treatment for emotional problems. You do them a disservice when you dismiss all the people over the past six decades who have found sobriety and a new life through the Program as lacking common sense.

*Also, because it is so ridiculously long (longer than the original post!) that it may not make it through moderation.

I love a good diagnostic challenge

One of the most interesting ever was a guy who had some weird kind of seizure/sleep thing going on that a couple of medical types had ruled was hysterical. Not funny, I mean, but entirely in his own mind. That didn't fit with the history, though, or with his presentation either, so we did some psychological testing, and the resulting personality profile clearly didn't fit with any of the somatoform, histrionic, or factitious-type disorders. So, not being a physician, I didn't get to say what the guy really had, but I could say I was about 99.99% sure it wasn't psychogenic, and that was cool. I love it when I get to say something definitive, clarifying, and helpful.

Recently, I had a young lady come in with three diagnoses from her previous therapy. But while I'm sitting with her, I'm thinking this isn't right. For one thing, the history doesn't quite fit, e.g., onset of symptoms in late adolescence for one diagnosis that is pretty firmly in place by early childhood, and for another that usually presents earlier or later. For another, the symptoms don't all quite mesh. And again, there's the presentation: She just doesn't feel like A, B, and C. So, I'm thinking, instead of A, B, and C, maybe her problems are X, Y, and/or Z. Then at the end of the session she tells me how much she's been drinking and drugging. And here beginneth the lesson.

When presented with a client who uses frequently and heavily, it's important essential to your differential to look at the onset of the symptoms. Somebody who starts having symptoms of a mental illness at about the time he started drinking could be drinking to cope with the illness. More likely, he doesn't have the illness at all, but the symptoms are a reflection of the intoxication/withdrawal cycle of the addiction. This is absolutely going to be the case if the symptoms of the supposed mental illness began after the alcohol and drug abuse. So unless you know different, the primary diagnosis and what you will treat first should be the addiction, people.

If, on the other hand, from the history you can clearly see that the symptoms predate the addiction by many years, then by all means go ahead and give a diagnosis of bipolar or borderline or whatever. Otherwise, you would be well-advised to get the client clean and sober and see if, 90 days or so later, they are still having symptoms before you give a diagnosis. Especially before you slap something as pejorative as a character disorder on 'em.

Regardless of which comes first, you can't do therapy with someone who is actively abusing substances. At a minimum, they need to not drink/drug 24 hours before and after a session. This allows them to not be anesthetized when they show up for therapy, so they will have some affect to drive the work, and it gives them a bit after the session to metabolize the work they've done. It's a minimum.

But as far as I'm aware, therapy never got anybody clean and sober, and therapists who think that working on the "root" of the problem (addiction is its own root, people, I'm here to tell ya) is going to help their patients proceed at great risk to the patient. Addiction is a progressive, lethal disease. And even if the person is "just" self-medicating, it can still kill them before you get to the root of whatever it is that you think is the real problem. So let's clean 'em up, if not first, then early in the treatment. You could save a life.

But I digress. We were talking about diagnosis, not treatment. Let's get back to that. Flip side is, if you have somebody come in who's in recovery and still having terrible anxiety or depression 90 days or more after her sobriety date, you have somebody with a free-standing mental illness. For the love o' Mike, diagnose it and treat it. Un-and under-treated depression, just as an example, is a notorious trigger for relapse. And remember, addiction is a relapsing, progressive, terminal disease.

And if you have somebody who's well-advanced in recovery, they've worked all the Steps, they have a sponsor and are going to meetings and working a good Program, and they still have character flaws left, right and Sundays too, then please feel free to give an Axis II diagnosis. And treat it. It's the only humane thing to do.

Regardless of what you do or don't diagnose, and decide to treat or not to treat, if you are a psychiatrist, don't give medications with abuse potential to clients who are drinking and drugging. You tryin' to kill 'em, or what? You are certainly aging me prematurely when you do that.

There endeth the lesson.