Brain illness? 

A couple of weeks ago, I posted a thought I had in reference to a post by Roy of Shrink Rap had made about health insurance coverage for mental illness. We had an exchange in the comments of my post that started out a bit testy but ended well. I have a some additional thoughts from that exchange I want to add today.

Roy and I discovered, as I thought from reading him over several months, that we see very different patient populations. Patients who are in hospital, who are acutely psychotic, hallucinating, disabled by their illness do indeed seem to be suffering from a brain illness, from something having gone awry in the brain. And I have no problem ceding that they are best cared for by psychiatrists and that indeed, they should have parity in insurance coverage, as with any chronic illness.

But these are not the people that I see in my practice nor that most therapists see. Health insurance rarely, for example, covers marital therapy for the simple reason that problems in a marriage are not mental illness. Makes sense to me. It also makes sense to me that the woman wrestling with the impact of her abusive parent on her in her adult life, the man who wants to change his life but doesn't know where to start, the woman who wants a husband and family and cannot understand why she hasn't found that -- well, I don't see that as mental illness either or brain illness either. In fact, I really do not believe that such problems should be covered by health insurance.

When a therapist sees someone like I described above and agrees to accept payment from health insurance, both therapist and patient are agreeing to the assignment of a psychiatric diagnosis and thus tacitly accepting that these problems in living are in fact symptomatic of mental illness. I opted out of accepting insurance when I realized that in my mind continuing to assign diagnoses to people who were not ill was unethical. It allowed me, as it has those therapists who continue to do so, to charge higher fees, but it was also putting me in the position of colluding with something I didn't believe in. 

I watched what happened when outpatient therapy became a mandated benefit in my state. I watched as fees rose rather sharply. Where a therapist might have charged $50/hr before insurance, now it was possible to receive $80 or $90 or more without increasing the out of pocket expense for the patient. Then i watched as the system struck back, imposing managed care guidelines and insisting therapists join panels of providers and changing which diagnoses they would cover. And most therapists stayed in that system because they no longer believed that they could survive outside it and because the income possible with it was and is seductive. And now the insurance companies, hand in hand with their friends the pharmaceutical companies, run the whole system. The camel poked its head into the psychotherapy tent 20 years ago; now the tent is his.

© Cheryl Fuller, 2018. All  rights reserved.