Insurance Woes: We Need Better Therapy Coverage

According to an article in the New York Times, psychoanalysis and psychodynamic therapy have been largely replaced by cognitive-behavioral approaches in the last couple of decades. The first two therapeutic approaches seek the reasons for a patient’s problems in their past, usually dwelling on childhood to a great extent. Cognitive therapy asserts that the origins of the problems are not important in the therapeutic process and seeks to change the patient’s distorted thinking, retraining them to think in a more productive manner.

The New York Times article asserts that this shift in popularity from psychoanalytic and psychodynamic therapy to cognitive therapy is due to hundreds of studies that have shown that cognitive therapy is effective. There’s no mention of whether it was found to be more effective than psychoanalysis and psychodynamic therapy, just that it was validated as a therapy by the studies.

The studies are probably part of the reason for the shift. However, this shift also just happens to coincide with the rise of HMOs (Health Maintenance Organizations). I worked for a big HMO for a few years. Their overriding concerns are making money and keeping Wall Street happy. Their first choice for depression treatment is medication because the cost for a month of antidepressants is much less than the cost of four therapy sessions (assuming you go weekly). If therapy is strongly indicated for depression treatment, they reluctantly approve it, but would much rather that it be cognitive therapy than psychoanalytic.

My own therapy fell victim to HMO cost cutting. I had been in therapy for a year when I switched health insurance plans, from an indemnity plan (the traditional health insurance plan) to an HMO. When my therapist filed a request for more sessions, the HMO told her that we needed to set some objectives and accomplish them within a set number of visits. But since we were exploring the part that family dynamics had had on causing my depression since childhood, it was kind of hard to set an objective. Um, not be depressed anymore because of things that happened when I was a child? If I was trying to quit smoking then this would make sense.

We gritted our teeth and set an objective that we felt we could accomplish in five sessions. Apparently, it wasn’t good enough, because the HMO wouldn’t approve more sessions. So my therapy was ended abruptly, leaving a lot unresolved. I ended up going back into therapy when the Mental Health Parity Act was signed, and insurers were under more pressure to set fewer limits on mental health treatment.

Cognitive therapy, while appropriate for some patients, doesn’t work in every situation. It seems unlikely that 10 to 15 sessions of cognitive therapy are going to be effective in the long-term for someone who, for instance, who endured a childhood with an alcoholic abusive father. It seems disingenuous, to say the least, to say that he should just learn how to correct his negative thinking. Many therapists use a combination of psychoanalytic and cognitive therapy. In many cases they complement each other very effectively.

Now, I am not against keeping goals in mind during therapy, treating depression with antidepressants or cognitive therapy. But I object to the mental health professional being pressured to choose a certain type of therapy because of its cost-effectiveness, not because it’s the most effective, or likely to be effective, for that particular patient. And it’s scary to think that cost-effectiveness may have caused a drastic shift in the perception of which therapy is more effective overall.