| To
Share or Not to Share
When I sat down
to write this article for Trauma Response, I experienced
ambivalent feelings. On the one hand, I was highly
motivated to share with the membership an experience
that occurred with a popular managed care company.
Motivated because the managed care company's behavior
was at best irresponsible, and had the potential
to interfere with the psychotherapeutic process
with a patient. On the other hand, I also experienced
a fear; a fear of being caught, a fear that to
the objective observer bordered on paranoia. Even
though I have not given my name, had changed all
identifying information, and did not make reference
to the managed care company by name, I was concerned
that in some way the managed care company would
find out I wrote this article, and without cause,
drop me as a provider. While acknowledging that
the likelihood of this occurring was rather remote,
I just could not shake this fear. Allowing reason
and rationality to prevail, I describe my experience
below, an experience that I feel is important
to share: important because I am sure that I am
not the only health care professional working
with trauma survivors who has had such an experience;
important because as health care providers we
need to communicate our negative and our positive
experiences with managed care companies to each
other so that there is a better chance for constructive
and positive change. Finally, it is important
because as an individual I believe it is healthy
psychologically to be active, as opposed to passive,
when a perceived injustice has taken place.
Brief Background
The patient's
name and identifying information has of course
been changed in order to preserve confidentiality.
The woman has
been married approximately 25 years and is in
her early fifties. She currently resides with
her four children: two sons aged fifteen and nineteen,
and two daughters, aged seventeen and 23. Her
husband is not living within the home and has
been openly having an affair for two years. A
significant event in the patient's life was a
rape that occurred at age sixteen; a family friend
was the rapist. While family knew that this had
occurred, it was not discussed. No treatment was
afforded this patient prior to seeing me. With
the exception of myself, the patient never told
anyone outside of the family of the rape.
The patient began
treatment approximately a year and a half ago.
During this time she was brought to the hospital
emergency room on three occasions due to her verbalizing
suicidal ideation and making suicidal gestures.
On one occasion, immediately prior to the police
escorting her to the hospital, she cut herself
across her arms with a razor. Surprisingly, she
was not admitted on any of these occasions. She
finally made a serious suicide attempt, ingesting
sleeping pills, aspirin, and decongestants, a
total of approximately forty pills. She was hospitalized
for two weeks and released. She currently takes
Prozac, which has reduced her major depressive
symptoms. Her diagnosis is Post-Traumatic Stress
Disorder and Major Depression. There are borderline
qualities to her personality; however, she clearly
does not meet the criteria for borderline personality
disorder. While the course of therapy has been
rocky, on the whole the patient has made significant
improvement in her functioning over the past year.
She is now setting more limits with her children
and her husband, and is functioning better at
work. Her calls to me between sessions have decreased
to the point that they rarely occur, something
of which she is proud. I have on a few occasions
made suggestions to the patient to become involved
in an ancillary support group to increase social
support and to have her communicate with individuals
who have had the same horrific experience (i.e.,
the rape). The reason for mentioning the recommendation
for a support group will be evident shortly. The
patient had expressed consistent resistance to
such an intervention. Her distrust of others and
intense feelings of vulnerability appear responsible
for her resistance.
The patient was
seen for her usual appointment early in the evening.
Her affect was more depressed than had been usual
in the months immediately previous. She spoke
about the rape, something she had not done for
a long time. There was a different quality to
her verbalization this time. She was being more
detailed about the experience and was able to
relate it to her functioning throughout her adult
life. I had not seen this patient so upset and
was concerned about her ability to function until
our next session. While I was not concerned about
her suicide risk, I was concerned about her ability
to bind the flood of emotions she was experiencing.
Because the session was running late and I had
many patients scheduled back-to-back that evening,
I gave the patient the option of returning the
following evening, which she choose to do.
The Utilization
Review
I was scheduled
to call the managed care company for a utilization
review the following day. The reviewer asked very
detailed questions about the case, many of which
I thought had little relevance to determining
medical necessity (e.g., time of day patient takes
the medication). I had difficulty answering some
of these questions, and some I had to consult
my notes on, something which seemed to cause the
reviewer frustration. His frequent sighs on the
phone and continued rapid-fire questions were
uncomfortable. I had never felt this way during
a review, nor did a reviewer ever behave in such
a manner. There was a sense of tension in the
air which only seemed intensified with each additional
question that I could not answer or could not
answer within the expected time. While speaking
about the case, I mentioned the need for an additional
session for that evening. The reviewer said we
would speak about that after the review was completed.
He authorized an additional eighteen sessions,
and then stated that the additional session was
not medically necessary and rejected my request
for authorization. When I asked what criteria
he was using to determine that this session was
not necessary, he had difficulty articulating
it. After approximately thirty seconds of looking
through the patient's past reviews on the computer,
he stated that the patient had spoken about the
rape approximately six months earlier, that an
additional session was authorized then, and that
he saw no reason for an additional session at
this point. My attempts at changing his decision
were futile and I had the strong feeling that
the reviewer was not about to change his decision.
I was told that the only alternative I had at
this point was to speak to a peer reviewer and
that I needed to schedule an appointment. An appointment
was scheduled for that afternoon with a psychologist.
Upon reaching
the psychologist, he told me that the call was
going to be taped. When I asked why this needed
to be done, he indicated that it was the procedure
of the managed care company and did not offer
any more explanation. Being hesitant to be seen
as a "problem provider," I did not question
further, but nonetheless felt uncomfortable with
such a procedure.
I began describing
the patient's current situation and why I thought
that an additional session was medically necessary
for that evening. After approximately thirty seconds
of speaking, the psychologist interrupted me and
informed me that he had treated many such patients
and that I was proceeding incorrectly in certain
respects in treating this patient. He indicated
that it was clear that the patient needed an ancillary
support group, and that eventually a group situation
would meet this patient's therapeutic needs. He
wanted to know why I had not attempted to have
the patient become involved in such a group. When
I tried to inform him that I had spoken to the
patient about this type of group and to explain
my hypothesis as to why she had been resistant,
he again interrupted me and stated that he felt
it was imperative that I have her in a support
group. He indicated that I should focus the treatment
on reducing her resistance to the support group.
I didn't disagreed with him that her resistance
(due to her distrust and anxiety) was an important
issue. However, I disagreed that this should be
the primary focus of treatment at that point in
time. When I stated my hesitancy to confront her
resistance at that time and that I thought that
other therapeutic foci would be more fruitful
with respect to reducing her functional impairments,
he stated that he disagreed with me. He did authorize
the session for that evening under the condition
that I speak about a support group. He also indicated
that the support group issue would be discussed
at the next review. Needless to say, I felt angered
by what I perceived to be the peer reviewer's
pedantic and condescending attitude, and his refusal
to take into consideration my perceptions of my
patient. Yet I was not in a position to express
my feelings, given the power that the managed
care company has with respect to determining my
provider status.
The Next Weekly
Session: Making the Best of the Situation
The patient's
mood was better during the following weekly session.
The second session the week prior did meet the
goal of helping the patient to cope with the flood
of emotion that emerged. Knowing that she would
be receiving a copy of the peer reviewer's decision
regarding the support group, I decided to be proactive
and discuss the reviewer's suggestion. Reflecting
back on the situation, my own anxiety regarding
the review, as well as my always tenuous provider
status with the managed care company, also played
a role in my decision to be compliant and discuss
the support group with the patient. I explained
to the patient that the managed care company had
suggested that she become involved in a support
group, in addition to the individual psychotherapy.
The patient's response was as expected: she stated
that she did not want to become involved. She
also expressed her fear that the insurance company
was going to stop paying for the sessions if she
did not comply with their request. I reassured
her that this would not happen at this time. She
became more agitated and began to verbalize her
feeling that again she was being forced to do
something that she did not want to, feelings similar
to those she experienced frequently in her life
and that she experienced most intensely during
the rape. Her feelings of helplessness emerged,
as did the feeling that in some way she was going
to be victimized again. I felt myself becoming
more angered by what I perceived as the managed
care company's hand reaching into the session
and disrupting the therapeutic process with this
patient. I decided that at that point I would
share with her my feelings regarding having to
do something I myself did not want to (i.e., suggest
a support group to her) and that, while it was
to a lesser degree, I too felt helpless and had
few options but to comply with an entity perceived
as more powerful than I. We discussed how our
analogous experiences put us in similar positions,
and that the challenge for both of us was to find
ways to feel more in control of our respective
situations. My hope was that this experience could
be used therapeutically if I showed my patient
the analogous nature of our experiences and then
model more active and healthy behavior for her.
In addition, given that this patient has significant
difficulty acknowledging and accepting her own
angry feelings, I thought I could show her that
anger is a natural reaction to a perceived injustice.
It is of interest that according to the contract
I signed with the managed care company, I should
not have been discussing my feelings regarding
their decision with my patient (i.e., the gag
order), and therefore to attempt to use what had
occurred therapeutically would have breached my
contractual obligation with them.
The following
day I received the conformation letter from the
managed care company. To my surprise, the number
of authorized sessions had been reduced from eighteen
to six. My immediate reaction was to become angry
because I felt I was being punished for asking
for the second session the previous week and for
not having this patient in a support group. I
immediately called the managed care company and
spoke to a representative. She indicated that
the sessions had indeed been reduced at the request
of the peer reviewer in order "to more quickly
assess the status of the ancillary support group."
I asked if it was common procedure for sessions
to be reduced by a peer reviewer and for the provider
not to be told. The representative indicated it
was not, and asked if I wanted to make a complaint.
I thought to myself that I certainly wanted to,
but wouldn't dare, due to that recurring fear
of losing provider status.
I now added deception
to the list of feelings I had experienced over
the previous two weeks. My anger at this point
could have better been described as rage. Because
I felt powerless against this corporate giant,
I thought that my anger would have to simmer and
dissipate with the help of time. Over the next
few of days I informed several of my colleagues
of this occurrence and while most were empathetic
toward my plight, I was hardly comforted by their
repeated response of "You ain't seen nothing
yet when it comes to managed care."
While not initially
intending to write an article about my experience,
I began to think how I would structure an article
and what I would include if I would write one.
Reflecting back, this type of thinking served
as a means of helping me to cope, for I felt some
comfort in engaging in such thought. It then occurred
to me that I might be able to share my experience
with colleagues by putting it in written form
and submitting it to the Academy for publication
in Trauma Response. While perhaps imagined, I
did experience more of a sense of control over
the situation. By sharing this experience with
my colleagues I would potentially be doing something
about changing irresponsible behavior that takes
place within the managed care industry, and because
of that I felt a bit more in control.
I felt compelled
to inform my patient that I intended to do this
for two reasons. First, I did want to obtain her
permission given that her history is very sensitive
for her. Somewhat surprisingly, she gave her permission
without apparent hesitancy, stating that, "If
by doing that you can possibly help for it not
to happen again to myself or others, I have no
problem." This statement I found notable.
It had a sense of boldness and assertiveness to
it, something not usual for this patient. Second,
and more important therapeutically, I was now
able to model how action could be taken to influence
a situation, and how this action can help one
to feel more in control of one's environment.
The topic of conversation within the session turned
to the differences in behaving in an active/constructive
manner, as opposed to passive/self-destructive
manner. Discussion ensued about how the latter
results in perceiving oneself as a victim of one's
surroundings, with little control of outcome,
while the former results in more self-worth and
feelings of control. This discussion then lead
to her expressing her fears regarding behaving
in an assertive and proactive manner, as well
as how she can begin to behave assertively and
possibly have more control regarding outcomes
in her life.
Epilogue
The following
week the patient reported how she helped her son
deal with an emotional and problematic situation
with his father (her estranged husband). Her suggestions
to him were rational, assertive and apparently
very appropriate. She helped her son navigate
through a situation that in the past had immobilized
him emotionally and behaviorally, leading to conflict
between the father and son, and avoidance on the
son's part. Although it was her son who ultimately
carried out her suggestions, it was apparent that
the patient was putting into practice some of
the strategies we discussed in the session. It
is hoped that as time progresses she will begin
to utilize these skills more in her own life,
especially in situations with her family. Perhaps
it was safer for the patient to watch her son
implement her strategies, and possibly his success
will increase her chances of implementing them
herself.
In an attempt
to live by my belief that no experience is totally
negative because of what can be learned from it,
I reflected on the occurrences of the preceding
three-week period. The incident had reinforced
how occurrences that have an impact on the psychotherapeutic
process can be used to help the therapy progress.
These occurrences can be used as "grist for
mill," to be processed, understood and incorporated
into the patient's life so functioning is less
impaired. I learned better how to use my own feelings
(i.e., countertransference) to help therapy progress.
I learned that managed care has a big effect on
me, and does influence decisions I make, no matter
how much I don't want to admit it. I learned that
managed care companies can be irresponsible in
their decisions, and that as health care providers
we need to make sure in any way possible that
this is decreased.
Believe it or
not, the intent of this article was not to "bash"
managed care, but to share my own experience and
help me to work through some of my own "managed
care related trauma". I am not against managed
care per se. I believe, as I suspect many of my
colleagues believe, that there were major abuses
to the health care system in the past and that
there needs to be some form of cost control. What
I am against is irresponsible behavior by managed
care companies that has the potential to interfere
with patient progress or can be destructive to
the patient; what I am against is the position
in which health care providers are placed with
respect to having to make decisions that not only
take their patients' best interests into consideration,
but also their always tenuous status as providers
with the managed care company; what I am against
is substandard care that is a result of the influence
of managed care.
I know that I
am not the only professional who works with trauma
victims to experience these feelings about managed
care. I encourage my colleagues to share their
experiences, as I did, so we all may learn and
benefit. The pendulum has swung where the insurance
and managed care companies are making decisions
regarding patient care. What better forum than
something like the Trauma Response to share our
experiences, and possibly help the pendulum to
swing back a bit the other way so as providers
we have more decision making powers when it comes
to the care of our patients. I thank you for listening.
©1997
by The American Academy of Experts in Traumatic
Stress, Inc.
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