|
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.ortly.
|
