Treating Victims of Trauma in the Managed Care Environment:
A Mental Health Practitioner's Experience



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.