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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.
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