From 2006 until 2014 I was a psychotherapist working in the psychiatry department of the largest HMO in California. Most of my time was spent in individual sessions using the eye movement therapy EMDR to help people recover from severe trauma. At first I loved my job—my clients, my colleagues, my supervisors, my pay. But the honeymoon soon ended. My enthusiasm eventually faded after what I viewed as flaws in the managed-care system seriously began to erode my ability to practice ethically.

During my first year on the job, as my caseload ballooned, the lag between individual psychotherapy sessions grew from weeks to months. Long breaks in treatment make it impossible to care for mentally ill clients safely. When one of my clients killed himself during a six week lag between scheduled visits, I blamed myself, even though I had given him my next available appointment. Over time, I concluded that some of the responsibility for this lovely man’s suicide lay within the structure of managed care itself.

According to federal and state mental health parity laws, all medical systems in the United States must treat such mental health conditions as depression, anxiety, and substance abuse with the same rigor they treat physical conditions like diabetes, cancer, and heart disease. The chief impediment toward achieving parity between physical and mental health care is, of course, the cost of providing adequate care. Effective individual psychotherapy is even more labor intensive than primary medical care. Primary care providers typically see their clients for twenty minutes or less and sometimes resolve a problem in one visit.

Though the initial parity laws date back to the 1990s, we are only now engaging in the painful process of bringing these laws to life. Up until this point, HMOs have been able to ration individual psychotherapy because there aren’t clearly defined minimal standards of care. Only recently have therapists, in cooperation with consumer groups, been successful prodding state regulatory agencies in California to act despite the ongoing challenge of defining standards of care. After eight years of fighting to increase staffing and raising these issues with California politicians and the media, I finally accepted that the current structure was not going to change quickly enough for me. I decided to leave my HMO job to work at a nonprofit public health clinic in my hometown.

In my new clinic, I get to meet with people as often as I deem necessary. I get to use only two basic criteria: (1) Does the client have a problem I am trained to treat? and (2) Is the client willing and able to benefit from therapy? When my caseload grows too large to treat clients effectively, I send the overflow of referrals to colleagues who have more availability, something I was unable to do in my old job.

HMOs in California are currently under attack by state regulatory agencies and class action lawsuits. I suspect that the quality of mental health services within managed care will eventually catch up with federal parity laws. But haunted by the memory of my client who killed himself during a long wait between sessions, I was unable to tolerate the slow pace of change.

After a long day at my new job, providing what my clients need, as they need it, I sleep much easier.

 

Andy Weisskoff is a Licensed Clinical Social Worker and the author of the novel Glass Palace.

Illustration by Pete Ryan.