St. Louis. -- Recently, in my psychotherapy practice, I received these communications:
* An insurance company wanted all records on a client, including all session notes, in order for the client to continue getting coverage.
* An HMO demanded over the telephone a treatment update for a client, in order to certify that client for another five sessions.
* An HMO sent complete psychological and medical records of a professional woman with an eating disorder, a woman who was not yet a client and did not become one.
In the debate over health care, focusing on cutting costs and quality of care, one issue gets little attention: protection of patient confidentiality.
My clinical training taught me that the client-therapist relationship is a sacred trust. Part of that trust is absolute confidentiality. I was instructed never to release over the phone the name of anyone I was treating; such information could be given only with the client's written permission. I was taught also to be careful about placing diagnostic labels on people, because certain labels could harm and follow the patient for a lifetime. For example, any hint of suicidal tendencies, however temporary, could forever bar a person from buying life insurance.
Today, concerns about confidentiality seem to have disappeared. Many insurance companies and HMOs limit psychotherapy to 6 to 20 sessions; justification for continued treatment is required every five sessions. This means I am expected to report in every five weeks, usually over the telephone. The evaluator is always someone I don't know. Yet the expectation is that, for coverage to continue, I will discuss intimate details of a client's life with a stranger. Thus, I am caught in the bind of giving enough information to get the therapy continued, yet not violate confidentiality -- an increasingly difficult ethical dilemma.
Insurance companies also are demanding complete client records, including all session notes, in order to continue coverage.
I have yet to work with a client who consents to this demand. This is a nice game for the insurance companies, which use this refusal as justification not to cover the charges for treatment. I get labeled an "uncooperative provider," while the consumers must pay for the therapy themselves, or when they cannot afford it, stop treatment altogether in order to protect their confidentiality. This seems a senseless barrier for those in need of real help.
Another possible breach of confidentiality are the "precertification" papers authorizing therapists to treat certain individuals. None of the people I've received precertification papers on has contacted me for an evaluation or treatment. I believe it is none of my business that someone in my hometown is having personal problems until the person chooses to inform me and ask for help.
The other horrifying aspect to this situation is that this information is stored away in a computer somewhere for who knows how long -- information that could affect the person in getting insurance, loans and jobs. (An insurance agent I know admits his company will not grant life insurance to people who reveal they take the anti-depressant Prozac.)
According to the July issue of Macworld, once you get categorized in someone's data bank, you almost never get out. That means once you're labeled an alcoholic, that tag follows you for years, even though you may be successfully managing a sober life.
The breakdown in confidentiality has many causes: the escalating costs and abuses of mental-health care, the increasing dependence on insurance for coverage, the ease of computer data storage and, finally, many people's growing willingness to expose their private lives in the circus of the television and print media. If confession is good for you, why withhold private confidences from a bureaucrat, file clerk or computer?
Far more important than how we got ourselves into this situation is how we're going to get out of it. We must not let ourselves be seduced into thinking that it's OK to violate confidences in order to get paid.
Solutions aren't simple and will require compromises. Those working on a national health-care plan need to keep in mind that psychotherapy is a process based on relationship and trust, and that trust is probably not going to develop in the course of five to ten sessions.
On the other hand, if I were an HMO administrator or insurance carrier, I doubt that I would approve an open-ended psychotherapy at $150 a session, or psychiatric medication checks (usually 15 minutes or less) at $75 a visit. One solution might be to cover 75-80 percent of the first five sessions, 50 percent of the next 20 and only 25 percent for further sessions in a calendar year. This model would leave room for extended treatment, yet discourage abuse of the system.
Such a plan would also deepen trust between provider and carrier. Treatment would be granted on diagnosis alone, but the provider would know that the client picks up more of the cost as therapy progresses. Treatment updates would not be required. And potentially damaging information would be erased every two years from data banks.
Finally, I believe those in the field of delivering mental-health services need to take a long and deep inner look. Part of the sacred trust involved in therapy is making healing available as reasonably as possible.
James M. Jarvis is a psychologist.