Your 14-year-old son refuses to go to school. Your wife says she's leaving -- maybe she'll be back when she finds herself. Your boss gives you a poor evaluation based on repeated late entrances and you know why -- alcohoism.
You need help. But chances are your insurance company will offer the following menu: group or family therapy. Brief therapy. No therapy.
While interest in psychotherapy has never been greater, families in need increasingly find their choice of therapists and the length and kind of treatment they get limited by managed care companies trying to help employers cut costs.
Even before they knock on the therapist's door, the patients' anxiety is heightened over the possibility that treatment will end before the problem is solved. As their autonomy shrivels up, therapists themselves are becoming fearful and depressed.
"Any major conference you go to, there are always workshops on how you can deal with anxieties of managed care or how insecure therapists feel," says Mary Beth Smith, a Baltimore social worker who no longer takes new managed care contracts. "They are working more hours, getting more patients, making less. It's depressing."
Indeed, more than a dozen sessions on managed care are being offered for 3,000 family therapists gathering in Baltimore this weekend for the annual conference of the American Association for Marriage and Family Therapy.
Family therapists are selling themselves as part of the solution to the managed care crunch, arguing that such therapy is more efficient and solution-oriented than more traditional one-on-one therapy. In fact, those who embrace family therapy could find their practices booming in the new world order.
The new mental health therapy is short-term, solution-oriented and inexpensive.
Directing people into care is often done for an employer by a specialty company that stands to profit from providing as little care as possible. Therapists who criticize the dictates of the managed care company risk being dumped.
But the quality of these companies varies greatly. Typically, many families in trouble find:
* Individual therapy is out, and group therapy or family therapy is in.
* Gone are the years of examining one's childhood on the psychiatrist's couch. Instead, patients are urged to forget the past and focus on the here-and-now. The goal is to develop a practical plan to get functioning again. The briefer, the better.
* Therapy is limited to an average of 10 sessions. Some companies allow only two or three.
While insurers say they follow the best clinical practices for managing illnesses such as depression, there is evidence that some companies have used incentives to deny care. In July, United Behavioral Systems of Minnesota paid more than $100,000 in fines to the state of Rhode Island after being accused of illegally paying bonuses to executives who kept 80 percent of outpatient therapy to 10 sessions.
* Choice of psychiatrists and psychologists is limited as insurers steer patients to lower-cost professionals, such as social workers, or set up their own networks of therapists who agree to follow their rules.
* Insurers are questioning whether help for problems once routinely covered is "medically necessary." Treatment for severely disruptive adolescents, for instance, is being denied by some companies on those grounds.
Whether managed care's approach to mental health works remains to be seen, many say, but in the past, people got unnecessary, costly care.
"We participated in the decade of greed and we are downsizing like everybody else," says William Doherty, director of the marriage and family therapy program at the University of Minnesota.
Eric E. Anderson, until recently an executive of MEDCO, one of the dozen large companies nationwide that manage most mental health care, calls the current system to manage mental health therapy "primitive."
"The focus has been -- and this is the argument by detractors -- on financial, cost reduction. It's a legitimate criticism," says Dr. Anderson, a New Jersey psychologist. "The focus should be on clinical intervention."
But change is in the air.
MCC Behavioral Care Inc., a Cigna subsidiary, takes the long view, paying for therapy for troubled teens to prevent more serious -- and more costly -- problems down the road.
GreenSpring Health Services Inc., of Columbia, which manages care for 11 million people nationwide, credentials therapists for only what they are trained to do.
"Unlike other companies, we don't assume that all providers provide brief therapy," says Clarissa C. Marques, senior vice president and chief clinical officer. "When you get a lot of long-term psychotherapists trying to do it, they get lost."
Therapists fall into four main categories -- psychiatrists, who are doctors and can prescribe drugs; psychologists, who are expert at testing for various disorders; social workers, who have a master's degree, and, in Maryland, people who have a master's degree in a counseling field.
Social workers are in demand by managed care companies because they charge less. Psychologists and psychiatrists, who because of their training command fees twice as high, have a hard time getting on -- and staying on -- an insurer's approved provider list. Psychiatrists are often reduced to 15-minute "meds check," in which the doctor assesses the patient for medication.
But Dr. Marques says providers who work with her company are judged not only on cost but also on quality, and GreenSpring uses licensed clinical therapists rather than nurses or clerks to assess patients.
Management companies such as GreenSpring also say they actively lobby insurers to allow treatments they think should be covered for long-term savings -- therapy for families, couples, troubled teens and children with attention deficit hyperactivity disorder.
Group therapy, family therapy and even multi-family therapy are becoming popular with all types of therapists. Using it, managed care companies can cut the bills in half.
The trend toward groups is partly a response by therapists who are being forced to slash fees and see more patients to win managed care contracts. A therapist can make a lot more money charging six people in a group $40 each than one person $80 for an hour's session.
Replacing cognitive therapy with brief, solution-oriented therapy is viewed by many as a band-aid approach that fails to get at the cause of the problem. Others say it can equip the family or individual with the tools to solve future problems themselves.
"The truth differs for each practitioner," says Richard A. Perlmutter, a psychiatrist at Sheppard and Enoch Pratt who favors a family approach over individual therapy. He warns: "Beware of the invariant prescription -- whereby everybody has to be treated the same way."
Family therapy is a method of treatment that assumes the problem -- a child acting out, for instance -- lies in the way the family of which he is part functions and not in the child himself. Solving the problem requires changing the family relationship. It is often used to treat adolescents and young children.
A soon-to-be published study by the American Association for Marriage and Family Therapy shows family therapy is more effective than individual treatment for a variety of mental health problems. They include hypertension, dementia, obesity, anorexia, attention deficit hyperactivity disorder and chronic physical illness, says Michael Bowers, executive director of the association.
Today, many insurers see family therapy as the most effective way to treat young people, particularly adolescents who take up a large chunk of the hospitalization bill for mental health.
"We really believe in it and promote it particularly with children and adolescents and substance abuse," says Don Fowls, a psychiatrist and senior vice president-national medical director of FHC Options, the Norfolk, Va.-based firm managing care for Maryland state employees.
In the past, he says, too many children and adolescents were readmitted to the hospital because the family wasn't involved in therapy. "The real problem may be marital, and you can spend a lot of time with the child and not get at the problem," he says.
Just over half of insurers cover marriage and family therapy.
"Some of them are real good about it, and for some companies, therapists write on the bill they are doing individual therapy and see the whole family," says Eileen Dewey, a Columbia clinical social worker who works with substance-abusing adolescents in managed care practice.
She says that for her specialty, multi-family groups are more effective even than individual family therapy. Often, parents whose kids have been using drugs for years look around and see others' kids who have gone through the same thing and are on the road to recovery.
But treatment for teens with a chemical dependency isn't quick, she says. On average, it lasts four to six months, she says.
Family therapy or group therapy isn't for everyone, however, and many therapists find a cap on sessions is unrealistic, since problems and solutions don't always emerge quickly. Janet Stevenson, a Columbia psychologist, recently treated a family whose problem -- drug use by one member -- remained secret from everybody until the ninth session.
Limits can backfire on patients such as anorexic teens who need support throughout adolescence, she says. One of her patients was dropped from treatment when her weight returned to normal and the insurer concluded she was medically safe. In her first year at college, the patient regressed and dropped out. "It's the presence of the support that stabilizes," Dr. Stevenson says.
These kinds of cases try therapists' souls.
"Working in this field is a day-to-day challenge," says Susan Robison, a psychologist who with her husband, Philip, counsels married couples in Columbia. In the past two years, she says, the unpredictability of insurers' rules, longer hours, less pay -- back to 1970s levels -- and high turnover of patients before their problems are solved means that "morale and burnout becomes a concern for us."
Therapists such as the Robisons are trying new things to appeal to the 50 percent of people who pay their own way for marriage and family therapy. Last week, they hosted an all-day seminar in lieu of more costly therapy for couples who want to improve their marriage.
A sizable number of therapists now refuse to accept new managed care patients and prefer to see patients who can pay their own way. "I got tired of feeling all that anxiety," says Mrs. Smith, the social worker.
Managed care companies acknowledge that therapists work in fear of losing their patients, but they also point out that therapists for years had no accountability and ran up costly bills trying different treatments.
"The way to deal with anxiety is to develop a very good relationship with one or more different companies," says Peggy DiCarlis, MCC's regional vice president.
The good news is that mental health service is more available and more accessible today than even 10 years ago, Dr. Anderson notes. There are more people trained to deliver it and more interest in personal change and therapy than ever before.
The bad news is that, with 100 million people covered for mental health benefits under some form of managed care -- the industry still doesn't know what works.
"Although some therapists are appalled by the ratcheting down of sessions and group work, they can't really turn to any data," says Dr. Doherty, the Minnesota professor. "We just don't know."