EDITORIAL
Will the Health Care Crisis Sabotage the Practice of Psychotherapy? The United States is in the midst of a health care crisis of massive proportions. Every citizen from the President to the average person on the street is aware of the magnitude of the problem, but no one has yet come forward with clearcut recommendations for solving it. Because this is a presidential election year, we are being regaled with solutions by all the major candidates. We can only hope that viable programs emerge from this heated debate and that the state of our health care system does not come to fit Mark Twain's witty remark about the weather: "It's something everybody talks about, but no one does anything about." The statistics associated with the delivery of health care in this country are alarming. To illustrate, Americans spend an estimated $23,000 per second on medical care, more than $2 billion each day, totaling $733 billion per year. That is almost twice the amount spent a decade ago. Nor does the future bode well. If the ailing health care system is not administered a dose of corrective medicine soon, the U.S. medical bill may skyrocket during the next decade to an estimated $1.6 trillion. Some pundits predict that within twenty years Americans will be spending fully one third of their resources on medical care. Most of us have at least some vague notions concerning the causes of this crisis. Both Medicaid and Medicare have ballooned beyond recognizable proportions and, to a certain extent, have deviated from the mission they were intended to perform. Abuse is rampant in a system where physicians often feel that most of their time is spent either filling out bureaucratic forms or practicing defensive medicine. Health care resources are also disproportionately administered. This lopsidedness affects both physicians and hospiA M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. X L V I , No. 4, October 1 9 9 2
499
AMERICAN JOURNAL O F PSYCHOTHERAPY
tals. For example, most cities have a glut of high-priced medical specialists, while many suburban and rural areas lack primary-care physicians. In addition, hospital space is often allocated unwisely. For example, it is not necessary for every hospital to have a CAT scan, but every American should have access to a hospital that is equipped to provide basic prenatal as well as neonatal care. Nor has psychiatry, as a medical specialty, been immune from the general health care crisis plaguing the nation. For instance, the price of a Bufferin tablet for a patient in a psychiatric hospital is $3.75 on the average, while a 50-minute session with a prestigious psychotherapist may cost as much as $160. Moreover, the perception is that psychiatric practice has contributed to the overall decline in the quality of life in other respects. A notable percentage of the homeless population inhabiting our cities is reputed to consist of former mental patients who experts now agree, should be re-institutionalized. Although the psychiatric profession was certainly not responsible for the release of large numbers of these patients from public facilities in recent years—a decision made by legislators—the profession has nonetheless occasionally been blamed for the consequences of this action. Another trend that has had dramatic repercussions for psychiatric psychotherapists involves the demedicalization of the field. In the past few decades the number of nonpsychiatrist psychotherapists has climbed steadily. In fact, at this juncture psychotherapy is predominantly a nonmedical activity and it is likely that this trend will continue until, as some experts forecast, the medically trained psychotherapist becomes an endangered species. Several factors are responsible for this change. The heightened emphasis on biology in medical training may persuade medical students to pursue specialties other than psychiatry, while increased differentiation and subspecialization within the psychiatric field itself has led to a decline in the number of psychiatrists who conduct primarily a psychotherapeutic practice. In addition, other physicians from other specialties, such as general practice or internal medicine, have been treating psychiatric conditions with greater frequency. Changes in psychotherapy have also been influenced by monetary factors. For example, most psychiatrists continue to charge higher fees for psychotherapeutic services than other health care professionals—a factor that may eventually contribute to pricing them out of the market. Because they have more sophisticated training and are more expensive, psychiatrists will increasingly be called upon to perform critical medical functions for patients, such as treatment planning, supervision and evaluation, electroconvulsive therapy and pharmacotherapy. As these activities proliferate, psychia500
Editorial
trists will have less time to conduct psychotherapy and, as noted above, it will be less cost effective to let them to do so. The health care crisis confronting this nation also raises a host of more immediate concerns that are critical to the psychotherapeutic field. First and foremost is the fact that many Americans lack access to the basics of good health care. More than thirty million Americans are estimated to lack any form of health care insurance, for example. In effect, this means that when such people have the flu, when they or their children run high fevers, or when they suffer from chronic conditions like diabetes and have heart conditions, they have no doctor to turn to and are virtually denied access to medical care unless they go to the emergency room of a general hospital. For these patients only acute medical conditions—frequently only emergencies—are treated. Thus, a host of more subtle conditions, including child abuse, substance abuse, eating disorders, depression, anxiety, compulsive disorders, and family problems remain currently untreated because for these patients such conditions are not serious enough to seek a physician's care. What about schizophrenia or a suicide attempt? While schizophrenics will generally come to the attention of the health care system because of an acute episode of disruptive behavior, modern medicine has not yet determined the most advantageous means of dealing with these individuals over the long term. Thus, after treatment of an acute episode, such patients may be turned back on the streets. The situation is equally bleak for individuals who attempt suicide. Without insurance to pay for psychotherapy, most of these patients generally receive only emergency care after their attempt and are then released. Putting these issues aside, there is an entirely different aspect of treatment that psychiatry has just begun to approach in the past decade—the issue of prevention. It is known that early intervention is often highly effective for deterring a wide variety of future problems. Programs designed for high-risk mothers and their infants have proven beyond doubt that guided intervention designed to heighten the mother's sensitivity to developmental trends can result in numerous benefits. Among these benefits are an increase in the emotional rapport between caregiver and infant or toddler, prevention of child abuse, and a decrease in the behavioral problems manifested by the child in the school setting. But such benefits fall by the wayside without protocols that can compete for adequate funding. These programs have also been shown to be beneficial for pregnant women, particularly those considered in the "at risk" category for potential familial dysfunction. Teenage mothers would fall into this category, as would mothers with histories of psychiatric conditions. Moreover, programs ad501
AMERICAN JOURNAL OF PSYCHOTHERAPY
dressed directly to children have also been found to be effective. Almost all of these programs are preventive in the sense that intervention begins before the problem becomes manifest. We must take issue with any view that disagrees with this premise. The time has come for psychotherapists to dispel this notion and enlarge the definition of a health care * emergency." The services that psychotherapists provide as skilled practitioners are far from a luxury. Particularly in this time of limited resources and funds, we must set forth our priorities boldly. Ultimately, the provision of comprehensive psychotherapeutic programs aimed at prevention will help us to curb the wave of dysfunctional behavior that is sweeping through our families today. Psychiatric disorder is every bit as real and painful, and in need of attention and treatment, as is physical illness. For all of these reasons, as the nation unites to solve the health care crisis, we must remind legislators not to neglect allocating resources for psychotherapeutic prevention. Funds spent on prevention would save infinitely larger expenditures required to institutionalize or even incarcerate those individuals who have been permanently damaged by their dysfunctional environments. Programs aimed at prevention may be one of our wisest investments in the future and in our children. 4
PAUL V . TRAD, M . D .
502
Will the Health Care Crisis Sabotage the Practice of Psychotherapy? The United States is in the midst of a health care crisis of massive proportions. Every citizen from the President to the average person on the street is aware of the magnitude of the problem, but no one has yet come forward with clearcut recommendations for solving it. Because this is a presidential election year, we are being regaled with solutions by all the major candidates. We can only hope that viable programs emerge from this heated debate and that the state of our health care system does not come to fit Mark Twain's witty remark about the weather: "It's something everybody talks about, but no one does anything about." The statistics associated with the delivery of health care in this country are alarming. To illustrate, Americans spend an estimated $23,000 per second on medical care, more than $2 billion each day, totaling $733 billion per year. That is almost twice the amount spent a decade ago. Nor does the future bode well. If the ailing health care system is not administered a dose of corrective medicine soon, the U.S. medical bill may skyrocket during the next decade to an estimated $1.6 trillion. Some pundits predict that within twenty years Americans will be spending fully one third of their resources on medical care. Most of us have at least some vague notions concerning the causes of this crisis. Both Medicaid and Medicare have ballooned beyond recognizable proportions and, to a certain extent, have deviated from the mission they were intended to perform. Abuse is rampant in a system where physicians often feel that most of their time is spent either filling out bureaucratic forms or practicing defensive medicine. Health care resources are also disproportionately administered. This lopsidedness affects both physicians and hospiA M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. X L V I , No. 4, October 1 9 9 2
499
AMERICAN JOURNAL O F PSYCHOTHERAPY
tals. For example, most cities have a glut of high-priced medical specialists, while many suburban and rural areas lack primary-care physicians. In addition, hospital space is often allocated unwisely. For example, it is not necessary for every hospital to have a CAT scan, but every American should have access to a hospital that is equipped to provide basic prenatal as well as neonatal care. Nor has psychiatry, as a medical specialty, been immune from the general health care crisis plaguing the nation. For instance, the price of a Bufferin tablet for a patient in a psychiatric hospital is $3.75 on the average, while a 50-minute session with a prestigious psychotherapist may cost as much as $160. Moreover, the perception is that psychiatric practice has contributed to the overall decline in the quality of life in other respects. A notable percentage of the homeless population inhabiting our cities is reputed to consist of former mental patients who experts now agree, should be re-institutionalized. Although the psychiatric profession was certainly not responsible for the release of large numbers of these patients from public facilities in recent years—a decision made by legislators—the profession has nonetheless occasionally been blamed for the consequences of this action. Another trend that has had dramatic repercussions for psychiatric psychotherapists involves the demedicalization of the field. In the past few decades the number of nonpsychiatrist psychotherapists has climbed steadily. In fact, at this juncture psychotherapy is predominantly a nonmedical activity and it is likely that this trend will continue until, as some experts forecast, the medically trained psychotherapist becomes an endangered species. Several factors are responsible for this change. The heightened emphasis on biology in medical training may persuade medical students to pursue specialties other than psychiatry, while increased differentiation and subspecialization within the psychiatric field itself has led to a decline in the number of psychiatrists who conduct primarily a psychotherapeutic practice. In addition, other physicians from other specialties, such as general practice or internal medicine, have been treating psychiatric conditions with greater frequency. Changes in psychotherapy have also been influenced by monetary factors. For example, most psychiatrists continue to charge higher fees for psychotherapeutic services than other health care professionals—a factor that may eventually contribute to pricing them out of the market. Because they have more sophisticated training and are more expensive, psychiatrists will increasingly be called upon to perform critical medical functions for patients, such as treatment planning, supervision and evaluation, electroconvulsive therapy and pharmacotherapy. As these activities proliferate, psychia500
Editorial
trists will have less time to conduct psychotherapy and, as noted above, it will be less cost effective to let them to do so. The health care crisis confronting this nation also raises a host of more immediate concerns that are critical to the psychotherapeutic field. First and foremost is the fact that many Americans lack access to the basics of good health care. More than thirty million Americans are estimated to lack any form of health care insurance, for example. In effect, this means that when such people have the flu, when they or their children run high fevers, or when they suffer from chronic conditions like diabetes and have heart conditions, they have no doctor to turn to and are virtually denied access to medical care unless they go to the emergency room of a general hospital. For these patients only acute medical conditions—frequently only emergencies—are treated. Thus, a host of more subtle conditions, including child abuse, substance abuse, eating disorders, depression, anxiety, compulsive disorders, and family problems remain currently untreated because for these patients such conditions are not serious enough to seek a physician's care. What about schizophrenia or a suicide attempt? While schizophrenics will generally come to the attention of the health care system because of an acute episode of disruptive behavior, modern medicine has not yet determined the most advantageous means of dealing with these individuals over the long term. Thus, after treatment of an acute episode, such patients may be turned back on the streets. The situation is equally bleak for individuals who attempt suicide. Without insurance to pay for psychotherapy, most of these patients generally receive only emergency care after their attempt and are then released. Putting these issues aside, there is an entirely different aspect of treatment that psychiatry has just begun to approach in the past decade—the issue of prevention. It is known that early intervention is often highly effective for deterring a wide variety of future problems. Programs designed for high-risk mothers and their infants have proven beyond doubt that guided intervention designed to heighten the mother's sensitivity to developmental trends can result in numerous benefits. Among these benefits are an increase in the emotional rapport between caregiver and infant or toddler, prevention of child abuse, and a decrease in the behavioral problems manifested by the child in the school setting. But such benefits fall by the wayside without protocols that can compete for adequate funding. These programs have also been shown to be beneficial for pregnant women, particularly those considered in the "at risk" category for potential familial dysfunction. Teenage mothers would fall into this category, as would mothers with histories of psychiatric conditions. Moreover, programs ad501
AMERICAN JOURNAL OF PSYCHOTHERAPY
dressed directly to children have also been found to be effective. Almost all of these programs are preventive in the sense that intervention begins before the problem becomes manifest. We must take issue with any view that disagrees with this premise. The time has come for psychotherapists to dispel this notion and enlarge the definition of a health care * emergency." The services that psychotherapists provide as skilled practitioners are far from a luxury. Particularly in this time of limited resources and funds, we must set forth our priorities boldly. Ultimately, the provision of comprehensive psychotherapeutic programs aimed at prevention will help us to curb the wave of dysfunctional behavior that is sweeping through our families today. Psychiatric disorder is every bit as real and painful, and in need of attention and treatment, as is physical illness. For all of these reasons, as the nation unites to solve the health care crisis, we must remind legislators not to neglect allocating resources for psychotherapeutic prevention. Funds spent on prevention would save infinitely larger expenditures required to institutionalize or even incarcerate those individuals who have been permanently damaged by their dysfunctional environments. Programs aimed at prevention may be one of our wisest investments in the future and in our children. 4
PAUL V . TRAD, M . D .
502
