On Mad in America, we tend to be outraged at the pharmaceutical companies and psychiatrists who would rather peddle pills than understand persons. Rightly so. We’re apt to rant against DSM and the pathologizing of everything that hurts. Rightly so—or not, depending on what we want to accomplish.
The hard fact is that our society does not have institutions, cultural norms, or professional values that would allow either clinicians or their practices to survive without DSM and its constant expansion.
Clinicians do not want to work for what patients could afford to pay, and patients can’t (or don’t want to) pay what clinicians think they need for a living wage. Hence, everyone wants medical insurance to pay for care.
But medical insurers, quite reasonably, only want to pay for medically necessary care.
Hence, we need to pathologize—diagnose as a medical disorder—any suffering for which people need help.
Patients who want insurance to pay for their care, and clinicians who want more money than their patients are willing or able to give, have little grounds to gripe about the general drift of DSM. We can complain about exactly how its lines are drawn, but if you want someone other than the patient to pay for care, you really can’t logically complain about DSM’s ever-expanding reach. It makes no sense to rail against “pathologizing” suffering while asking health insurers to pay for care.
The viability of the mental health professions has long depended on expanding its market from those disabled (or rendered unreliable) by their problems to those who work, make good money, and show up for appointments on a regular basis. (I talk about how this began happening early in the last century in Health and Suffering in America. One reason psychoanalysis became so powerful was its utility in this expansion.) DSM simply continues that trend, expanding the reach of mental health care to all those who can access insurance.
With the passage of the Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008, which took effect in July 2010, and the Affordable Care Act of 2010, which is supposed to be fully in effect by 2018, mental health care will have expanded its reach to pretty much everybody. Everybody, that is, who qualifies for a diagnosis.
Now, it’s no wonder that talk therapy depends on third-party funding. Therapy fees range from about $50 per session (for beginning counselors and social workers) to around $175-225 for experienced Ph.D.’s and M.D.’s. The best figures I’ve seen show that, nationwide, therapy costs average out to about $100 an hour. The median hourly wage in the U.S is a bit below $25. The average therapy hour, then, costs about four pretax work hours. Since people pay with after-tax dollars, though, on average a patient would have to work almost six hours to pay for an hour of care. If you make less than $25 an hour, or your therapist charges more than $100, the percentage of your work week required to buy care is higher, of course.
I’d like to say that fees should be lower—and in fact, I think they should be: clinicians should see themselves as more like teachers and ministers, making a middle-class wage, rather than like doctors or lawyers, aspiring to an upper middle-class lifestyle. But in reality, fees will never be small.
Generally, twenty-five hours of patient contact per week is considered full-time work. Assuming a modest office and utilities, minimal advertising, and inexpensive professional insurance, monthly overhead will be in the neighborhood of $1200-1500—call it $16,000 a year. The self-employed therapist has to pay his or her own health insurance, which we can conservatively estimate at $500 a month, or $6,000 a year. Remember that the therapist has to pay self-employment tax—which is 6% to 8% higher than payroll taxes. For the therapist to earn the equivalent of a $45,000 salary, he or she would have to gross somewhere in the neighborhood of $75,000. Assume the therapist works forty-nine weeks a year (1225 patient contact hours). The fee will have to be somewhere around $60 dollars per session.
Of course, few therapists are going to be content making the equivalent of $45k per year, at least not beyond their early years in practice. In reality, fees will be significantly higher. (Full disclosure: my fee is $80—considerably lower than similarly-trained and experienced therapists, but more than I wish it were.)
The sad fact is that we can expect DSM to skew the thinking of clinicians, and the knowledge base of mental health care, more, not less, in coming years. The Wellstone-Domenici Act and the Affordable Care Act will place financial pressure on insurance companies to look more carefully at what is and isn’t medically necessary in mental health care. Clinicians, in turn, will face more pressure to think in DSM terms to justify the insurance payments that sustain them.
Clinicians, being human, cannot long maintain the cognitive dissonance of hoodwinking insurers, so they will come to believe that, in fact, the DSM terms they use to gain their material security are correct.
We’ve already seen this happen with affective disorders—a drastic change in the ways that clinicians think about, diagnose, and treat their clients, and the ways that clients think about themselves. We can expect more of it in the next few years, as more of us become dependent on third-party payers.
Thinking Carefully. Bob Fancher explores the gap between what we believe about suffering and what we think we know about it, all the while asking how to strengthen the “knowledge base” we use to care for people in pain.