The Inevitable Illness of Everyone

Bob Fancher, PhD
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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.

28 COMMENTS

  1. So, we need a total overhaul of our entire insurance, policy, and funding systems? Thanks for writing on the origins and effects of profit/policy collusion. Very tricky.

    In the case of Medicaid and Medicare, it’s a shame that states must pay such exorbitant rates for services such as hospitalizations and costly medications that measurably fail to promote wellness, especially when models such as Peer Respite cost less and offer better outcomes for “consumers.”

    Ha! Here’s an excerpt of a letter I wrote (on a particularly broad-minded and enthusiastic day a few months ago)to our state-level lobbying Coalition re: MHDDSA services here in NC. All they had to say in return was, “We’re doing this…we’re doing that…we’ve done a lot.” I certainly wasn’t suggesting that they hadn’t. However, it seems that more could be done.

    “…I understand what is so deeply wrong with our mental health system and I believe that, working together at every level, we can establish a system of care that truly supports the recovery of both consumers and the system itself.

    “We can not fix it. It is too complicated. We can stitch it, but you’ll have a scar. We can medicate it, but you’ll have some serious side effects. You’ll need to do this. You’ll have to do that. There is nothing you can do. Sign here and come back next week.”

    This is what coercive profit-driven medical model psychiatry taught me about my potential to recover, that there was no better way. They taught me, in fact, that attempting a better way would, in fact, be a risk. They taught me that I could not manage myself to best meet my needs and that further, I was not even able to identify what my needs may be.

    Just as people who profited from my disorder and denied me my rights in doing so (the right to refuse and the right to be informed), I see that the MHDDSA system in the state of NC is also being coerced. In very real ways, North Carolina is being denied the right to manage MHDDSA systems in ways that actually work for us and meet the unique needs of our communities and the individuals within them.

    Lobbyists and profit-interest groups have coerced North Carolina into what is, by and large, a narrow and dysfunctional model of care that actually creates more problems than it solves.

    There are evidence-based and cost-effective modalities that support proven and measurable recovery. Recovery Education Centers are Peer Respite are just two examples.

    Why is it that these proven alternatives to medical model services are not more broadly funded?

    The reason that our MHDDSA system is struggling is this: Interest groups, such as those from the Pharmaceutical and Insurance industries, are profiting.

    This is not a political issue. This is an economic issue.

    However, it is also a human rights issue. We see every day that people’s needs are not being met, or worse, are needs are being responded to in ways that measurably violate their rights as patients and consumers and cause further harm.

    The state of NC is paying a lot of money for people to have no option other than to go to the hospital, no option other than to take the expensive medication, no option but to get the ECT treatment.

    For far less money, Recovery Education and Peer Respite could bring true recovery to North Carolinians and yet these services are being made inaccessible due to manipulation of funding structures.

    Recovery is possible. I live it every day and I see it all around me. However, it is only possible within a system and a culture that supports the reclamation of the worth of our lives and potential to live them well. A system of care that profits mightily from “illness” requiring costly care is not likely to support true recovery. There is ample evidence that the traumatic effects of some medical model practice actually cause great harm to people.

    I believe we can do better than that.

    However, in order to do so we must stand up to those that lead us to believe that this is the best we can do.

    Please do encourage advocacy for Local Management, Recovery Education, and Peer Respite Crisis Alternatives.

    Thank you for your time in considering this vital issue that, in some way or another, affects all North Carolinians.

    Sincerely,

    Faith Rhyne, CPSS

    • Peer respite homes can provide care for about $250 per person per day, as opposed to $1,000-1,200 per person per day in state hospitals. I wonder why hospitals charge so much since most of what you are getting while there is drug maintainence. I was in the hospital for two and a half months and received a bill for $364,000. They want me to pay $4,000 of it which I think is still high. Unfortunately there are only about eight respite houses in the United States. So, what’s wrong with this picture? People get better in the respite house and go back to their lives and this is all accomplished without the toxic drugs. However, if I tried to set up a respite house in the city where I live, which is also the city where the state hospital is, I’d be tared, feathered, and run out of town. Everyone here believes in biopsychiatry, the DSM, and the toxic drugs.

  2. This is a convincing statement about the forces at play. But you don’t mention that there is an end-game, and powerful counter-forces: the third-party money comes from somewhere.

    There is only so much money that society will accept (or can afford) to spend on mental health through collective insurance. At some point the “non-diagnosed” or “non-users”, will push back against the transfer of too much of their insurance premium to mental health services, probably through the intermediary of the insurance companies, or legislation (teachers, police, other public services are competing for the available “collective money” too).

    So not everyone will become mentally ill, because the money will dry up first. Money often corrupts and distorts, but its scarcity can also have a virtuous effect: a majority has to have integrity and intelligence, for the money (or equivalently the things of real value that can be exchanged with it), to exist in the first place.

    So the DSM expansion, and pathologizing of normal suffering could be close to its peak, and people thinking like you should then finally have more power to shape the debate, once that peak is passed.

  3. I agree that those who earn their living from the DSM model of medicalizing emotional well-being have little incentive to reform the system. So be it. Reform has to come from the taxpayers who support a system that does not actually bring well-being to the patients. This is one industry that could do better with less funding.

  4. This is a tricky topic. It brings into view concepts of the free market, subsidies for the “poor” and “disabled” and good ‘ole fashioned horsetrading.

    I’m a free market guy, so I believe if you provide a service/product that people want good for you. Go forth and prosper. But as you say Bob, what happens when you want more than what the market will pay? You should go out of business or adjust your busindess plan but here’s where subsidies via insurance step in and muddy things. Once we start down the subsidy road, all kinds of perversions await.

    I’ve no solutions here. In a perfect world, I’d like to think the work I did was valued enough by enough that I could support myself and family. Thanks for raising these issues.

  5. “Patients who want insurance to pay for their care, and clinicians who want more money then their patients are willing to give, have little grounds to gripe about the general drift of DSM.”

    “It makes no sense to rail against “pathologizing” suffering while asking health insurers to pay for care.”

    It makes all the sense in the world if you believe that all medical and mental health care should be a basic human right that a just society should guarantee to all those who need it.

    Why accept the logic of a system that is inherently oppressive and unjust to those on the bottom of their “dog eat dog” profit based pyramid?

    In a just world with a single payer type system, there would be no need for insurance companies acting as “middle men” that ends up raising overall health care costs by at least another 25%; the same insurance companies that reap enormous profits by often limiting necessary care to those that really need it.

    In community mental health most clinicians are “fee for service” and make far less that you suggest; 30 to 40 thousand a year is probably more accurate. The “fee for service” trend allows nonprofit clinics to provide fewer benefits for it clinicians. This trend was mainly driven by the rise in Biological Psychiatry where clinics were forced to hire more psychiatrists to service the take over of the medical model and the millions of psychiatric drug prescriptions. This has created somewhat of a financial crisis for these clinics because psychiatrists make about 4x the income of a clinician. The medical departments in these clinics actually lose money and are virtually supported by the clinical units of therapy.

    People who request therapy are looking for help to cope with an incredibly stressfull and unjust world; they want to solve problems that ultimately will require revolutionary type changes in all major institutions. Until those changes come they may need immediate support and “coaching.” In the mean time we all need to challenge every aspect of the medical model, including the stranglehold that insurance companies have on our field. The approach of these companies is to maximize profits by generally seeking quick symptom reduction emphasizing the use of medications and thus downplaying the value of therapy and community and peer supports.

  6. You are exactly right; a single payer system under the current economic and political system would do nothing by itself to challenge the medical model’s hegemony.

    I am questioning your point that we have no right to speak or complain if we are forced under the current system to use the DSM to get care for needy clients. Many working in the field “hold their nose” when complying with insurance requirements to use “their” labels. If we just go along to get along without rebelling or causing some trouble in their system then your criticisms are fair. But there are some people working in the community health system waging the “good fight” from within and believe me it is not easy. I wanted to write a blog essay titled “How to work in community mental health without losing your mind or your job.”

    • That’s a blog I would be interested in reading Richard!

      It is difficult to reform from within. You have to say things to clients like, “I have to give you this label, so that the care you receive will be paid for by your insurance, but I want you to know that I don’t believe in labels and don’t think any human person could be reduced to a label. Is this ok with you?”

      But the label is there, its in the record and other professionals that aren’t reformers see that as validation of the diagnostic procsess. You have to be careful which supervisor you tell about just giving a label for insurance covereage…you may not want to mentio to the insurance carrier either..in fact you may not want to mention to your good friends…you see how tough this is? Just one example of the contortions reformers in a broken system deal with. But what about the so-called clients? If we’ve got it rough, what about them!

  7. “It is simply illogical to claim medical benefits for nonmedical conditions.”

    “It is also fraud.”

    Bob, it is only illogical if you accept “their” logic and it is only fraud if you accept “their” morality.

    There is nothing illogical and immoral about trying to help people in grave psychological stress get the help they need. If you have to “play the game” and use thier labels at this time to get people that help, then so be it. Until we can replace the system that promotes this oppressive medical model of treatment we need to work with what they have given us. At the same time we can try to educate clients and clinicians that psychiatric labels represent a version of “genetic theories of original sin”( Ashley Montagu’s wonderful phrase )and do not accurately describe the learning process that clients are going through. We can also attempt to steer clients away from psychiatric meds being proposed as the solution to their problems.

    Bob, you have raised many interesting points, but your post has a theme that tends to place clinicians that are forced to use the current system on the same level with psychiatry and the pharmaceutical corporations. We need to narrow that target and unite all who can be united.

    Yes, many clinicians working in the field have accepted the “big lie” propagated by Biological Psychiatry and have their heads buried in the sand. But many more are demoralized and alienated by this medical model and need to be educated and awakened. This website and the launching of Occupy the APA are just two threads of a growing movement in its infancy.

  8. Bob, I respect your efforts to challenge and provoke people working in our field to take a cold hard look at what they doing. But when you say:

    “We have, in fact, seen psychologists and other talk therapists change what counts as science and what counts as good care…” this misses the main target. Biological Psychiatry is the wedding of genetic theories of mental illness with the pharmaceutical corporations, APA and the main teaching institutions of modern psychiatry. They have foisted this whole medical model upon our field of work. Most therapists are not in the field for the money; this society does not value this type of work, and again, the incomes in community mental health ( except for psychiatrists )are not very high. Of course everyone needs to pay the bills and also lives in a bloated consumer driven society that convinces people to purchase many toys. Most clinicians use the DSM labels because they have to, not because they created them or want them to continue or see this as a source of greater income.

  9. Hi Dr. Fancher – I really appreciate 3 things about this comment thread:

    1) You were relatively tolerant of naive oversimplifications (which a particular specialty of mine)

    …and these statements:

    2)I would point out that everyone who makes a living providing mental health care is working “for profit.”

    3) Most people cannot live with the cognitive dissonance and moral queasiness of knowingly misrepresenting their work for money. Most people come to believe (that what?) they say (is true?)

    Did I say 3, I meant 4: “The American Psychological Association and the National Association of Social Workers, for instance, engage in significant lobbying and PR to make sure that their constituents get their piece of the medical pie.”

    I wonder what will be discussed at the APsychiatricA w/APsychologicalA convention in Oct?

    This post really contributed to my understanding of the forces that direct state-funded systems. Other than wait for the dysfunctional system to destroy itself with the burden of cost it has created, what can be done to minimize harm to people seeking help and prevent opportunistic fraud? There’s no need to answer, but I’ve been trying to spot a feasible/achievable solution and there does not appear to be one…unless states shift funding to models that show higher efficacy re: cost/benefit?

    It’s going to be a mess when it collapses, isn’t it?

    • Faith,
      Let me add a comment about your final thoughts (states shifting funding to models… and mess).

      Yes and Yes!

      I work at the local level but also interact with our state partners. At least in Ohio, the biological narrative has been predominant for the last 25 years or so, but it was not always so.

      Bob’s book has helped us focus that, from a state perspective, the biological narrative isn’t working. State folks are also starting to recognize that we’re creating dependency in the people seeking services as a way to fuel the “fee-for-service monster”

      I think from a purely economical point of view, states will start to question the notion of biological narrative, pills for all and fee-for-service. But as you say, it will be messy!

      One opportunity for you and others is to work with your local “behavioral health authority” It’s called different things in different areas. Typically there is a local entity, given the authority to raise local funding (levy) for mental health and substance abuse services. Work with them on developing approaches that are consistent with what we talk about here on MIA. These funds, since they’re local, are extremely flexible and not constrained by what the Feds or Medicaid deem “treatment”

      Hope that helps.