Dear Howard Stern: People in my profession are utterly thrilled to witness you on the talk show circuit crediting psychotherapy as a life-transforming experience. You unabashedly revealed on The Late Show with Stephen Colbert: “I pushed myself into psychotherapy, and I’ve gotta tell you—I’m the poster boy for psychotherapy. I think it’s terrific, and I got in touch with a lot of things I didn’t like. It was quite a journey.” You even stuck your neck out in an interview with CNN’s Anderson Cooper, claiming that your friend, President Trump, was traumatized by his childhood and has a high level of narcissism, as well as trouble with empathy, such that he would do well to locate professional help: “I wish he’d go into psychotherapy. I’d be so proud of him if he did. He’d flourish.” What may come as a surprise to you is that the quality of talk therapy that was available to you—time-intensive, in-depth sharing of feelings, exploring childhood traumas, examining and changing difficult personality traits—is steadily becoming unavailable to the average American seeking mental health care.
Case in point is what is occurring within the Kaiser Permanente mental health care delivery system. Recently the National Union of Healthcare Workers (NUHW) announced that some 4,000 Kaiser psychologists, therapists, social workers and psychiatric nurses were prepared to go on strike across California to improve patient access to quality mental health care. A newly released NUHW survey found that due to understaffing and high-volume caseloads, 77 percent of Kaiser mental health professionals have to schedule return appointments further into the future than is clinically appropriate, with over 60 percent reporting that their first available return appointment was more than a month away. A Kaiser mental health administrator I interviewed for my book a couple of years ago summed the situation up: “It has become a medication-management, crisis-intervention model, not a real psychotherapy model where patients get the time and space they need to build a relationship, address the real issues that trouble them, and emotionally unload.” But, Kaiser is not alone in skimping on quality psychotherapy services.
In March, ruling on a class-action lawsuit against United Behavioral Health (UBH), a subsidiary of UnitedHealth Group, the nation’s largest health insurer, Judge Joseph Spero of the U.S. District Court of Northern California drew the conclusion that UBH adopted treatment guidelines that focused on cost savings through limiting the treatment being approved to the management of acute mental health episodes. In essence, he faulted UBH for denying their subscribers mental health treatment of sufficient duration to get to the heart of their psychological difficulties and achieve long-lasting change. Can you believe it Howard, he busted UBH for only covering short-term, crisis-management therapy, lessening some mental health symptoms, but not leading to the sort of life-enhancing benefits you recently told ABC News’ George Stephanopoulos you derived from psychotherapy: “I have learned through therapy, maybe I could love myself a bit and love what I’m doing and really throw myself into it . . . learning how to be a man . . . having successful relationships . . . listening more on air.” If you would allow me a professional speculation, I surmise that psychotherapy rid you of your shock-jock persona and helped you express sorrow, envy, regret, shame, and rage you didn’t consciously know you had, making you a more loveable version of yourself!
You once quipped to your radio audience that your main goal in psychotherapy was to cut back to two sessions a week from your years-long customary three. Setting aside how legions of readers might see this as an obscene amount of therapy, you will be appalled to discover that most Americans are receiving a fraction of the psychotherapy they actually need to get better. Scientific analysis of over 10,000 psychotherapy cases conducted by Endowed Chair in Psychology at Brigham Young University, Michael Lambert, and his co-researchers, strongly suggests that it takes 20 or more sessions for most clients to manifest real behavioral progress. Yet, in a study looking at national trends in psychotherapy usage by Mark Olfson in the Department of Psychiatry at Columbia University, up to 50 percent of patients drop out after the first or second visit, and only about 9% of those entering treatment attend twenty or more sessions.
The main reason people in emotional need discontinue psychotherapy before it is of sufficient duration to attain real improvement is that too much of the cost is shifted over to consumers by insurance companies. Milliman Inc., released a report a few years ago charting how mental health services are four to six times more likely to be provided out-of-network than general medical or surgical services. In a nutshell, what is occurring is that droves of psychotherapists are unwilling to contract with insurers because of low reimbursement rates, leading to a sizable number of clients paying out-of-pocket for needed care, which pressures them to underutilize it for affordability reasons. The American Psychological Association estimates that about a third of psychologists refuse to take insurance, primarily because of low reimbursement rates.
If I may, it sounds to me that psychotherapy has equipped you with a newfound capacity to be tactfully honest, instead of your old tendency to be tactlessly so. Perhaps then you will respect my candor in suggesting that you team up with fellow celebrities who have gone on record about the lifeline psychotherapy can be—Jay-Z, Brad Pitt, Katy Perry, Gwyneth Paltrow, Halle Berry, Jennifer Aniston, Jon Hamm, Emma Stone, to name but a few—and leverage your collective cultural status to address the underfunding of mental health services by insurers, lest quality talk therapy be more out of reach for the average American and available only to Hollywood types and those with means.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.