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Psychotherapy in the Age of Trump


Journal of Psychiatric Practice®: January 2017 - Volume 23 - Issue 1 - p 1–2
doi: 10.1097/PRA.0000000000000206


January 2017. Other than acknowledging my bewilderment, disorientation, and personal dismay regarding this election season, I’ll resist the temptation to use these editorial pages to expound on my personal feelings and theories about its outcome. Though I have a lot of them, and a bully pulpit is hard to resist! But what I will not resist is discussing the imperative that is now before us—to protect the progress we have made to achieve mental health care parity and to fight to retain the designation of mental health care and substance abuse treatment as essential benefits in insurance plans. The explicit terms of the Affordable Care Act (ACA) make this coverage a clear requirement for all ACA plans, establishing a long-overdue standard that has powerfully influenced all insurance plans, even if many companies embed technicalities and “fine print” that sustain unacceptable limits and inequities. However, as we all know, President-Elect Trump has loudly “trumpeted” a campaign promise to dismantle “Obamacare” as one of his highest priorities.

As of this writing, it is true, there are some media reports that Trump’s tone seems to be softening a bit, and he has indicated that he might be potentially receptive to retaining some parts of the ACA, such as coverage for preexisting conditions. But he has said many things along the way, and the jury is definitely still out on this issue. The American Psychiatric Association, the American Psychological Association, the National Association of Social Workers, and many other organizations are already on high alert, as each and every one of us should be, to oppose any weakening or reversal of the protective advances now in place for our patients.

Even before the outcome of the election, however, despite the achievements of the ACA, a battleground that has confronted clinicians and patients on a daily basis is the tussle with insurance company reviewers to obtain approval for needed treatment. This process isn’t always a wrestling match, but all too often it is, and it occurs in most of our worlds, at least those covered by insurance. One slugfest surrounds the draconian limits on funding for inpatient treatment, and you’re familiar with my concerns about what I refer to as “Band-Aid treatment.” (I recently gave grand rounds at a medical school in another state where the psychiatric inpatient average length of stay in the teaching hospital was 3 days.) But another big universe of concern is getting approval for coverage for psychotherapy. Even when evidence-based guidelines contain clear recommendations for psychotherapy, the “marching orders” dictating the decisions of mental health reviewers, who approve or disapprove continued funding for a patient engaged in psychotherapy, often disregard these standards.

In this issue of the Journal, Plakun eloquently considers these and related issues in his column entitled “Psychotherapy, Parity, and Ethical Utilization Management.” From his vantage point as head of the Psychotherapy Caucus of the American Psychiatric Association and as an active member of its member-driven Assembly, he highlights the difference between the charge to the clinician provider (to care for the patient) and the charge to the clinician reviewer (to follow the requirements of the insurance employer). Plakun is shining a light on this ethical dilemma and is spearheading a focus on these concerns in the APA Assembly, for which we are indebted.

Also in this issue of the Journal is another piece focusing on psychotherapy, in the Practitioner’s Corner section. Yager and Feinstein present a wonderful “tool kit” to be used by psychotherapists of all stripes: “Tools for Practical Psychotherapy: A Trans-theoretical Collection.” Drawn from long expert experience by the authors as well as input from many other experts, they present a down-to-earth, pragmatic, no-nonsense set of tips and suggestions that would be valuable to all trainees and early career clinicians in the mental health field, but also to seasoned clinicians who would like refreshing views on the hard work of psychotherapy. Of course, though not the focus of Yager and Feinstein’s article, the issues discussed above can be an elephant in the psychotherapy room, as carrying out the advice provided in this toolkit can only be done if the patient has a way to pay for treatment that continues long enough to do the job, and many patients can only do so with the help of insurance coverage.

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