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Dr. Bob is Robert Hsiung, MD,
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Posted by pseudoname on July 13, 2006, at 7:39:32
This editorial was in the Bangor Maine “Daily News” July 12, 2006 http://www.bangornews.com/news/templates/?a=137240&z=35%20class=
By Thomas J. Gaffney
Maine’s most vulnerable people, poor children and families, and the disabled soon will have their challenges to cope with life complicated.
In 2007 the MaineCare program is determined to bring managed care into the state’s mental health service system. It is ironic that insanity has been defined as doing over and over something that doesn’t work, and expecting a different result.
Managed care has been around for more than 15 years. The idea was, having an insurance company watching what doctors were doing with patients, would cut costs and improve treatment outcome. The idea was never popular with doctors or patients, and the lofty goals have proved elusive. In the world of medicine, where diagnosis + prescriptive treatment = cure or symptom amelioration, the idea could pass the common-sense test, however, there were certain real world variables left out of the equation, such as conflicts of interest, politics and disease care being a growth industry.
Transposing managed care to mental health services requires swallowing a mass of assumptions that would choke a horse. Unlike medicine, the diagnosis in mental health services has poor reliability and unknown validity. Diagnosis does not predict treatment outcome; is of little help in treatment selection; and surveys consistently find that therapists don’t like it, or find it useful.
Since the ’60s, the number of treatment approaches has grown from 60 to more than 400, each claiming superiority in usefulness and outcome. More than 100 so-called evidence-based treatments (the most likely to work if carried out as directed) have not increased the effectiveness of treatment in 40 years, and counting. With only a few exceptions, research has consistently shown different treatment approaches work equally well, about 80 percent of the time, compared to untreated control subjects.
Curiously, counseling was more effective, less expensive and more problem free than medication in the treatment of anxiety and depression. So why have managed-care companies and the pharmaceutical industry been pushing medicine so aggressively for these conditions?
At a recent international conference in Bar Harbor, the principal researchers and clinicians from the Florida-based Institute for the Study of Therapeutic Change described what is at the heart and soul of change. Research and common sense merged, offering Maine a better way to help its people, while saving more money than managed care ever could.
It turns out that 40 years of research into what accounts for successful counseling outcome are four factors. Drum roll please. The first factor which accounted for 40 percent of the outcome was the client — his or her strengths and resources, their social and environmental support, and chance events that occur while they happen to be in therapy.
The second factor, accounting for 30 percent of the outcome, was the quality of the relationship between the client and therapist, as viewed by the client, not the therapist. The better the alliance, i.e. agreement on goals, agreement on tasks and relational bond (the therapist’s ability to listen empathetically to tap into the client’s world to identify what they already have, and can be put to use in reaching their goals), the more quickly, and less costly it will be to succeed.
The third factor accounting for 15 percent of the outcome is the client’s hope and the expectation of success. When the client knows he is being "helped"; believes in his helpers’ rationale and methods, finding a good fit with his own world view; and when both client and helper believe what they are doing will work, a good outcome is more likely.
The last factor, accounting for only 15 percent of the outcome, is the ideas and techniques of the helper. No wonder all approaches and techniques are equally effective! They don’t really matter all that much, at least compared to what potentials the client brings for change, and the alliance between the client and the helper.
No matter what the problems that brought people for help, no matter the age, children, teens and adults, marriages, families, alcoholics, marijuana-abusing youth, involuntary clients, and even people having “major mental illness,” e.g. schizophrenia, the four factors account for successful outcomes in counseling. Therapists can use virtually any idea or technique they believe in, and as long as the client feels it fits them and taps their possibilities for change, and the therapist monitors the pulse of the alliance, it will work.
Unfortunately for clients, therapists, efficiency, effectiveness and cost, what managed care has been managing is barely relevant. Maine is now planning to spend a considerable amount of money to waste money on the pretense of making counseling more efficient, while reducing costs.
There will be people in an office in Augusta who will decide what clients and their therapists can and cannot do, without a clue about what the client brings to counseling, or the nature of the alliance with the therapist. The research says managed care has accounted for zero percent of successful outcomes in counseling.
Scott D. Miller, Ph.D., Barry L. Duncan, Psy.D., and their colleagues at the Institute for the Study of Therapeutic Change have a much better idea. Therapists can simply monitor the outcomes and the alliance during each meeting with their clients, using reliable, valid, user-friendly measures to guide the counseling process.
The clients win by getting what they want in a way they can use. The therapists win by increasing effectiveness. Agencies win by increasing productivity while reducing costs. Maine wins by helping its most vulnerable people, while sensibly stretching the tax dollars of its citizenry.
There is computer software available for therapists and agencies to use this information to monitor case, and program progress. Community Health and Counseling Services is well on its way, applying its own managed-care model using these practices, including supervision and administrative support tracking client outcomes and therapeutic alliances. The state of Arizona is moving ahead with what has been called The Heroic Client model.
Maine should set aside the managed-care models from away and take up a way of helping its people that fits it tradition and character, practical, no-nonsense, caring and thrifty. It would neither be difficult nor costly for MaineCare to monitor client outcomes and therapeutic alliances, in lieu of questionable diagnoses, privacy invasive treatment plans and burdensome paperwork for already overloaded clinicians.
Maine is ready for this change.
•Thomas J. Gaffney, Psy.D., is a psychologist at the Highland Sanctuary and Retreat in Stockton Springs [Maine]. He is also chair of the Bucksport Bay Healthy Communities Coalition.
Posted by Dinah on July 13, 2006, at 8:28:56
In reply to managed care in therapy in Maine, posted by pseudoname on July 13, 2006, at 7:39:32
I just don't get the practice of medicine by non-doctors. Last month I was distressed to find that my insurance company only paid for half of my prescribed migraine medication. I had my husband call them (since I would have just cried) and they said that was the standard doseage, and I'd have to have written authorization from my doctor for more. Hello? What in the heck is a prescription then?
I think I might really resent having to fill out a satisfaction survey at the end of each session. At the end of a session, I like to decompress, not be called on to rationally fill out a form. I don't even think I'd like having it as homework to fill in. Maybe once every month or so would be fine.
Posted by pseudoname on July 13, 2006, at 9:13:43
In reply to Re: managed care in therapy in Maine » pseudoname, posted by Dinah on July 13, 2006, at 8:28:56
> I'd have to have written authorization from my doctor for more. Hello? What in the heck is a prescription then?
LOL!!
> I think I might really resent having to fill out a satisfaction survey at the end of each session.
They actually fill the form out at the beginning of the next visit. I've never used one, but I like the idea of feedback.
Posted by Jost on July 13, 2006, at 11:01:15
In reply to forms » Dinah, posted by pseudoname on July 13, 2006, at 9:13:43
I've run into that--- if you need more than the usual amount of a certain medication, the doctor has to fill out further forms explaining why and for how long, etc etc you need this amount.
My insurance also won't pay for off-label uses of drugs-- which accounts for about 30% of prescriptions.
Cost-cutting you know.
Jost
Posted by pseudoname on July 14, 2006, at 9:35:51
In reply to Re: forms, posted by Jost on July 13, 2006, at 11:01:15
This is from an email today by a therapist in Barry Duncan's listserv (see article above) talking about using those evalution forms as part of therapy.
<quote>
I have been using the [therapy progress evaluation] scales for some time now[…]. It is still a small sample and early in the process, but my effectiveness as a therapist is not showing itself to be anywhere near average — quite low in fact. Talk about narcissitic injuries! I thought I was cutting edge! I am doing this voluntarily and with enthusiasm, and I can just imagine how it would be if someone told me I had to do it. […]When I told [a colleague] that so far I am turning out to be a below-average therapist he started to laugh and said, “that's the real reason I don't want to do [evaluations], I'm afraid that is what I am going to discover.” […]
I actually feel sort of defiant looking at my low effectiveness numbers. I am going to do everything I can to improve them.
<unquote>
This is the end of the thread.
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