New York Times

Posted By admin on August 14, 2010

Psychotherapy at the Price of Volunteering
THE NEW YORK TIMES, SUNDAY, SEPTEMBER 22, 2002

Insuring Privacy by Bypassing the Insurers.

By DICK AHLES

In Connecticut, you can barter four hours of volunteer work in a soup kitchen for a private hour of therapy with a psychologist, courtesy of a group know as Volunteers in Psychotherapy or V.I.P.

Not that you would be restricted to working in a soup kitchen in exchange for your therapy. You can help out in a hospital, a museum, a shelter, a library or any charity you choose so long as it is recognized as a legitimate, nonprofit organization.

V.I.P. was founded in 1999 by four psychologists and two nonprofit specialists to make psychotherapy truly private and available to anyone who needs it, according to Dr. Richard Shulman, one of the founders and the current director of V.I.P. The founders were motivated by the conviction that the treatment offered by their profession and the rules of health insurers are a bad mix.

If a person isn’t up to volunteering for four hours for therapy, he or she can work three hours and pay a $10 fee, or two hours and $25 or one hour and $40. The going rate for psychotherapy in the Hartford area is around $100 an hour.

Volunteers in Psychotherapy is located in a modest, one-room office over a restaurant on South Main Street in West Hartford Center. It is on the Web at www.ctvip.org.

V.I.P. is overseen by a volunteer board of directors, composed primarily of professional psychologists.

After a decade at a clinic operated by Hartford’s Institute of Living and Hartford Hospital, Dr. Shulman had become increasingly concerned that managed care and its financial pressures were severely cutting into the private therapy the clinic was providing. “People were shifted into short-term group therapies and pills were overemphasized,” said Dr. Shulman, who has a private practice but devotes more than 30 hours a week to V.I.P.

He was especially troubled by the rejection of two young women who said they had been sexually abused as children and were seeking therapy. “But managed care wouldn’t pay for such ‘unfocused’ or ‘exploratory’ therapy discussions,” Dr. Shulman said.

When therapy is approved, “insurers require doctors to send detailed reports about the therapy and the private life of the client every three to six sessions,” Dr. Shulman said. This doesn’t happen to patients with physical ailments and Dr. Shulman said he sees it as a way for insurers to discourage payments for therapy.

Laurie Ahearn, who heads the National Empowerment Center, an organization of recovered psychiatric patients, agreed there are problems. “With the advent of managed care and the rationing of psychotherapy,” she said, “the ability to build a trusting and empowering relationship is elusive at best, if not impossible.”

The Connecticut Association of Heath Plans, a trade association of managed-care companies, has a different view.

“It is decidedly untrue that there’s a blanket effort to keep people from going into one-on-one, long-term psychotherapy,” said Keith Stover, a lobbyist for the association. He added that essential information is not collected to discourage such therapy or invade the patient’s privacy.

“Its purpose is to help the insurer determine if an effective treatment plan is being followed, whether for a physical or a mental illness,” Mr. Stover said.

As to workers’ concerns about embarrassing information reaching employers, Mr. Stover said, “Providing such information would violate both state and federal law and Connecticut’s law against dissemination of such information is as stringent as you’ll find anywhere.”

He said a perception that employers would have access to information about an employee’s mental health care dates back to a time when large companies were self insurers and there “wasn’t a large enough fire wall between the people running the company.”

He added that most Connecticut employers “recognize the real need to provide good mental health coverage because it makes for happier, more productive employees.”

But that may not always be the case. Dr. George Allen, a professor of psychology at the University of Connecticut who also has a private practice, has found that even high-ranking employees of supposedly enlightened managed-care providers had reason to worry about their privacy.

“Over the past decade,” he said, “I’ve seen six individuals who worked in rather high-level administrative positions within the insurance industry. Without exception, all declined using their own insurance benefits to pay for services.”

In a letter he wrote to Dr. Shulman, Dr. Allen said one of the insurance executives told him that if an executive’s therapy was reported to his own insurance company, he would according to Dr. Allen “most certainly” lose his job.

“Ironically,” said Dr. Allen, who is a contributor to V.I.P., “these individuals all had the financial resources to ensure their own privacy yet they held positions in an industry that denied the same basic rights to those who were less economically advantaged.”

Had Dr. Allen’s insurance executives sought the services of V.I.P., they wouldn’t have had to worry about their privacy but they couldn’t have paid cash for their therapy even though they could afford it. V.I.P. insists that clients exchange at least the minimum one hour of charitable work and $40 in cash for an hour of therapy because, said Dr. Shulman, “giving something as a volunteer is a form of therapy in itself.”

“We’ve had people who were physically abused as kids who worked with hospitalized children, people with physical problems of their own who have worked with handicapped folks,” he added.

Those for whom volunteering is therapy come to “appreciate being valued by the volunteer agency,” he said

In 2001, V .I.P. clients received 250 hours of therapy. This year, they have already surpassed 250 hours and are on their way to more than 500 hours. Support for the nonprofit group comes from individual donors, foundations and recently, the federal Department of Health and Human Health Services

The psychologists see people with various forms of depression, anxieties, difficulties in coping with everyday life, marital and parenting problems, substance abuse and other disorders. Some clients need many hours of therapy while others require only two or three sessions, which is the number usually sanctioned by insurers before the therapist is, according to Dr. Shulman, “pressed to provide pills and not therapy.”

He doesn’t entirely blame the insurers for this problem.

“We shrinks are ultimately responsible for this,” he said. “Years ago, we fought for health insurance coverage to include the problems for which people sought psychotherapy. Many therapists and clients were happy at the prospect of a free lunch, of therapy sessions paid for by some else. But these third-party payees – employers, governments and insurance companies – eventually realized he who pays the piper calls the tune.”

No Privacy

Posted By admin on August 14, 2010

Is Privacy Necessary in Psychotherapy?

Read the Reactions of:

- The Supreme Court of the United States

- Two Directors of the New York Psychoanalytic Society

- President of the American Psychiatric Association

- Dr. Donna Shalala, Secretary of Health and Human Services

- Wall Street Journal

- Consumer Reports

- Medical Economics Magazine

- National Coalition for Patient Rights

- Hartford Courant

- Professional Psychology: Research and Practice


Supreme Court v. Managed Care

Supreme Court of the United States Jaffee v. Redmond 95-266

“Effective psychotherapy…depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories, and fears. Because of the sensitive nature of the problems for which individuals consult psychotherapists, disclosure of confidential communications made during counseling sessions may cause embarrassment…For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment…

The psychotherapist privilege serves the public interest by facilitating the provision of appropriate treatment for individuals suffering the effects of a mental or emotional problem.”

But Therapist reports to Managed Care &
Insurance Companies destroy privacy


Two Letters to The Wall Street Journal on Privacy and Psychotherapy 11/6/96

To the Editor,

…Your headline implies that a psychotherapeutic process can be established with or without privacy. This is simply not true. Without privacy there can be no more effective psychotherapy than there can be a fully functional doctor/patient – , priest/parishioner – , or attorney/client relationship. Patients must be made aware that when they invite care managers into their therapies the effort may be entirely vitiated… The entire process will be skewed, details omitted, truths bent, and a less than fully open atmosphere established. Such an atmosphere spells certain death to the difficult psychotherapeutic tasks of openness, honesty, trust and confidence.

Richard M. Gottlieb, M.D.

Chairman, Scientific Program Committee

The New York Psychoanalytic Society

To the Editor,

Your article speaks to the very critical issue facing all of us: the danger to the effective conduct of psychotherapy which results from the loss of privacy and confidentiality [under managed care]. In the Jaffee v. Redmond decision, the Supreme Court ruled that psychotherapy cannot be conducted unless the patient’s privacy (i.e., the confidentiality of the interaction with the therapist) is assured. Your article makes clear that only those individuals who can afford private care, without third-party reimbursements, can fully assure themselves of complete privacy….

Leon Hoffman, M.D.

Director, Parent Child Center, New York Psychoanalytic Society


The President of the American Psychiatric Association

Herbert S. Sacks, M.D. (President-elect): The New York Times, Sunday, October 27, 1996, “Connecticut Section”.

“One grave concern we have has to do with…the demands of managed care organizations for full medical records. They claim they need them for accountability. That is not true. … There are leaks all over the place. In my private practice dealing with … patients who work in corporations, banks and the media, perhaps half of them who have coverage will not use it. They pay out of pocket because of their concern about these breaches, because of what they observe in their own workplaces.”


The Secretary of the Federal Department of Health and Human Services:

Donna E. Shalala, Ph.D. (Secretary of H.H.S.) from National Public Radio feature of August 26, 1997.

“My video card has more federal protections for the privacy of those records than my health care card does… There are no federal protections, there are no standards to protect my health records.”

National Public Radio continues… “Some clinics and many pharmacies sell lists of their customers as do insurance companies and health management and billing companies. There are simply no national laws saying who can and who cannot use this information for non-medical reasons. Two of the nation’s biggest drug companies also run management firms for HMO’s so they have access to patient medical records, and at the same time a tempting supply of potential customers whose addresses and medical information they already know.”

NPR then quotes Dr. Rindfleisch, an expert on medical information from Stanford University: “the sensitivity of health care information is probably higher than in other areas. For example, issues of substance abuse, issues of psychiatric care, issues of sexual activities… that can affect profoundly our relationship to our employers and to the society around us”. NPR then paraphrases Dr. Rindfleisch, “the information can be used to the patient’s detriment. Insurance companies might decide not to insure a patient… employers might use information when making decisions about hiring and promoting.”


Wall Street Journal, Jan. 22, 1998, “Psychotherapy Patients Pay a Price for Privacy”

“It’s none of your business.

So say a growing number of patients who are deciding not to submit health-insurance claims for psychotherapy, preferring to pay bills out-of-pocket to keep their sessions private.

Under managed care, therapists must file reports about their patients to case managers, who review the clinician’s observations and recommend a treatment plan before approving insurance benefits. Therapists also must submit frequent progress reports, and sometimes even share their notes about what patients have confided in them.”


Consumer Reports, October, 1994, “Who’s Reading Your Medical Records?”

“A few years back, a University of Illinois study of Fortune 50 corporations found that fully half of the companies surveyed used employee medical records in making employment-related decisions. And of those, nearly 20 percent didn’t inform the employee. A 1991 survey of the Congressional Office of Technology Assessment found that almost a third of the employers that maintained employee medical records let their personnel departments read those records without notifying the employee.


Medical Economics Magazine, May 26, 1998, “Medical Privacy? Forget it!”

“…managed-care companies — which fund more than a third of all visits to psychotherapists — frequently balk at reimbursing extensive therapy without exhaustive information about the ailments of the patients. Where once a simple, standard psychiatric diagnosis was enough for therapy to be authorized, mental health insurers today want the nitty-gritty details, therapists say. “The more specific you are, the more dirty laundry you give them, the more approvals you get,” says Jennifer Katze, a Baltimore psychiatrist.

Therapy patients, as a rule, do not trust the unseen bureaucrats who examine these records… As a result, patients increasingly pay for therapy themselves, cutting the insurers out of the equation.”


National Coalition for Patient Rights Psychiatrist

“Margo P. Goldman, M.D., is National CPR’s [Coalition for Patient Rights] director of policy development and a practicing psychiatrist. She answered [a therapist’s question about privacy and insurance forms] this way:

‘In a nutshell, most insurance claim forms have an authorization for the patient to sign to release information to process a claim. Because there are no rules about what information is enough, this could range from basic claim information to the entire patient record,’ Goldman said…. ‘The only way now to prevent an insurer from accessing therapy information is for the patient to pay privately for his or her treatment.”


“Patient Confidentiality At Risk, Report Claims”, Hartford Courant, Dec. 14, 1999

“The surgeon general’s report on mental health released Monday warns that managed care and information technology have threatened the confidentiality between therapists and clients. The erosion of privacy, the report says, will make people less likely to seek treatment, and less likely to honestly disclose their symptoms if they do see a therapist. ‘It’s a very scary issue for us,’ said Mary Graham of the National Mental Health Association, and one of the top reasons that Americans who could benefit from therapy are staying away. Increasingly, she said, therapists are being required to routinely submit to managed care organizations the most personal and detailed information about their clients’ mental state and personal problems. Often that information is transmitted by fax, e-mail, and, in some cases, over the Internet, and stored in huge data banks….

‘One study of Fortune 500 companies says that 30 percent acknowledge using medical information they had acquired in hiring and promotion decisions, and only half of them told people they were doing it,” said John Ringwald, a clinical psychologist…


Professional Psychology: Research and Practice (American Psychological Association Journal)

From “Confidentiality Limits of Managed Care and Clients’ Willingness to Self-Disclose” by Thomas G. Kremer and Ellis L. Gesten (1998, pp. 553-558)

 “The impact of managed care requirements on clients’ willingness to disclose [talk about revealing personal matters] was quite powerful, indicating that psychologists may be deprived of significant amounts of client information due to fears about confidentiality infringements…The implication that managed care clients may be unwilling to disclose therapeutically relevant, even necessary, information presents a serious challenge for practicing psychologists…Only when the psychotherapeutic relationship is given its necessary respect and freedom from constraint can therapy be truly effective for all concerned.”