Therapies for Conditions with no Effective CBT Protocols

[Sanman]

I work in a psychoanalytic clinic that takes insurance. I am not aware of any insurance company that specifically refuses to pay psychoanalytic psychotherapy, or any other modality in specific.

Not sure about forensics but there is an considerate number of articles and meta analysis that claim that psychodynamic psychotherapy is an effective treatment for a variety of disorders. The Austen Riggs website used to have a compilation of articles but I could not find it. Of course I am very skeptical about psychotherapy efficiency and efficacy research irregardless of the modalities of psychotherapy since there are a lot of questionable studies.

It is true that CBT is not managed care. However one critique to manage care is that it overvalues psychotherapies that are easier to manualize, systematize, that use quantifiable outcome metrics, etc and CBT appears to be a better fit to this approach to health care, and at the same time, excluding other psychotherapy modalities that do not focus on the criteria evaluated and valued by managed care. This also has an impact on funding for research since if CBT is advertised as the gold standard for psychological treatment, why waste money on researching other modalities? A lot has been written about this, a great article would be "Philip Cushman Will Managed Care Change Our Way of Being?"

It was great that you had a program that was balanced in terms of the different schools of psychology/psychotherapy. I find those to becoming rarer.

Some insurances do limits coding based on modality (e.g. 90837 only for exposure therapy) and can limit how frequently a client can be seen without prior authorization (once a week max usually). This can fly in the face of how psychoanalysts may choose to practice. In NY, if you are a licensed analyst and not a psychologist/psychiatrist, this can also affect reimbursement.

Insurance does prefer psychotherapies that are easier to manualize. They also often have carve outs for wraparound care and other services. They are in business to get the most bang for the buck in the most cases. Comparatively, metformin does not cure diabetes. A comprehensive nutritional and exercise plan might. Yet, my health insurance will not cover more than a cursory nutritional consultation and certainly not a personal trainer. They are cover counseling/coaching programs (that are usually in house). Gold standard individualized care for anything is not what managed care does in this country. They are about providing a set standard of care for the premium paid. Your fight is not with CBT, but society.

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[hum1]

Some insurances do limits coding based on modality (e.g. 90837 only for exposure therapy) and can limit how frequently a client can be seen without prior authorization (once a week max usually). This can fly in the face of how psychoanalysts may choose to practice. In NY, if you are a licensed analyst and not a psychologist/psychiatrist, this can also affect reimbursement.

Insurance does prefer psychotherapies that are easier to manualize. They also often have carve outs for wraparound care and other services. They are in business to get the most bang for the buck in the most cases. Comparatively, metformin does not cure diabetes. A comprehensive nutritional and exercise plan might. Yet, my health insurance will not cover more than a cursory nutritional consultation and certainly not a personal trainer. They are cover counseling/coaching programs (that are usually in house). Gold standard individualized care for anything is not what managed care does in this country. They are about providing a set standard of care for the premium paid. Your fight is not with CBT, but society.

Yes, well, I am not sure if I want a fight. But it does concern me how managed care, increasing institutional regulations, and the for profit/cost reduction mentality is becoming more and more dominating in the field of mental health. But what concerns me is that some clinicians, especially the new ones, might buy all this for profit agenda disguised as science under the name "evidence based" when there is a lot of research that claims e.g. that long term psychotherapy has better outcomes for some people (and diagnoses) than short term psychotherapy, that the evidence for manualized treatments is not as strong as some people advertise it to be, etc etc. And the funny thing is I see them getting frustrated and blaming themselves when standartized "one size fits all" treatments do not work, because "Well, if it is evidnece based and it is not working, I must be doing something wrong". This was definitely the mentality from some of the places where I worked where clinicians were blamed for pts not recovering "according to protocol". What they never read was the literature that claims that the most important factor for the pt's recovery is the patient themselves and the diagnosis. There are no panaceas in mental health and people are better helped by different approaches, people, etc.

When I was doing case management at a residential setting, some insurance companies required me to do an insurance review every 2-3 days. They would ask me "Ok, so what changed for the patient in the last couple of days and what was the treatment plan?". What can one say to this? How can one answers this question? Some insurance companies become persecutory, or hire other companies to do this work for them, and if they can save one day of treatment that is a whole victory for them, they are being "efficient". But efficient at saving money, for sure.

Perhaps because I came from a foreign country which has a national health system, but that has its own set of problems too. No, I do not want a fight. I'll work in the field until I am not obliged to give an app to my patients or follow a manual page-by-page. At that day I will stop enjoying this work and maybe I'll become a truck driver.

 

[Sanman]

Yes, well, I am not sure if I want a fight. But it does concern me how managed care, increasing institutional regulations, and the for profit/cost reduction mentality is becoming more and more dominating in the field of mental health. But what concerns me is that some clinicians, especially the new ones, might buy all this for profit agenda disguised as science under the name "evidence based" when there is a lot of research that claims e.g. that long term psychotherapy has better outcomes for some people (and diagnoses) than short term psychotherapy, that the evidence for manualized treatments is not as strong as some people advertise it to be, etc etc. And the funny thing is I see them getting frustrated and blaming themselves when standartized "one size fits all" treatments do not work, because "Well, if it is evidnece based and it is not working, I must be doing something wrong". This was definitely the mentality from some of the places where I worked where clinicians were blamed for pts not recovering "according to protocol". What they never read was the literature that claims that the most important factor for the pt's recovery is the patient themselves and the diagnosis. There are no panaceas in mental health and people are better helped by different approaches, people, etc.

When I was doing case management at a residential setting, some insurance companies required me to do an insurance review every 2-3 days. They would ask me "Ok, so what changed for the patient in the last couple of days and what was the treatment plan?". What can one say to this? How can one answers this question? Some insurance companies become persecutory, or hire other companies to do this work for them, and if they can save one day of treatment that is a whole victory for them, they are being "efficient". But efficient at saving money, for sure.

Perhaps because I came from a foreign country which has a national health system, but that has its own set of problems too. No, I do not want a fight. I'll work in the field until I am not obliged to give an app to my patients or follow a manual page-by-page. At that day I will stop enjoying this work and maybe I'll become a truck driver.

Not trying to start a fight. Simply questioning the role of health insurance. Many people in this country managed care to be synonymous with healthcare. It is not. Why become a truck driver? Just charge cash and practice how you want. If the practice model has legs, the people will come. If not, perhaps the issue is with the client interest (or lack thereof) more than anything else.

 

[WisNeuro]

Yes, well, I am not sure if I want a fight. But it does concern me how managed care, increasing institutional regulations, and the for profit/cost reduction mentality is becoming more and more dominating in the field of mental health. But what concerns me is that some clinicians, especially the new ones, might buy all this for profit agenda disguised as science under the name "evidence based" when there is a lot of research that claims e.g. that long term psychotherapy has better outcomes for some people (and diagnoses) than short term psychotherapy, that the evidence for manualized treatments is not as strong as some people advertise it to be, etc etc. And the funny thing is I see them getting frustrated and blaming themselves when standartized "one size fits all" treatments do not work, because "Well, if it is evidnece based and it is not working, I must be doing something wrong". This was definitely the mentality from some of the places where I worked where clinicians were blamed for pts not recovering "according to protocol". What they never read was the literature that claims that the most important factor for the pt's recovery is the patient themselves and the diagnosis. There are no panaceas in mental health and people are better helped by different approaches, people, etc.

When I was doing case management at a residential setting, some insurance companies required me to do an insurance review every 2-3 days. They would ask me "Ok, so what changed for the patient in the last couple of days and what was the treatment plan?". What can one say to this? How can one answers this question? Some insurance companies become persecutory, or hire other companies to do this work for them, and if they can save one day of treatment that is a whole victory for them, they are being "efficient". But efficient at saving money, for sure.

Perhaps because I came from a foreign country which has a national health system, but that has its own set of problems too. No, I do not want a fight. I'll work in the field until I am not obliged to give an app to my patients or follow a manual page-by-page. At that day I will stop enjoying this work and maybe I'll become a truck driver.

I am trained in many specific treatments within the frameworks of CBT and psychodynamic (e.g., PE/CPT, IPT, FAP, etc). I am not aware of the any of manualized treatments actually taking a "one size fits all" approach. It merely provides a scaffolding from which to work with, utilizing the patient's clinical presentation and context, to provide a tailored treatment plan. Anyone merely following a manual was simply poorly trained. You still need to be well trained in therapy in a broader sense to properly use a manualized treatment.

 

[texanpsychdoc]

Second this--I would say that PDs outside of BPD would be the biggest diagnostic categories where we lack solid EBTs in a lot of cases. I also might include anorexia nervosa in adults--family-based treatment works well in children/adolescents/some young adults, but we don't have anything with comparable long-term remission and return-to-functioning rates in adults.

CBT can teach a psychopath how to be a better one

 

[smalltownpsych]

I can see that my red pill analogy created a lot of thoughts here. Well, at least I've learned what an incel is

Hehe. The only thing I knew about the red pill thing was from the Matrix and it being a meme for seeing the reality behind the matrix. Guess that makes sense why internet conspiracies would reference it. The incel dynamic is kind of scary and my thoughts on that is that if these guys spent less time online reinforcing their negative and maladaptive beliefs with each other and went out into the real world then maybe they could actually find a sex partner.

 

[smalltownpsych]

I am trained in many specific treatments within the frameworks of CBT and psychodynamic (e.g., PE/CPT, IPT, FAP, etc). I am not aware of the any of manualized treatments actually taking a "one size fits all" approach. It merely provides a scaffolding from which to work with, utilizing the patient's clinical presentation and context, to provide a tailored treatment plan. Anyone merely following a manual was simply poorly trained. You still need to be well trained in therapy in a broader sense to properly use a manualized treatment.

The problem is more about how insurers and governmental agencies are using the one size fits all approach to create a “standard of care“ that is not the same as what we would do for our clients. At least with pharmaceuticals there are at least two powerful interests battling over the money. Some days I feel like Don Quixote. In other words, my revenue was only slightly up last month and my net was lower and then I start wondering if I should get on a panel. I don’t think I will, but I need the phones to start ringing again.

 

[hum1]

Hehe. The only thing I knew about the red pill thing was from the Matrix and it being a meme for seeing the reality behind the matrix. Guess that makes sense why internet conspiracies would reference it. The incel dynamic is kind of scary and my thoughts on that is that if these guys spent less time online reinforcing their negative and maladaptive beliefs with each other and went out into the real world then maybe they could actually find a sex partner.

Yes, I am kind of old fashioned and have been missing on the current cultural associations... perhaps to my luck. I use it in the way how e.g. Plato used the cave allegory, Kant's distinction between the phenomena and the noumena, Nietzsche's genealogical method, critical theory's concept of ideology, etc. I guess I'll me a bit more careful when using it now

 

[hum1]

The problem is more about how insurers and governmental agencies are using the one size fits all approach to create a “standard of care“ that is not the same as what we would do for our clients. At least with pharmaceuticals there are at least two powerful interests battling over the money. Some days I feel like Don Quixote. In other words, my revenue was only slightly up last month and my net was lower and then I start wondering if I should get on a panel. I don’t think I will, but I need the phones to start ringing again.

The focus shifted from people to diagnoses. As if someone has a certain diagnosis like one catches a flu. As if the diagnosis is not an attempt of self cure and a now failed solution to some other problem. But what happens when we try to remove someone's symptoms? They resist it or they become worse, become more in touch with trauma, unbearable emotions, develop self-harm, etc. This is what puzzles clinicians who are fully accepting of the medical model, why would a pt resist cure and be so attached to their symptoms and not wanting to change? Because that is not where the problem is. Of course not all symptoms are deep issues, some are learned phobias, temporary crisis, etc. That is why case formulation is one of the most important steps in treatment.