We have the opportunity now to present our vision, to argue for the holistic integration of medical and psychological services in a way that is true to the core principles of psychotherapy. We must resist the inevitable attempts to define therapy as, in essence, a treatment that gets dispensed by a professional to a patient and argue instead for therapy as a process of change that is entered into by client and therapist working together as allies. And it is critical to do so now, when psychotherapy is on the brink of another tectonic shift that could well discredit the majority of approaches therapists use today.
Carving In, Carving Out
To understand what lies ahead for the field of psychotherapy, we must first review some basic principles of health care economics. To state the matter in accountants' terms, mental health services have traditionally been "carved out"--handled and paid for separately from general health care costs and considered to be distinct from patients' medical needs. Most of us have grown accustomed to the idea that the point of entry for taking care of our medical needs is different from that of our mental health. Currently, 88 percent of the mental health cases are handled in this way. But experts such as noted psychologist Charles Kiesler--whose critical commentary on the accuracy of psychotherapy research and the expense of inpatient psychiatric care has been a springboard for policy discussions for more than 30 years, and who, in the mid-1980s, predicted that fledgling MCOs would soon dominate the American health care industry--see another sweeping change in the offing. Soon, they say, behavioral care, like most other medical specialties, will be "carved in"--that is, mental health services will be treated as an integral part of medical patient care and administered accordingly, with all the advantages and liabilities that entails. According to Kiesler, the changes to be ushered in by carve-ins will be "as dramatic as the computer revolution."
The reason for this coming change, of course, is the tremendous pressure on health care administrators to reduce spiraling costs, especially those that are racked up by patients who repeatedly seek medical treatment--often expensive specialty consultations--for complaints that are at least partly due to undiagnosed psychological issues. A typical scenario goes like this: A patient visits a physician or emergency room with a physical complaint, say neck pain. Doctors treat his physical symptoms, but don't refer him to a therapist, who might help him tackle the stress contributing to his symptoms. As a result, his neck pain flares regularly and he frequently seeks treatment from doctors. This pattern may repeat for years unless and until his behavioral problem is identified.
Over the last four decades, studies have repeatedly shown that as many as 60 to 70 percent of physician visits actually stem from psychological distress that finds somatic expression. Advocates of carving in behavioral care say it will not only save money, but will bring real advantages to therapists and patients alike. Imagine that before even meeting a client you could open a computer file and learn that her doctor put her on Prozac some years ago when her mother died of congestive heart failure. Curious about the mother's mental health history, you could click on the link to "familial predisposition" and find that the mother, too, had been treated for chronic depression. If such information were available to you in advance, argue advocates for carving in care, you'd obviously be better prepared to meet this person, and you'd have a deeper understanding of her situation.