Therapy on the information highway a strange fiction based on a stranger reality. Article first published in the September/October 1994 issue.
TODAY, IN THE YEAR 1999, IT IS HARD TO BELIEVE THAT MENTAL health providers (who used to be called “therapists”) once held sacrosanct the belief that a face-to-face relationship between clinician and client was the sine qua non in the delivery of behavioral health care (which used to be called “therapy”). It is even harder to believe that clients once had the burden of choosing their own clinician and that professional ethics cast an obfuscating shroud of privacy over the encounter between client and provider.
Even as recently as 1994, when the computerized data bases and communications systems that made these practices obsolete were already in place, some members of the old-line therapeutic guilds were still fighting a rear-guard action against the march of accountability. Nonetheless, as we know now, the forces of history (not to mention standardized outcome measurements, automated client data bases, cost-benefit ratios, preferred provider profiles and paperless claim-processing systems) have transformed the practice of mental health care.
To show how far we have come, here is a typical day in the life of a modern mental health care practitioner as she skillfully and efficiently guides her clients through the shoals of human misery and confusion without once having to resort to time- and energy-wasting procedures like appointments and direct, personal interviews.
THROUGH EYES BLURRED BY TEARS, the young woman strains to read the 800 number on her new health benefit card. She punches in the number, and after a few rings a cheerful, yet professional, voice answers, “EAP, this is Jenny, may I help you?”
“I… I… I’m calling to get some help,” is the halting reply.
“I’m glad you called,” the phone counselor says supportively. “May I have your Social Security number?”
“Well, my company’s just started with your plan, so I’m not sure you’ll have it,” says the caller, choking off tears.
The caller can hear the clicking of computer keys and, after a brief pause, Jenny replies, “That’s okay, I think I have it anyway. Is this Mary K. Smith, of Maple Street in Omaha?”
“Yes,” she responds with a mixture of surprise and relief. “How did you know that?”
“I show you are fully registered in the SkyNet Managed Care plan. The computer uses Caller I.D. to automatically confirm your eligibility. That saves a lot of time so we can focus on your concerns. How can I help you?”
Mary begins to sob and pleads, “I can’t take the pain anymore. I feel like I want to die!”
Another few clicks on the keyboard and Jenny replies, “Mary, I’m with you, and I’m not leaving. Did something just happen to upset you?”
Talking above the muted clicking, Mary asks, “Are you a counselor, or will I have to talk with someone else?”
“I’m a fully trained and licensed mental-health care specialist. I can help you. Tell me what’s going on,” offers Jenny empathically, speaking softly into her headpiece. Her fingers race across the keyboard, while her computer screen flashes data in layered windows.
“He left me again, just like before, but I know this time he isn’t coming back,” cries Mary.
“You mean John, your husband?” queries Jenny.
The shock of hearing his name from this stranger hits her like a slap. “How do you know about John?”
“I’m sorry to surprise you. He’s listed on your benefits schedule, along with your children,” offers Jenny. “You say he’s left you and you’re feeling alone?”
“Yes, and I just want to die. I can’t go through this pain again. I just don’t know how I’ll cope,” says Mary, choking back her tears.
“You seem completely overwhelmed, but you’re definitely a woman of strength, a survivor,” says Jenny warmly. “You’ve made it through this before. You just need a little help. Maybe you can see Dr. Jones again, he’s on the panel and has great outcome stats.”
“Yes, Dr. Jones would be … How do you know about Dr. Jones? And how do you know I’ve been through this before?” Mary asks in total perplexity. “I just signed up with your company last month.”
“Mary, SkyNet Managed Care is dedicated to providing integrated health care. We like to go that extra step to meet the needs of our clients. I’m just reviewing your treatment history in the health claims data base so I can help you get the care you need. I notice that John has left you twice in three years. You were treated successfully both times with Prozac and the help of some popular self-help books. Do you still have the books?”
“Yes, but John wouldn’t read them. He never lifts a finger to help. He always says it’s me.”
“Well, he does seem to come back when you’re on Prozac,” offers Jenny hopefully, her keyboard clicking. “According to my survey of clinical practice standards and outcomes, 50 percent of distressed marriages improve when one spouse takes Prozac or a similar medication. I think it’s pretty clear how successful it’s been with you. I can authorize three sessions. Should I call Dr. Jones’s office to set up an appointment?”
“Wait, can’t we go to couples’ counseling? Isn’t he part of the problem too?” Mary cries.
“I’m sure we can talk about that after the initial crisis is over, but first things first,” says Jenny, with a hint of firmness. “Besides, you had similar episodes before you even met John. Loss has been a recurrent theme for you. The death of your father, your abortion, that child abuse investigation. These are tough issues around loss and abandonment. Tough problems need a tough solution.”
“How do you know all this stuff,” cries Mary, in a small, quiet voice.
“We only want to help you, Mary,” says Jenny, echoing the flashing words on her monitor. “We have a computer network connected to resources, therapists, insurance companies and professional associations. When you signed on to this service, you bought the most integrated treatment program available. We can tell you which therapists are the best, what treatment is right for you, and how long it will take to get better. SkyNet links all of these resources for you, Mary.”
“I just want the pain to stop,” says Mary, clearly awed by the power of SkyNet. “Please make it better.”
“Mary, we’ll do all we can to help you out, but you must do your part. A treatment is only as good as your compliance.” Jenny always likes that answer, number 23 on the client-resistance screen.
“But how can I get to treatment?” Mary laments. “I have no time.”
“Maybe we can get your supervisor, Jim, to help flex your schedule to make some appointments, like he did before,” Jenny suggests, casually crosslinking employment data from the host company.
“Yeah, he did help out before,” Mary realizes. “Maybe this really is what I need. You know, I feel as if you know me so well. It makes me feel, well, important. Thank you for being there.”
“It’s our pleasure, Mary. We’re truly here to help valued members like you. Now, I want to make that doctor’s appointment for you immediately, and I want you to dig up those books on depression. Next week you can give me a call and we’ll see how things are going.”
Jenny leans back in her ergonomic chair, stretching a little before taking the next call. Her eyes scan the monitor, but there are no calls waiting! At that moment, she hears the voice of Jim, the counselor-in-training in the next cubicle.
“Hey, the call-waiting queue is empty. What gives?” asks Jim.
“The 800 lines must be down,” replies Jenny. “It happens about once a month. AT&T will re-route them in a few minutes and we’ll be back on-line.”
“Will this mess up our keystroke stats? I got reprimanded last week for low keystroke totals. I don’t want to look bad again,” says Jim, with some concern.
“Don’t worry, MOM knows the lines are down,” Jenny offers.
“You know, the Multiaxil Outcome Measurement system. We call her MOM for short. She’s the master computer module we use,” says Jenny.
“I thought outcome measures had to do with therapy,” says Jim.
“Outcome has to do with everything, including us,” replies the seasoned computer therapist.
JENNY, CAN YOU TAKE A CALL FROM a mental-health provider while the member lines are down?” asks Sue from provider relations.
“Sure, let me switch to provider screens “
“Okay, but beware, you may need to play hardball with this guy,” warns Sue “He doesn’t want to let go of the client.
“What does MOM say about his outcome stats,” asks Jenny.
“Not good. New provider, always asks for the max sessions. Tries to get the clients to pay privately. Really builds up dependency in them quickly.”
As the provider screen pops up on her monitor, Jenny greets the doctor with her sunniest voice, “This is Jenny of provider services, may I help you?”
“Yes. I’m Dr. Nick Wilkins in Plant City, Florida. I just evaluated one of your clients and I’m trying to arrange for her treatment.”
“Yes, Ms. Washington passed me the call. I see you’re recommending intensive treatment for an eating disorder,” Jenny offers in summary.
“Yes, this is a rural area and there are almost no therapists who specialize in eating disorders,” Dr. Wilkins explained. “In fact, I’m the only one in town.”
“Yes, Dr. Wilkins, you’re the only one on panel, but there is a Ms. McClane in Lakeland who has an eating disorder group,” noted Jenny.
“But that’s almost two hours away, which would be quite a hardship on the client. Besides, I think she needs some individual work first. I would be willing to see her.”
“Well, Dr. Wilkins, as you are aware, to avoid any conflict of interest, we require that assessment and treatment be separate processes. Since you have done
the assessment, she must be referred to another provider. And since she is under our managed care program, she must see one of our contracting providers. I’ll have to recommend that she join Ms. McClane’s group,” countered Jenny firmly.
“Well, I can’t support that and I think it’s a violation of practice standards to require a patient to travel so far for treatment that I don’t think will be adequate, anyway,” says Dr. Wilkins.
Jenny was ready for this, popping up a row of provider problem screens. “Dr. Wilkins, according to my data, the Florida Health Security Act states that specialists need only be within two hours travel time. Our recommended provider is within that travel time.”
“Why doesn’t this guy get the message?” Jenny wonders privately.
Dr. Wilkins is clearly frustrated. “I will have to go to the insurance commissioner if you don’t provide a better alternative. Or I simply will recommend that she see me privately and complain to her employer about the shoddy care you’re recommending.”
Jenny pops up Dr. Wilkins’s credentials screen. Malpractice, licensing, hospital affiliations. It’s all there. Off-line, Jenny mutters, “If this guy’s gonna throw hard-balls, he better have a big, big mitt!”
“Dr. Wilkins, you are entitled to pursue that option, but I offer a word of caution,” Jenny says in a sobering voice. “Your contract with SkyNet clearly shows your agreement with our policies regarding the separation of assessment and treatment. To see the client yourself would violate that covenant as well as many professional standards. We would consider it a dual relationship that exploits the client and promotes a dependency. We would be duty bound to notify your regulatory board, the Department of Professional Regulation in Florida, and the American Professional Insurance Company regarding potential malpractice. Depending on how adversarial your regulating board is, such a query might be quite troublesome. You also would be required to notify your professional association and any of the other managed care companies you have signed with, since you probably have agreed to alert them in the event of any professional complaints. Additionally, your actions with this client may trigger a retrospective review of your earlier cases with SkyNet. You have already contractually agreed to abide by any retroactive denials with a refund of payments. I would recommend you think very hard about what would be in the best interest of this client.” Jenny had set up the transmittal forms to the respective agencies on her screen and now gently stroked the “send” key, awaiting final word from Dr. Wilkins.
After a lengthy silence, Dr. Wilkins sighed. “I see your point and agree that the outpatient group is worth a try. Please fax me the referral materials and I will help her get in touch with McClane.”
“Thank you, Dr. Wilkins,” says Jenny, a smile of clinical victory on her lips.
THE MEMBER LINE WAS AGAIN acttive, demonstrated by the full call-waiting queue signal on her computer screen. Jenny took the next call. “EAP, this is Jenny, may I help you?”
“I think I need some marriage counseling,” said a husky, gentle voice. “My wife and I, we’re fighting all the time. We can’t get along, always blowing up.”
“Let’s see if we can help you. I need your name and Social Security number,” Jenny queries. Before the caller could respond, MOM already had provided the caller’s identification and confirmed eligibility, but it was sometimes better to let the client retain a sense of control, so she accepted the Social Security number. “Yes, Mr. Schultz of Houston. You are fully registered with SkyNet Managed Care. Tell me, how long have you been having this problem?”
“She’s always been spirited and passionate, but it’s gotten out of hand lately,” he explains.
“Any changes in your life or your wife’s?” Jenny asks, searching the medical record for any clues.
“Well, to be perfectly honest, about two weeks ago she found out about an affair I had. It was brief, it didn’t mean anything; it happened a long time ago. Now my wife’s gone ballistic, screaming all the time, crying, shouting how she hates me. I don’t know what to do.”
“Mr. Schultz, I see from your medical record that you recently received stitches in your hand at an emergency room. Is that when you told your wife, Lucille?”
“Why, yes,” said Mr. Schultz, startled. “She got so angry she picked up a skillet and whacked me. Hit me in the hand, causing me to bleed pretty badly. I had to get 13 stitches.”
“Your medical record says it was a gardening accident,” Jenny replies.
“Well, she felt so terrible about it, and I didn’t see the point in bringing it up to the doctor. As I said, she’s very spirited.”
“Mr. Schultz, this office is located in California. As a licensed mental-health care provider, I am bound by the laws of this state. The State of California requires us to notify the authorities of any incidents of domestic violence. You have indicated this is an unreported violent act. I’ll have to report this to the local authorities in Houston.” Jenny hated this part of her job. The domestic violence screen popped up, she auto-filled the data, did a zip-code search for the nearest law enforcement office, and transmitted the report to Mr. Schultz’s local police precinct.
“But I don’t want that! I don’t want the police! We just need to get back on track. Some counseling sessions. Please don’t report it,” Mr. Schultz pleaded.
“It has already been transmitted Mr. Schultz, but I can help you anyway. Let’s see if we can find a good counselor for you,” said Jenny.
“What do you mean it’s already transmitted? I thought this was a confidential conversation. That’s what the brochure says. How can you just run and tell the police?”
“Mr. Schultz, our talk really is confidential. But there are some limitations, which were outlined in your original benefit agreement. I’ve pulled it up on my screen and I’m looking at your initials next to a list of exceptions in confidentiality. It’s on the Global Release Form you signed with your benefits package. Surely you must have read it.”
“What will happen now?” he asks in a disheartened voice.
“That depends upon the jurisdiction. Social Services or the police may want to talk with you and Lucille. They may require you to attend some domestic violence counseling.”
“I suppose you can give me a referral for that.”
“I sure can, but court-ordered therapy is not covered in your benefits package. It’s almost universally excluded as a mental health benefit,” explained Jenny.
“Wait just a minute here,” says Mr. Schultz in an incredulous voice. “I called up to get marriage counseling. You find out my wife hit me and immediately tell the police. Then you tell me because she hit me, the counseling I want is not a covered benefit. It’s almost to your advantage to get my wife and me in trouble so you don’t have to pay for anything. So why have I been paying you this money in premiums?”
“I understand how confusing this is, these systems are so big. But SkyNet wants to see you get the best care possible. Let’s see what we can do. As you know, there is a reduced benefit for marital counseling. You have 10 sessions with a 50-percent co-pay up to $40 per session. Let’s see if I can get you an appointment with our local contract marital mental-health care provider.”
“You mean I went through all this conversation, I have the police coming to my door, and you only pay 20 bucks toward my counseling?” Mr. Schultz asked, too stunned to be angry. “I went with this policy because I thought it would be cheap and reasonably effective, but it will cost me a bundle and may ruin by life as well. Some bargain.”
JENNY FINALLY LOGS OFF FOR THE day, placing her headset on the monitor, watching the screen blank out. Goodnight MOM, she thinks to herself. She reflects on how different this kind of clinical practice is from what she had imagined in graduate school. She never dreamed that as a mental-health care professional she would be riding a computer all day. At first, she was reluctant and awkward in front of the machine it seemed somehow inhuman and alienating. But now, she feels unprepared without the awesome resources of the computer at her fingertips client profiles, benefit plans, community resources, outcome studies. How could she once have thought that just seeing and talking to a client might be sufficient to get a grasp of what was needed? Now she knows better.
Nobody can hope to match up individual clients to the precisely calibrated services they require without a powerful cybernetic system to integrate the vast number of potential resources linked by the information superhighway. Besides, even if her work isn’t exactly the way she thought it would be in graduate school, she still gets a lot of highly satisfying client contact. Even over the phone, she can sense the clients’ needs, hear their pain, their fear, their anguish. And then, there is the extra thrill of playing detective in their claims histories to find dysfunctional patterns in their lives, to learn more about their job background, their families, their medical histories, even their school records. It’s amazing how much she can know about clients in the first five minutes of conversation, all without ever laying eyes on them.
Michael Freeny, M.S.W., is a clinician and professional educator in Longwood, Florida. He is the author of the book Managed Mental Health Care: Smart Choices for the Independent Provider.