The Therapy Beat

Psychotherapy and the Affordable Care Act

Ecstasy in the Consulting Room

Tori Rodriguez and Kathleen Smith
Magazine Issue
January/February 2014

Throughout the fall, news about the landmark Affordable Care Act (ACA), designed to extend healthcare coverage to millions of the country’s currently uninsured, has been overshadowed by the egregious technical glitches that plagued its website after its launch. But now that the worst computer issues have been addressed, more attention has begun to turn to ACA’s impact on the delivery of healthcare, including the mental health services that payers must cover under the act. ACA’s expansion of the benefits of the Mental Health Parity and Addictions Equity Act of 2008 means that millions more people will receive mental health benefits, with the mandate that they must be reimbursed at the same level as coverage for physical illnesses. At first glance, that huge growth in the potential insured client pool would appear to be a boon for therapists in private practice, but ACA’s practical impact may not be as favorable as many clinicians expect.

In the interest of efficiency, increased oversight, and cost control, ACA will effect fundamental changes in the ways that healthcare is monitored and delivered. According to Katherine Nordal, American Psychological Association’s (APA) executive director for professional practice, ACA will move insurance companies away from fee-for-service models (paying one provider for one session) toward a global payment model, in which mental health services are “bundled” with fees for other healthcare services relevant to the patient’s condition. To decrease healthcare spending, the ACA emphasizes an increased focus on three areas: accountability for patient outcomes, with more responsibility placed on the provider to demonstrate effectiveness; greater reliance on outcome measures in evaluating treatment, such as patient satisfaction and symptom reduction; and value-based care models, designed to reduce the cost growth of healthcare. The increased demand for demonstrating positive outcomes will require more collaboration and technical infrastructure, including the increasing use of sophisticated (and expensive) electronic medical records systems.

Many believe that the result will be a trend in which insurance companies contract with large medical systems to form accountable care organizations (ACOs) that will provide all healthcare services (medical, mental health, pharmacy, and lab services) for all a plan’s members in certain geographic areas. ACOs offer providers financial incentives for positive patient outcomes, and they’ll probably embrace the model of a patient-centered medical home, in which all care is funneled through a patient’s primary care physician. Therapists will need to be on staff to provide mental health triage and treatment in these collaborative settings, but they’ll enjoy far less of the autonomy embodied in the current private practice model. Clinicians working in these more collaborative and medicalized settings will need a different kind of training to enable them to see more patients in shorter sessions and adapt to increased interaction with physicians and other healthcare providers. With more centralized and coordinated oversight of treatment decisions, the emphasis on providers using evidence-based treatment approaches will likely continue to accelerate.

Some observers believe that these changes in the healthcare system will transform the landscape of private practice in the years to come. According to Nick Cummings, a former president of the APA noted for his prescience in anticipating the advent of managed care and other practice trends, “It won’t happen right away, but private practice will essentially be a thing of the past, as 95 percent of practitioners will be on salary, either working in government-sponsored systems or large healthcare companies.” He says the remaining private practitioners will probably be based within concierge plans, which are typically expensive and accessible only to high-income patients. He believes that because of the glut of psychotherapists—about 700,000 therapists in the United States alone, twice as many as needed, he says—the prospects for therapists’ incomes aren’t bright.

In addition, psychotherapy will likely continue to take a back seat to psychiatry from the perspective of payers. “Under the ACA, mental health services will continue to be mostly psychotropic-prescribing psychiatry,” Cummings says. “Most psychotherapy that is referred will be secondary to medication—which is unfortunate because, in most cases, psychotherapy is less effective when used secondary to meds.” He says another unfortunate effect of ACA will be that “the psychotherapy that is done will be the vapid, less effective, cognitive-behavioral therapy, while active, deep, and incisive therapy that incorporates psychodynamics will all but disappear.”

Not everyone agrees with Cum­mings’s grim prognosis. According to Nordal, “the settings and ways in which treatment is delivered are certainly evolving, but I don’t think private practitioners are doomed; however, they’ll need to get smarter about how they do business.” She maintains that those who survive will need more marketing savvy than ever before to demonstrate their value and skill sets. There will still be a need for specialists, so within the healthcare system, therapists who have niche practices—like those with expertise in treating children and adolescents—will have a significant advantage. But insurers will be looking for more proof, such as certifications and records of continuing education, that therapists have the expertise they claim, especially if it involves evidence-based treatments like prolonged exposure therapy for post-traumatic stress disorder.

“I do think the future is limited for ‘plain vanilla’ private practitioners who only treat ‘generic’ problems like depression and anxiety,” Nordal says. “Especially where the economy is weak and there are lots of other therapists, these clinicians will face economic challenges before others do.” She recommends that practitioners consider joining forces—since group practice models will probably be a preferred model—to form integrative mental health practices with soup-to-nuts treatment offerings, like psychotherapy, medication management, and behavioral training.

This model offers the benefit of reduced overhead and ease of collaboration, and insurers have data proving that those in group practices tend to show better outcomes more quickly (and insurers like the simplicity of having to deal with only one tax ID number). Nordal points toward another emerging model: the independent provider association, in which several different providers or groups of providers join together to negotiate collectively as a group but maintain their individual practices.

“I don’t think the ACA is a death knell for private practices, except for those who won’t be innovative or find someone to do it with them,” says Nordal. “We can’t just want to sit and wait for people to come in—but when has that ever worked anyway? We need to redouble our efforts to achieve what our goal has always been: to get and keep clients.”

— Tori Rodriguez

Ecstasy in the Consulting Room

At a time when public attitudes toward the medical use of marijuana are rapidly changing, it’s probably not surprising that the therapeutic use of MDMA—better known by its street name, ecstasy—is receiving renewed attention. But rather than recalling Harvard psychologists Timothy Leary and Richard Alpert’s Psilocybin Project in the 1960s, today’s investigators are undertaking government-sanctioned research using the traditional methods of systematic observation and careful measurement. Leading the way is the Multidisciplinary Association for Psychedelic Studies (MAPS), an independent nonprofit that’s raised millions of dollars to fund research on the use of MDMA to treat war veterans and other trauma survivors.

In 2008, after years of waiting on approval from the Food and Drug Administration (FDA) and the Drug Enforcement Administration, psychiatrist Michael Mithoefer and his wife Annie, a nurse, completed their first randomly controlled pilot study, funded by MAPS, on the therapeutic efficacy of MDMA. Published in the Journal of Psychopharmacology, the research reported that MDMA-enhanced psychotherapy sessions with trauma victims resulted in a significant reduction in post-traumatic stress disorder (PTSD) symptoms for more than 80 percent of the participants, compared with only 25 percent in a placebo group. A 2012 follow-up study, published in the same journal, indicated that these positive results held up over an average of three and a half years without any reports of negative effects from taking the drug. The success of this pilot study led the Mithoefers’ team to begin a second study, still underway, involving police officers, firefighters, and veterans from Iraq and Afghanistan. All participants had PTSD and combat or sexual trauma, and all had engaged in psychotherapy or pharmacotherapy treatment that had proven unsuccessful. Former students of Stanislav Grof, a psychiatrist known for his studies on LSD and the psyche, the Mithoefers view MDMA as a catalyst to a more spiritual type of healing. “I saw the benefit of giving people a chance to have this deeper kind of experience in therapy, and that it helped a lot of people with PTSD before it became illegal,” explains Michael Mithoefer.

In the Mithoefer study, participants attended several talk therapy sessions to prepare for the drug-assisted experience. The subsequent three to five MDMA sessions were each eight hours long and held a month apart, with talk therapy sessions sprinkled in between to help participants integrate the experiences. After taking the drug, participants were encouraged to lie down and spend roughly half the time listening to music, wearing eyeshades, and focusing inward. For the rest of each MDMA session, the Mithoefers guided them through revisiting traumatic events.

According to Mithoefer, therapy with a mind-altering substance like ecstasy hits the fast-forward button on the therapeutic alliance, with patients feeling safe enough to reveal the most difficult of secrets or traumatic experiences. He describes MDMA as a mechanism for helping them pull back from the immediacy of their current symptoms, allowing them to hover over the landscape of their lives to gain a more therapeutic perspective. As he puts it, the impact of MDMA is that “it enables people to be neither overaroused nor underaroused, so they can revisit events with emotional connection but with enough equanimity to not be flooded by the emotions.”

Nevertheless, many barriers still exist to MDMA’s wider acceptance in the field of trauma research because of prevailing health concerns and the stigma of psychedelic drug use. “We have to be really careful about what we’re saying when we decide that someone is treatment resistant and therefore has to receive a novel form of treatment,” explains Francine Shapiro, the originator and developer of eye movement desensitization and reprocessing. “For instance, did they really have all the validated forms of therapy, or only one? And we need to be rigorous in evaluation. The Mithoefer study had only 19 people. By the follow-up, even though there were reductions in the PTSD symptoms, half of them were in active psychotherapy, and 12 were taking psychiatric medicines. How are we saying that this is a ‘cure’ if they’re still taking medications or getting psychotherapy?”

Mithoefer, aware of the skepticism about his research, admits, “Attitudes are changing, but the Department of Defense and the Veteran’s Administration are still very cautious about wanting to get involved.” However, research teams in Israel, Canada, and Colorado have been trained by the Mithoefers to repeat the protocol and have been granted approval to test the drug-assisted therapy as part of the MAPS $18.5 million plan to earn FDA approval of MDMA as a prescription medicine by 2021. The organization also funds clinical trials to develop the psychedelics psilocybin and LSD as prescription medications to treat anxiety in cancer patients.

Looking forward, Mithoefer envisions the use of psychedelics with more than just treatment-resistant cases of PTSD, and he’d like to use neuroimaging to explore the neuromechanisms that account for the effects, but he’s convinced that MDMA seems to activate a kind of “inner healing intelligence that takes the treatment where it needs to go.” He believes MDMA is especially useful for helping those unresponsive to other treatments to visualize and move in the direction of healing.

“People have revealing imagery of what the healing process looks like,” he says. “One traumatized woman described herself as feeling lost in the underbrush. ‘I didn’t know where I needed to go,’ she admitted. After some MDMA sessions, she said, ‘Now I have a map.’”

—Kathleen Smith