On “Managed Care”

Insurance in the news.
This is from Slate’s Today’s Papers feature. I’ll be examining some of the issues surrounding managed care, how they effect mental health practitioners of all stripes, sometime [in the next weeks].

The Los Angeles Times, USA Today, and the Wall Street Journal‘s world-wide newsbox lead with new census figures that show the number of people without health insurance increased by 2.2 million in 2006 to a grand total of 47 million. In terms of the overall population, 15.8 percent of people lacked insurance, which is the highest level since 1998. At a time when President Bush is in a fight with Congress over health insurance for children, the LAT points out the number of uninsured children grew by 600,000. The LAT also mentions, while USAT goes inside with, economic figures in the census that showed there was a slight increase in median household income and a modest drop in poverty rates in 2006, although pretty much no one (except President Bush and some Republicans) saw this as particularly good news.

Why do so many psychologists not take insurance?
Many psychologists simply don’t take insurance, directly. This has to do with a number of reasons, including reimbursement rates, privacy issues, not to mention devaluation of the profession. How do we serve our patients, then, if we aren’t taking insurance? We’ll look at that.

Kalea Chapman, Psy.D.

Psychology in the Media: Not As Bad-As-Usual

Importance of a “good fit”.
Today the New York Times is running a piece on psychotherapy by a psychiatrist. It’s not as bad as the usual Times articles on this topic. The headline is good, emphasizing the importance of a “good fit” in the relationship between one and one’s therapist. This is critical.

And it speaks to the importance of human relationship, rather than procedures (the medical model) in “treatment” (again, the pesky medical model).

The story’s lead, however, is misleading, perhaps even irresponsible. Here it is:

Americans seem to like psychotherapy. Whether it’s for the mundane conflicts of everyday life or life-threatening illnesses like major depression, psychotherapy is widely viewed as a healthy, if not harmless, pursuit.

Real risks.
While this is presented as “widely viewed”, the part about “harmless” could be misinterpreted as being true. This is far from the case. Endeavoring to undertake psychotherapy can be risky. Like surgery (again, medical model), something powerful enough to do substantial good is a double-edged sword (military model?).

The author is right in asserting that a “no pain, no gain” approach to therapy is misguided. But he fails to address that painful moments in psychotherapy, particularly in long-term therapy, can be a necessary component of facilitating growth. Perhaps this is because the medical model doesn’t really account for growth.

Limitations of the medical model.
The medical model focuses on removing pathology, without regard to underlying causes. In the medical model, it doesn’t matter how you got the illness — lung cancer, bronchitis, arthritis — removing symptoms is the order of the day. This would be less true of illness that has a behavioral component — diabetes, for instance. Still, with physicians being reimbursed by insurance companies, procedures are what get reimbursed. Getting a non-compliant patient to comply is frustrating and time-consuming and common process. It is also non-reimbursable.

Symptoms are not necessarily indicative of progress. This would not hold if one was seeking relief for a phobia, an obsession, or post-traumatic stress. Indeed, persistent deterioration ought to be non-defensively addressed by your therapist. The article rightly states that a therapist resistant to consultation is a therapist to be very skeptical of. In a non-procedural therapy, addressing concerns about effectiveness are the meat and potatoes of treatment. Concerns about competence are a natural and integral part of an honest, trusting relationship. This is bedrock.

Ambiguity in human problems.
Nor does the article adequately address an important aspect of psychotherapy. It frequently involves a lot of uncertainty. It often requires that one suspends judgment. It often requires a willingness to tolerate ambiguity. These are human problems. Increasingly, the medical model does not allow for ambiguity. Either the treatment works or it does not. This makes sense if one has lung cancer, bronchitis, arthritis. If it’s not working, try another treatment. Human problems are not the focus.

Devaluation of primary care.
This was not always the case with the medical model. Primary care physicians — pediatricians, general practitioners — often spent considerable time getting to know their patients. But this is a non-reimbursable activity. This can’t really be emphasize enough, because it reflects the current state of medicine as molded by “managed care”. Getting to know patients is a non-reimbursable activity. The salaries of primary care physicians consistently decline. The salaries of physicians that perform procedures — radiologists, surgeons, podiatrist — consistently increase.

Psychologists as primary care providers.
In this light, one could regard many psychologists as practicing primary care. And it is primary care guided by empirical research (Not incidentally, done by psychologists.). Psychiatrists don’t do a lot of studies on the effectiveness of therapy. Their research tends to be on the effectiveness of pharmaceuticals. Moreover, that research is largely funded by pharmaceutical companies themselves –a standard that would never past muster in psychological research, but that’s another post.

Kalea Chapman, Psy.D.

APA Votes Down Moratorium on Interrogations

A piece in the San Francisco Chronicle confirms that APA overwhelmingly voted down the moratorium on interrogations. This seems like a case of APA falling short, but I’m waiting to hear more about this decision and the debate surrounding it.

Here’s a second, slightly more informative Chronicle article.

And another story, this one at the Washington Post.

In the meantime, for the avid reader, here’s the open letter from psychologists Steven Soldz, Brad Olson, and Steven Reisner (and many co-signers) to APA’s president, Sharon Behm, Ph.D.

Kalea Chapman, Psy.D.

Psychologists and Interrogation

A role in prescription privileges?!
There’s been some press on psychologists’ role in interrogations, for instance, at Salon.com, the New Yorker, Vanity Fair.

On Friday, the ACLU called on the American Psychological Association (APA) to prohibit members from participating in torture. This morning, August 19, there was to be a vote at the APA convention proposing a moratorium on such participation.

In the past, APA has shied away from an out-and-out moratorium, preferring a position asserting there is an ethical place for psychologists in interrogations.

I don’t yet know what happened with the vote.

Here’s a juicy quote from Democracy for Missouri that makes a loose, but thought-provoking connection between prescription privileges (RxP) and psychologists involved in interrogation:

Eban, the author of Rorschach and Awe, an investigation of the relationship between the APA and government interrogators, contends that the presence of psychologists in interrogations allows interrogators to employ more dangerous techniques in the belief that detainees are being safeguarded by the presence of psychologists.

A crucial APA Council vote on a moratorium on the presence of psychologists in interrogations is expected Sunday morning. A second resolution, drafted by the APA Board, which lists prohibited torture techniques, will come up for a vote in the same session.

“The resolution proposed by the APA Board is little more than an affirmation of the APA’s existing opposition to torture. It is designed to prevent a vote on the moratorium,” said a spokesperson for Psychologists for an Ethical APA.

When asked to speculate on the APA’s reluctance to support passage of the moratorium, Brad Olson, Ph.D., chair of Divisions of Social Justice, a collaborative of 13 divisions of the APA, pointed to the APA’s long history of cooperation with the U.S. military, current internal conflicts of interest, and the role of the Dept. of Defense in helping the APA give psychologists prescription privileges.

This is certainly a charged issue, and one to watch.

Kalea Chapman, Psy.D.

Arguing Persuasion

Cialdini on unconscious modes of persuasion.
I mentioned Cialdini in an earlier post, a social psychologist, whose books you can find in the business section. (A recent New York Times article “Who’s Minding the Mind?” covered the surprising range and variety of powerful ways we can be manipulated — without any conscious knowledge of what is going on. In the Yale study, people’s judgment was strongly affected simply by handing them a cup of coffee.) Cialdini writes about the ways in which human beings respond automatically, without thought. Here are the ways he outlines that we can be easily manipulated:

The need to appear consistent:
Once we commit to an idea, particularly in public or in writing, we feel a strong pull to do what we say we will do. Cialdini asserts that this is why grass roots organizations and political parties often want you to sign petitions. (He even states that often they don’t do anything with those signature, throw them away in some cases.) It is the act of commitment and its effects that their after, moreso even than a particular financial commitment or signature for petition. Once the initial commitment is there, people are much more likely to commit further and more substantially.

The power of public commitment:
As mentioned above, consistency can be further leveraged by getting people to publically commit. Once someone has committed to something, he or she will tend to produce further justifications, reasons, rationales to back up the commitment.

The compelling nature of authority directives:
Plain and simple, people like to follow leaders. There are many disturbing examples of this. Cults are one class of example. But also political parties and leaders. In the infamous Milgram Study, people were asked to apply increasingly dangerous electrical shocks to other study participants. Roughly two-third of the participants continued to apply the shocks even when it appeared the person receiving the shocks was moaning in agony. Even if they expressed their dismay to the expert in the labcoat, invariably they would continue to shock the subject if the “expert” pressed them to do so. Cialdini notes that we react to symbols of authority, particularly clothes, cars, and titles, whether they are substantive or not. Hence the labcoat in the Milgram study.

The tendency to use social referencing to guide our own behavior:
Wikipedia has a good example, well known to psychology students:

People will do things that they see other people are doing. For example, in one experiment, one or more accomplices would look up into the sky; bystanders would then look up into the sky to see what they were seeing. At one point this experiment aborted, as so many people were looking up that they stopped traffic

The need to reciprocate:
Reciprocation is integral to our social nature. It is why free samples are effective in marketing. There are a number of techniques that exploit this basic human need. A small gift is followed by a request. A small concession is offered, which instills a need for the other party to offer her own concession. We are not comfortable with feelings of indebtedness.

The response to scarcity:
The sense of scarcity tends to create demand. Cialdini cites a number of toy shortages, the cabbage patch doll, for instance. A common tactic is to promote something during Christmas, have a “shortage”, and then promote it again after Christmas. This also puts parents in the position of needing to appear consistent, as often with level of pre-Christmas promotion they had promised their child the item, only to find it was not available.

The lulling effects of feelings of liking or friendship:
Ever heard of a tupperware party? If the people who are selling are people you like you are more likely to buy. It’s kind of worn out, but sales people will still latch on to your first name and be your buddy — even credit card collectors.

Charged issues, forceful persuasion.
Each of these persuasive techniques is at play, intended or not, in any charged debate where a lot is at stake. Take a look at the arguments, here and here, for prescriptive authority for psychologists (RxP) and see where they apply. I’ll be following up, at the end of August, with my own applications to those arguments.

Kalea Chapman, Psy.D.

Smooth Persuaders: Leveraging Human Nature

This is the fourth entry in a series on the implications of psychologists pursuing prescription privileges. What those implications are exactly, is far from clear — they ought to bear close scrutiny. Others in the series include:

An important rule of thumb.
I started reading Cialdini’s Persuasion: Science and Practice, on a hunch that this might be relevant to prescriptive authority for psychologists (RxP). I was not disappointed. Dr. Cialdini’s writing is persuasive and grounded in a solid background of social psychology research. His focus is the irrational, emotional basis for many human decisions. Since RxP is an emotionally charged issue — for psychologists, for psychiatrists, for an informed public — how we make decisions is exceptionally pertinent.

The rule of thumb, then, is that people, more than ever before, rely on “rules of thumb”, cognitive shortcuts, in order to make judgements. This is an important, uniquely human activity. Human beings are meaning makers. Developmental pscyhologists note that inductive logic, the ability to make generalizations from information, is one of the hallmarks of what is called “formal operations.” Formal operations is reached is reached somewhere around ages 11 to 14. It makes algebra, and other manipulations of abstract principles, possible. (One curious sidenote: Not everyone reaches the formal operations stage.)

We are required to make decisions, daily, based on incomplete information. Why is this more relevant that ever before? Because we are constantly bombarded by more and more information. Given this assault, we rely on experts to delve issues we don’t have the time or inclination in which to become experts. Accountants, tax preparers, financial analysts, medical doctors, journalists, lawyers, psychologists. Cialdini calls this submission to overwhelming amounts of information “modern automaticity”. A typical statement:

Because technology can evolve much faster than we can, our natural capacity to process information is likely to be increasingly inadequate to handle the abundance of change, choice, and the challenge that is characteritic of modern life.

A small group of highly motivated people.
Recent historical events have underscored an old aphorism: One should never underestimate the power of a small group of highly motivated individuals to change the world. Within psychology, there is such a group. Health psychologists work in medical settings. They focus on behaviors that facilitate good medical outcomes. In fact, one such psychologist, presenting at the California Psychological Association, recently opined, “I don’t call what I do psychology, I call it behavioral medicine.” It would probably be overreaching to claim that health psychologists are in the majority of those seeking RxP, but they are certainly a group of highly motivated people.

And an important part of health psychologists do, is focus on compliance. Compliance to medical guidance is particularly critical in some diseases. Consider the role of behavior in: diabetes, heart disease, bipolar disorder. All the medication in the world is of little avail if the patient does not comply — watching blood sugar levels, keeping an eye on cholesterol intake, moderating sleeping habits, taking medications regularly — in many cases, thinking they are “all better”, people simply stop taking their medication. This state of events, a constant source of frustration to medical doctors, does not result in good outcomes.

The devaluation of primary care.
Alas, in our current health care system, medical doctors are not paid to ensure compliance. In fact, the salaries of primary care physicians, (e.g., pediatricians), who traditionally spend more time getting to know the patient as a whole person — are considerably lower than that of physicians who perform procedures. Procedures: surgery, radiology, anesthesiology, etc. Procedures are what pay. Procedures are what get reimbursed. And when faced with a choice to run two different procedures, guess what factor, empirical data demonstrates, has more influence on their choice than any other?

Taking stock of persuasive rhetoric.
So why even mention all this? Because this group of psychologists, health psychologists, are experts in compliance, experts in motivating people to act in their best interests. This is invaluable, honorable work. In essence, without stretching too far, it could be argued that they persuade. Since this is part of their stock-in-trade, it could be reasoned that if they want something bad enough, they might, intentionally or not, employ their persuasive powers. Cialdini has an evocative phrase, which he applies to salespersons, he calls them “compliance professionals”.

Lest some of my colleagues get the wrong impression, I am not suggesting that RxP supporters are intentionally manipulating other psychologists, or the public, in order to achieve their aims. But since even experts are human beings, and the stakes are so high, we need to scrutinize the RxP rhetoric. Since the power of persuasion is so well documented by social psychologists, we would be remiss if, as psychologists, we did not examine the arguments closely. So let’s look at what Cialdini says about the chief methods used by marketers to tap into largely unconscious decision-making processes. Let’s take a fine-toothed comb to the rhetoric.

Motivating decisions at a base level.
Even the New York Times, which seems to excel in presentating slanted, out-of-context, and incomplete information — when it comes to matters psychological, ran a story yesterday on the powerful influence of unconscious rules of thumb, sometimes referred to as heuristics. (Not long ago they were running stories disputing the very existence of unconscious processes, but the current fashions of scientific opinion have changed, and the Times, dutiful, themselves reliant on experts, follows suit.) If you’re really curious, you can read it here. Typically, the Times takes the popular perspective of biological determinism. Noting that the frontal lobes, where rationality, higher decision-making, formal operations are thought to reside, “can be one of the last neural areas to know when a decision is made.”

Applying models of persuasion to RxP rhetoric.
Well, this is already a long post, in the world of blogs. So I’ll concentrate on the strategies employed by ad agencies, marketing firms, political parties, grass roots organizations, in order to manip — shape your opinion, daily. Cialdini focuses on these cognitive stumbling blocks, rules that the human mind appears to be hardwired to follow. Particularly when information is complete.

Here are some of the areas that are very compelling for human beings:

    The need to appear consistent.
    The power of public commitment.
    The compelling nature of authority directives.
    The tendency to use social referencing to guide our own behavior.
    The need to reciprocate.
    The response to scarcity, and finally
    The lulling effects of feelings of liking or friendship

Kalea Chapman, Psy.D.

This is the fourth entry in a series on the implications of psychologists pursuing prescription privileges. Others in the series include: