Managed care will increasingly shape the practice of psychotherapy. Some managed care systems may result in the wholesale denial of effective psychotherapy to large groups of people, based on psychiatric diagnosis. One group of people at high risk for exclusion from psychotherapy are patients with schizophrenia. Psychotherapists must take steps to ensure the survival of psychotherapy as an available treatment modality for schizophrenia. These steps include:
1. Developing an understanding of the impact of managed care systems of treatment for schizophrenia.
2. Promoting effective psychotherapy for schizophrenia.
3. Working through professional organizations to ensure that patients with schizophrenia will have access to psychotherapy in managed care systems.
This paper will review the ways that managed care systems can potentially curtail the practice of psychotherapy with patients with schizophrenia. It will discuss effective psychotherapeutic techniques for treating schizophrenia that work well in managed care settings. Finally, it will outline steps that organizations can take to safe guard the availability of psychotherapy for treatment of schizophrenia.
Effects of Managed Care on Psychotherapy for Schizophrenia:
Overview:
Managed care is a nebulous term, but usually implies clinical practice in a framework that includes some of the following features:
Benefit packages, with limitations on availability of health services.
Defined practitioner networks which limit the care available.
Gate keeping, which restricts access of patients to specific services.
Treatment guidelines, which define acceptable services for given health care problems.
Utilization review, with third-party participation and attempts at quality assurance.
We will examine how each of these features affects the practice of psychotherapy for schizophrenia within managed care settings.
BENEFIT PACKAGES
Benefit packages may specifically include or exclude treatments for certain illnesses. Psychiatric illnesses, especially chronic psychiatric illnesses are often excluded. Schizophrenia, especially after the resolution of positive symptoms, is often defined in benefit packages as a chronic condition in which treatment is a kind of "rehabilitation service" which is not reimbursable.
Benefit packages may also specifically include or exclude certain treatment modalities. Psychotherapy, especially long term psychotherapy and psychotherapy with high treatment intensity, in the psychiatric treatment modality most often excluded or restricted. Since psychotherapy for schizophrenia often entails a substantial commitment of time and therapist availability, it often lies outside of benefit packages. Benefit packages may specifically limit the amount of funding available for treatment of all health problems, or for specific health problems. Since the course of schizophrenia often spans many years, benefits may be exhausted while treatment is still necessary. When there are spending caps on specific illnesses, these usually include psychiatric illnesses.
NETWORKS
Characteristics Of Managed Care Networks:
Managed care settings often rely on a specific group of health care providers to deliver services, and may restrict the ability to make the best possible therapist-patient match. Network providers may be selected on a number of criteria, which often include:
a specific geographic provider density
provider acceptance of specific compensation for services
provider acceptance of capitation payments
provider practice pattern
Specific Geographic Provider Density:
Networks are often designed to create a specific geographic provider density. Optimal density ensures adequate patient volume for network providers and adequate provider access for patients using the network. Patients with schizophrenia may be among the least mobile of patients needing psychiatric services, since they are often unable to drive or navigate the city with public transportation. Thus, a provider density that is acceptable for many patients is not practical for those with schizophrenia.
Provider Credential Criteria:
Network providers must meet specific credential criteria, including type of training, licensing and practice experience. The type of training and other qualifications necessary to provide psychotherapy to patients with schizophrenia is still poorly understood, and may get short shrifted. As a result, networks may not include psychotherapy providers with the competence to treat schizophrenia.
Provider Acceptance Of Capitation Payments:
Network provider must sometimes accept capitation payments, in which they receive a fixed sum of money in return for accepting all future costs of treatment for a defined group. Thus, providers are placed at financial risk when agreeing to treat patient populations. The presence of ‘at risk’ arrangements with providers introduces financial disincentives for complete work. Long courses of high intensity treatment, such as providing psychotherapy for schizophrenia, may be avoided in long courses of high intensity treatment are the perceived treatment need.
Provider Practice Pattern:
Managed care systems often carefully scrutinize a provider’s practice pattern before accepting the provider into a network. The practice pattern mush show evidence that the provider uses managed care resources parsimoniously, and that patients do not frequently return after treatment for further care. Providers who do psychotherapy with patients with schizophrenia often must use many resources, and often must deal with periodic re-entrance of their patients into more intensive treatment. Thus, these providers may have more difficulty gaining access to treatment networks.
GATE KEEPING
Gate keeping refers to preliminary screening patients in order to decide which shall have access to specific services, including psychotherapy. Depending on the particular managed care system, gatekeepers may be primary care physicians, nurses or various kinds of mental health professionals. There is a clear incentive for managed care system gatekeepers to direct patients to the least expensive treatment modality which they might consider effective. Since the cost-effectiveness of psychotherapy for schizophrenia is poorly described, the presence of gatekeepers may prevent these patients from receiving psychotherapy.
TREATMENT GUIDELINES
Characteristics Of Treatment Guidelines:
Treatment guidelines are at the core of managed care. Often based on diagnostic classes, they describe what kind of treatment settings, treatment types, and treatment intensities, and provider qualifications are to be used. Treatment guidelines are based on "nationally recognized standards," but are currently hardly standardized, and vary widely in different systems. The basis of treatment guidelines for any given illness is consideration of cost-effectiveness.
Permissible treatment modalities must be generally accepted as efficacious for the particular disorder. Available data must indicate that the modality is the most inexpensive on that will deliver a good outcome. The balance between efficacy and economy can be highly subjective. The creation of treatment guidelines depends on information available in the clinical literature and on the judgment of individual providers and the managed care system.
The Importance Of Treatment Guidelines:
For a particular treatment modality to be included in the treatment guidelines for an illness, the relevant literature must demonstrate that the treatment works better than others, or that it works as well as other treatments and is cheaper.
Treatment guidelines determine who will get psychotherapy. In the past clinical literature has not emphasized the fact that psychotherapy is a cost-effective modality for treating schizophrenia. The emphasis of psycho pharmacological treatment of schizophrenia has marginalized psychotherapy research and practice with this diagnostic group.
UTILIZATION REVIEW
Utilization review is a process by which third parties participate in accessing clinical decisions and outcomes. It may occur before, during, or after treatment. Utilization review has several purposes in managed care settings.
1. It can be used to determine who may get what treatment.
2. It can be used to influence the course of treatment.
3. It can be used to determine whether treatment was reimbursable.
4. It can be used to assess the quality of treatment.
Regardless of the usefulness of utilization review, the intrusion of third-party reviewers may impinge on the intimacy and trust of the therapist-patient relationship. Issues of trust may be especially sensitive in the psychotherapeutic treatment of patients with schizophrenia.
RESPONDING TO THE CHALLENGE WITH AN EFFECTIVE PSYCHOTHERAPY
THE CURRENT ROLE OF PSYCHOTHERAPY FOR TREATMENT OF SCHIZOPHRENIA
It is clear to most of the mental health community and to managed care companies, that traditional forms of psychotherapy have been ineffective in ameliorating schizophrenia (4). No matter how prolonged and intensive the treatment, patients with schizophrenia are often unable to successfully process the interpretations offered through insight-directed psychotherapy.
The unfortunate first response to these findings was abandonment of psychotherapy as a treatment modality for schizophrenia, and substitution of much more effective and much cheaper biological treatments. A major validation for this approach was the 1968 study by Phillip May and associates which suggested that a biological treatment of schizophrenia alone was more effective than psychotherapy or milieu therapy, and that additional benefits of adding psychotherapy to biological therapy were "trivial" (1).
Less than a decade later, May concluded that drugs, psychotherapy and rehabilitation programs should complement each other rather than compete in the treatment of schizophrenia (May et al. 1976) (2). More recent studies by Liberman and Falloon have provided further documentation of the critical role of behaviorally oriented modalities (Liberman 1994). A renewed interest in psychotherapy for schizophrenia along with the development of measures of efficacy are developing in many countries. These newer therapies focus on behavior rather than meaning, and aim to help patients cope better with their living situations. They emphasize family work and social skills training. Measures of efficacy center on social function and quality of life.
New models of psychotherapy have created a framework in which biological and psychosocial approaches to schizophrenia are integrated to improve social competence and coping skills. As Liberman said, "The question is no longer whether or not schizophrenia and related serious mental disorders are treatable, but rather what can be done to accelerate functional recoveries in such individuals" (3).
Even though the importance of psychotherapy for schizophrenia has become evident, treatment guidelines in managed care systems continue to discriminate against those with schizophrenia who require psychotherapy to improve their condition. The limitations of psycho pharmacological treatments in schizophrenia are less dramatic than their extraordinary effectiveness in reducing acute psychosis. Managed care outcome measures for treatment of schizophrenia have emphasized the remission of those symptoms that respond to anti psychotic medications, and minimized those symptoms which require psychotherapeutic interventions.
Utilization review of psychotherapy for schizophrenia remains needlessly intrusive. Patients and their families are sometimes badgered into accepting either unrealistic treatment goals or accepting the managed care companies judgment that the condition is untreatable. Insensitivity is the bane of any clinical process. Specific training and education are essential for reviewers as well as therapists. If utilization reviews are to become more relevant and less destructive, psychotherapists must clearly outline the components of effective treatment for schizophrenia. They must be able to discuss the symptoms of schizophrenia that are being address in therapy, the specific type of psychotherapy being undertaken, and the treatment goals. They must respond to the challenges of managed care by demonstrating that certain psychotherapies are cost-effective and are essential to insuring acceptable quality of care. A few benefits packages now provide limited reimbursement for social rehabilitation, but psychotherapy which centers on the patient’s inner experience and feelings has been increasingly excluded. Will psychotherapy for schizophrenia disappear altogether as a viable treatment option for individuals in managed care systems?
NEW THERAPEUTIC DIRECTIONS
The Necessity of Change:
The core of effective psychotherapy involved change. Patients which schizophrenia require a therapeutic modality which will enable them to behave differently and help them change their behavior in an acceptable way. When psychotherapy does not produce change, there can be no clear treatment goals. Such psychotherapy then has little applicability to managed care.
Direct Treatment:
There are more recent psychotherapeutic directions for treating schizophrenia that are consistent with the concerns of managed care, shorter treatment, better outcome, and improved quality of life. Using direct and more active treatment methods can be effective in reducing symptoms rapidly and shortening treatment time for both the acute and long term schizophrenic patient.
Adapt Technique:
Adaptability of technique to individual patients in critical. There is a growing body of empirical evidence consistent with the hypothesis that the therapist’s ability to disconfirm the patient’s dysfunctional beliefs about interpersonal relationships through the therapeutic relationship is an important mechanism of change (6). Psychotherapy has little chance of succeeding without this collaborative effort. Resistance to change is always a part of treatment, but we need to view ourselves as changing with the patient and adapting our treatment to fit the patient’s changing needs. The psychotherapist must be willing to be different. The "veteran" (7) schizophrenic always looks at the psychotherapist’s behavior to see if he or she is different from their previous psychotherapists. After all, treatment has failed in the past so why take a chance now?
Focus on Goals:
Another essential direction for psychotherapy with schizophrenia is to focus treatment on realistic and achievable goals. We cannot continue treatment that leads to a steady widening of and diffusion of content. This creates a growing sense of ambiguity in the minds of both the patient and the therapist (and managed care reviewer) and tends to prolong treatment unnecessarily and unproductively. The awareness and pursuit of specific psychotherapeutic goals via specific treatment methods can shorten treatment time and provide meaningful and measurable outcomes. Important goals might include social responsiveness, a sense of worth, and improved impulse control.
SPECIFIC TREATMENT METHODS FOR EFFECTIVE PSYCHOTHERAPY IN SCHIZOPHRENIA
Fostering Awareness of the therapist’s presence:
Making the patient aware of the therapist’s presence forces a contradiction to the narcissistic component of schizophrenia, which is essential if the patient is to change in response to input from the external world. Simple and realistic steps are vital in order to make this a therapeutic reality. These steps include a consistent active intervention that permits the patient to become aware of his or her efforts to perpetuate schizophrenic symptoms that have become a life style and survival system.
Making rapid contact that leads to a therapeutic alliance is the beginning of a shorter treatment process. Establishing and maintaining a good therapeutic alliance can play a critical role in helping people change. The alliance has been conceptualized as a prerequisite for change in all forms of therapy.(8)
Forming an empathic connection:
If a therapist is to make a useful contact with the patient, he or she must form an empathic connection. We must go beyond diagnosis and symptoms, and try to understand the logic and language of each individual with schizophrenia. Enormous angst lies within the world of schizophrenia. It is not only the fear of annihilation that is so very terrifying and haunts these human beings, but also the fear of being "nothing." The condition we call schizophrenia becomes a something to that person, it is, in fact, an identity. Encouraging a patient to lost that identity requires tremendous empathy and sensitivity.
Focusing on strengths:
Harry Stack Sullivan observed that "no one is utterly schizophrenic." Focusing on the healthy parts of the patient rather than fixing on a toying with conflicts and pathology is a vital part of the psychotherapeutic effort. Making pathology the focus of treatment may serve to perpetuate it. Focusing on abilities and strengths of character help to build new competencies and effectiveness.
Creating a sense of responsibility:
We need to help our patients assume a sense of responsibility and help them gain the understanding that they are capable to making choices regarding their lives, including their treatment direction. As they gain a sense of respect from us a sense of margin of safety in the world around them, impulse control improves.
Avoiding "uncovering therapy" and severe anxiety:
Uncovering treatment methods (bringing unconscious conflict into awareness) are a part of the insight oriented traditional psychotherapies. The rationale for these techniques is that change comes about only through insight. We have stated that many of the long term schizophrenic patients cannot process interpretations and further that uncovering methods of psychotherapy can exacerbate the patient’s condition. We believe that change can lead to insight and that change, in our opinion is the goal of any psychotherapy, not insight.
Avoiding transference interpretations:
With the long term schizophrenic transference issues do not need to be addressed except when the negative aspects of the transference turns into a delusional transference, which can destroy the treatment alliance. It must be challenged so that the patient is able to distinguish between the unreality of the transference and the reality of the alliance.
Promoting self-worth:
One of our most important treatment goals is to prepare patients to live in the least restrictive environment with a sense of independence, dignity and self respect. This goal is achievable only if we promote a sense of self-worth in our patients. A sense of self-worth is created when we continuously adapt our techniques to meet the needs of the patient. The attitude of the psychotherapist, his or her willingness to join the patient in their world with an empathic, hopeful, firm conviction that change can take place does indeed influence the process of change.
Focusing on issues of daily living:
The therapeutic alliance must be based on a joint focus on external realities, not on transference issues. Encouraging patients to face the real issues of daily living results in the development of new skills. Lamb points out the importance of work for patients with schizophrenia (8). Our own attitudes about such issues can help patients establish an understanding of alternative possibilities in life.
Emphasizing interpersonal relationships:
We should encourage the patient to reach out toward other people to assuage their loneliness. Interpersonal relations that have depth and affection create a better and more lasting grip on reality. Difficulties in forming such relationships are a major part of the pathology in schizophrenia, and must therefore be a special focus of treatment.
Regaining a sense of control and self-efficacy:
The schizophrenic patient needs to regain control over his or her life as rapidly as possible. This is an accomplishment that creates a feeling of success and a healthy sense of independence. Psychotherapy must help each patient to find a more practical, logical direction.
RESPONDING TO THE CHALLENGE THROUGH ORGANIZATIONS
Influencing managed care systems requires a coordinated effort. Individual psychotherapists, no matter how committed, cannot greatly influence the managed care policies which harm their patients. For this reason, leading organizations of psychotherapists must assume an advocacy role if those with schizophrenia are to continue to have access to psychotherapy.
INSIST ON RECOGNITION OF PSYCHOTHERAPY
Organizations must insist that managed care guidelines recognize the essential role of appropriate psychotherapy in the overall treatment of schizophrenia, as supported by the clinical literature. Official publications must cite the many landmark studies that have clearly demonstrated that better results come with a combination of medication and psychotherapy than with medication alone. They must present an ongoing challenge to those managed care systems that only selectively attend to clinical research finds.
Organizations must remind managed system designers that cost control is not the only driving force for managed care, there is increasing emphasis on more effective, briefer, and more concise treatment methods. Out of this mandate for better quality treatment are developing many new directions in treatment (9) (10) (11). These newer treatments, while clearly cost-effective, are more complex than management, so managed care systems have been hesitant to recognize them. Recognition should be vigorously encouraged.
ENCOURAGE PSYCHOTHERAPY RESEARCH
Organizations must encourage further research to delineate the specific treatment goals for schizophrenia for which psychotherapy is the most efficacious and cost-effective modality. Psychotherapy research must devise measurable outcome indicators that demonstrate the cost-effective benefits of psychotherapy for schizophrenia. Further studies must be undertaken to clearly determine whether psychotherapy significantly improves the symptoms of schizophrenia that psychopharmacological treatment cannot so effectively alleviate. The literature should review and analyze the importance of establishing realistic and achievable goals using direct and more active treatment methods. It should emphasize those methods that are effective in reducing symptoms rapidly and shortening treatment time for both the acute and long term schizophrenic patient. The role of psychotherapy in helping persons with schizophrenia attain the overriding treatment goal of social acceptability must be even more convincingly documented. The effectiveness of psychotherapy in improving impulse control, an essential feature of any worthwhile treatment, must also be further elaborated.
DEFINE AND ENDORSE USEFUL PSYCHOTHERAPEUTIC INTERVENTIONS
Efforts must be made to reach organizational consensus about the specific types of psychotherapeutic interventions which are helpful in schizophrenia. As this is accomplished, psychotherapy treatment guidelines for schizophrenia might be endorsed and published. A similar process is already underway in many other clinical specialties, in part inspired by the challenges of managed care.
For instance, treatment guidelines might emphasize treatment goals and therapy techniques which have been shown to lead to socially appropriate behavior. They might include rapid contact techniques that lead to a therapeutic alliance and a shorter treatment process. They might specify techniques that lead to such goals as more socially acceptable behavior, improved self-efficacy, more independence, and better interaction with others. They might specifically define effective therapies like direct confrontation, skills training and family psychoeducation. They should include individualization of treatment, preserving a sense of respect and choice, and ensuring a margin of safety. Treatment guidelines might also indicate therapeutic techniques that are contraindicated in schizophrenia.
DEFINE NECESSARY TRAINING
Psychotherapy organizations should take the lead in defining the type of training and other qualifications necessary to effectively treat patients with schizophrenia, and urge that this training become a greater part of teaching curricula.
Numerous studies delineate psychotherapeutic directions that are teachable, that lead to better outcome and quality of life improvement (10). Schools must provide training in these new techniques for all relevant conditions, including schizophrenia.
OPPOSE DISCRIMINATION AGAINST PATIENTS WITH SCHIZOPHRENIA
Organizations must insist that managed care systems do not discriminate against patients with schizophrenia when it comes to the provision of cost-effective treatments. Treatment must be focused to prepare patients to live in the least restrictive environment with a sense of dignity and self respect. We should never let ourselves, our society, or our health care systems overestimate or underestimate the capacities of the patient to do or be involved in productive matters.
SUMMARY
It is our responsibility to ensure that managed care include schizophrenia as an acceptable condition for psychotherapeutic treatment. We have set forth some changes in the psychotherapeutic treatment of schizophrenia which fit into the framework of managed care, and the mandated by the consumer. We think this is a worthwhile beginning which takes into account the need to stem high treatment costs and still retain therapeutic integrity and efficacy. We can no longer afford a complacent attitude to resist this mandate.
REFERENCES
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Psychiatry 33: 474-478, 1976
(2) May, P.R.A. (1968) Tuma, H.H. and Dixon, W.J. (1976). Schizophrenia: a follow up study of results of treatment: I. Design and other problems. Archiver of General Psychiatry 33: 474-478
(3) Liberman, R.P., Editors notes: In Effect Psychiatric Rehabilitation. Jossey Bass, San Francisco, 1993
(4) McGlashan, TH. The Chestnut Lodge follow-up study. I. Follow up methodology and study sample. II. Long term outcome of schizophrenia and the affective disorders. Archives of General Psychiatry, 41: 573-601m 1985
(5) Rosberg, J. Studen, A.A. The Principles of Direct Confrontation: Psychotherapy With the Schizophrenic Patient. Nordisk Psykiatrisk Tiddsskrift 43-491-498, 1989
(6) Weiss, J., Sampson H. and the Mt. Zion Psychoterapy Research Group 1987. The psychoanalytic process: Theory, clinical observation and empirical research. New York: Guildford, 1987
(7) Quoted from Loren Mosher,
(8) Borodin, E., Psychotherapy: theory, research and practice, 16, 252-260, 1979
(9) Lamb, H.R. Individual psychotherapy, in Talbott, J.A. The Cronic Mentally Ill: Treatment, Programs Systems. New York, Human Sciences Press, 1981
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