Getting old has it perks. That is if you are fortunate enough to enjoy reasonably fair health and have been successful enough to save a sufficient amount for retirement.
What will I do now that I am not putting in up to 10, sometimes more, hours a day seeing patients, my friends and colleagues ask. Well, many things including, travel and enjoying life but also writing, teaching and giving back to the profession that has given me so much. How to find a way to give back that fits my personality and style has been an evolutionary process combined with a little serendipity.
Throughout my career whether my I was involved in direct practice, teaching, administration or a combination I was always a bit of an advocate. Among my first jobs was that of advocate for homeless skid row alcoholics. As a student in graduate school I fought for increased financial aid for students in need and as a clinician in private practice I advocated increased third party insurance coverage higher reimbursement and a decrease in managed care red tape and intrusion etc. However there are ways to advocate and ways one should not.
I recall like it was yesterday when I was in my own therapy. I was fortunate to have a job with health coverage that actually had some mental health benefit, a rare thing in those days. Once I went to my therapist with an insurance form and asked if he would please fill it out so I could get some money back. He said, “NO I will not”. “You see he said to get you reimbursement I would have to lie”. “I won’t tell”, I said. “That’s not the point”, he said. “If you know I am capable of lying for you, how will you ever be sure that if circumstances change I would not lie against you ”? “In my professional dealings, I will not deceive for any reason”. I guess that made an impression. I hope I have lived up to that in my own practice. I have aspired to live up to that at least.
However often times when we as advocate for patients we are also a bit self-serving. If we are not outright dishonest or lying to others are we deceiving ourselves? Now there is nothing wrong with self serving efforts as long as a) we are honest about it call it what it is and b) hopefully those efforts benefit at least a few others besides ourselves and perhaps most importantly c) our advocacy efforts do not have unintended negative consequences that might outweigh any of the benefits.
The problem is that many mental health professionals myself included have not always examined our actions in terms of the above criteria. Like General Motor’s execs in the 1950s who maintained that if it was good for General Motors it was good the country some of us entertain the belief that what is good for us must also be good for those we serve as well. Bit is that always so? Increasingly I began to ask questions and try to see things from the consumer’s point of view.
Is it always good for consumers/patients if our usual and customary fees are $100, $200 or more per session? What does usual and customary fee really mean anyway? When we offer a sliding scale fee are we really being charitable? These and other questions led me to write an article on the true meaning of the fee. Is there any other profession that will spend so much time talking about what our fees mean to patients while charging them for talking to us about what our fees mean to them? This along with other fees issues we concern ourselves with prompted me to write “ The Meaning of the Fee: See http://www.youradvocateonline.com/meaning_fee.html
Is it always good for our patients/consumers if third party insurance will reimburse us for our services? I once thought so but now I have second thoughts. If all mental health services has true parity with medical services and were reimbursable from martial counseling to psychoanalysis no matter if the services were provided by providers ranging from psychologists social workers, marital counselors and pastoral counselors etc. what effect would this have on the cost of insurance premiums? Whether we have one government single payer system of an array of payers, in any form of insurance the more claims the more the cost, which must be born by the consumer in the final analysis.
We know as practitioners that if we want insurance to reimburse for treatment it is necessary for us to provide a DMS diagnosis. No diagnosis, no reimbursement. Usually the more severe the diagnosis, the more or longer the insurance will reimburse. But what are the unintended consequences of consumers being diagnosed with a mental illness? We may think the stigma is a thing of the past but can a DSM diagnosis hinder a patient’s ability to obtain life insurance or obtain certain jobs etc. It’s problematic enough when the patient actually meets the criteria for a particular DSM diagnosis. However we know there are times when some of us have either concocted a diagnosis or given a more severe one merely so that an insurance company will pay for our services. Can we honestly say we are only doing this for the patient? Some time ago I wrote, “Don’t Worry, It’s in Code” to reflect my concerns on this matter. See http://www.youradvocateonline.com/its_in_code.html
Confidentiality is very important to all mental health professionals. Our work could not succeed without it. We talk about confidentiality about as much as we talk about the meaning of fees to our patients. Yet, how confidential are we really? Do we really understand what it takes to maintain the confidentiality of patient communications? Do we obtain true informed consent when we discuss our patient with other colleagues?
Do we discuss our patients with other colleagues in open forums such as lunchrooms, elevators or on open e-mail lists on the internet? While there are many threats to confidentiality, in this technological age from government intrusion, managed care etc. I have concluded the most common threat is ourselves, the patient’s therapist. For this reason I wrote a series of articles and conducted a number of interviews with experts on the subject of discussing patient’s online in non-encrypted e-mail lists. See http://www.youradvocateonline.com/confidentiality_intro.html
How important is it for a mental health practitioner to be law-abiding? Can one be a good therapist and disregard some laws altogether or pick and choose which laws to abide by and witch to disregard? It depends many of my colleagues would argue. Some laws are unjust and may be our duty to oppose them. There’s truth in that of course we may have a higher obligation to oppose and even disobey unjust laws as acts of civil disobedience. But as anyone who lived through the civil rights movement knows the whole point of civil disobedience is to oppose and or even break an unjust law publicly. It is by one’s willingness to go public and take the consequences that one can bring attention to unjustness of the law and rightness of your cause.
So it seems to me that it is hardly an act of civil disobedience or even advocacy for our clientele when some of engage in a violation of any number of civil and even criminal laws and claim we are only doing it for the patient benefit. Some time ago a colleague tried to make a case on a professional e-mail list that billing for telephone sessions as if they were in person sessions what the only way to help the client. So it inspired me to write “Do You Think This Orange Jump Suit Makes Me Look Fat”? See http://www.insiderlawethics.com/billing_phone_calls.html .
Managed care has wrought havoc on our profession not doubt. I understand the frustrations and concerns. It probably was a major factor in my decision to retire. However can we let our frustration and anger at managed care abuses cloud our judgment and allow us to engage in questionable activity? Internet discussion groups and e-mail list under the auspice of professional organizations are well aware of anti-trust laws and monitor their lists for any hint of anti trust activity. This is not the case with freestanding e-mail list. While not every day, often enough, one hears from independent practitioners that they should in one way or another agree on minimum fees (price fix) or engage in boycotts of managed care companies whose rates are too low. Even when the potential antitrust dangers of such activity are pointed out some practitioners dismiss such warnings as being alarmist and claim that consequences are almost non-existent.
The unintended consequences of such activity on consumers prompted me to conduct an entire series on therapists and anti-trust. See http://www.youradvocateonline.com/anti_trust_intro.html
Recently a respected colleague, Dr. Ofer Zur write an interesting piece on his website called the Google Factor. See http://www.zurinstitute.com/onlinedisclosure.html . In essence he cautions us that given the technology today, our patients can Google us and get access to just about everything we ever produced online. That includes some of our sagest comments but also some of out dumbest we might have made on what we thought were confidential e-mail lists.
One of my most recent projects is to take a closer look at how professional mental health therapists respect the intellectual property of others. On just about any discussion group or e-mail lists on any given day copies and pastes of full articles from news sources, magazines and journals without ever once asking for permission from the author and publisher can be found. Most often these are copyrighted articles and failure to seek permission to reproduce constitutes a copyright violation. However it is so prevalent on the Internet that the chances of any one of us getting caught or in trouble are negligible or so it appears. But I wonder what our patients would think if they knew we rarely bother to get the informed consent of the rightful owners. If we think so little of intellectual property of others how can they trust us their most private secrets, their “emotional property”?
What concerns me about many of the above issues is not that occasionally a mental practitioner has been driven to such irrational behavior by the pressures of the job. There but for fortune can go any of us. Many of work in a atmosphere of isolation and have a desperate need to communicate with peers. Often we act like teenagers on MySpace. However what concerns me not that this occurs but when unprofessional conduct occurs how few professionals seem willing to come forward to call such behavior what it actually is. When you come down to it Insurance fraud is insurance fraud no matter the good intentions; A breach of confidentiality is a problem even if the patients never finds out about it; Anti trust behavior is what it is whether or not the FTC or Department of Justice chooses to go after you or not; And an intellectual property violation is dishonest even if the rightful copyright owner does not seem to care or choose to do anything about it.
As I think about my old therapists words of wisdom I ask, if our patients learn that we are capable of dishonesty in our professional dealings in any form, how will they ever be sure that if it becomes convenient we will turn that dishonesty on them?
John A. Riolo, PhD is a retired private practioner who maintains websites for consumers and proferssional practioners. He is part of a larger network of consumers and consumer-centric therapists called Psychjourney.
http://www.insiderlawethics.com/
http://www.youradvocateonline.com/
http://www.psychinsider.com/
