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People tell me their secrets. As a psychotherapist, I spend my days listening to men and women talk about their failures, their disappointments, their shame. They are often survivors of sexual abuse; some have been literally tortured by a parent or relative. Others have caused great injury to someone they love because of their own pain. All are wounded. Together we try to create a place of safety where frightening emotions can be discussed.
But how can we do that when it is also my job to tell managed-care companies about certain aspects of those discussions? If a client wishes to have his therapy covered after an initial number of sessions, I am required to fill out a form requesting authorization for treatment. I have to answer a list of questions: Does the patient vomit after eating, steal, hallucinate, abuse drugs or alcohol? Does the patient want to kill himself or somebody else? Then I send the document off to the insurance company, where somebody who has never met my client decides if he's eligible to continue treatment. Some of my clients are so uncomfortable with this arrangement they elect not to use their insurance at all.
They have reason to be concerned. Where this most sensitive information ultimately ends up is always uncertain. Horror stories abound. Last year the Los Angeles Times ran a story describing how detailed psychological records of 62 patients were accidentally posted on the Web. That same year, a large drug company mistakenly disclosed the names of 600 psychiatric patients in a mass e-mail, and one of the country's biggest HMOs sent e-mails with confidential medical information to the wrong subscribers.
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Therapy can be a harrowing experience. It is humbling and frightening, as the client struggles with old grief or shame. Often, clients come from families in which they never felt safe, where they did their best to hide or to escape from intrusive and abusive parents. Yet sometimes a client will find the courage to make himself vulnerable, to revisit a trauma he turned away from decades earlier.
The following scenario is based on several clients: I was sitting with a man who had been in therapy with me for more than a year. Fifty-five years old and sober the last 20. A good man, with a deeply troubled history and an intractable depression. He loved his family very much, but he could not believe that he deserved love in return. His greatest wish was to be dead.
One day he walked into my office, sat down and closed his eyes. He took a deep breath and then looked up at the ceiling. He told me that one summer when he was 14 he had been sexual with an older neighborhood boy, whom he had admired. This boy had humiliated him in various ways, both physically and emotionally. My client had taken from this experience the belief that he was both utterly inadequate and unworthy as a human being. His expectation, now that I knew about what had happened four decades earlier, was that I would reject him. I did not speak for a few seconds, struck by the pain in his voice and the shame on his face. I was reminded how great a privilege it is to be present when another person reveals himself.
When I spoke I said something about the courage it must have taken to say what he had just said, and that I was moved. He took a breath. And then he said, his voice as small as a child's: "This isn't something you have to write down, is it?"
"No," I told him, feeling nonetheless complicit in this violation of his trust. Another insurance report was due in days, and although I would not reveal the specifics of our conversation, divulging anything at all about his symptoms and progress felt like a betrayal.
There is no doubt that health-care costs are increasing rapidly, and insurance companies have a right to make a profit. But micromanaging their subscribers' psychotherapy is not the answer. A better system is the one that's used by non-managed-care insurance companies. Instead of insisting that therapists disclose information about their clients, these companies simply make it clear that the subscriber is eligible for a certain number of sessions each year.
This system is not perfect. There is always the chance that a seriously disturbed person will run out of benefits and be forced to pay out of pocket or, if his therapist is not willing to reduce the fee, stop treatment until the following year. Despite this problem, I still believe it's a better alternative to managed care, which undermines confidentiality--the very bedrock of effective therapy.
I do not believe insurance companies need to know anything about the most private and painful aspects of our lives. If my clients are to heal, they must feel safe enough to speak the unspeakable.
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