Ethics of paying for mental health services

By THOMAS RUE

People seeking mental health services are often at a vulnerable stage of life. They enter a relationship with a professional counselor to learn to become emotionally stronger and more assertive, or to gain a new perspective and hope for the future. How money enters into this picture can dramatically effect the nature of the experience, and whether it is ultimately perceived by the client as good or bad.

The following true case history is by no means unique, and the questionable conduct it describes has probably been observed by most practicing counselors. Failing to think through how payment will be made can result in an experience that does the client more emotional harm than good. The client here, called Betsy, has given permission to have her story published, with names changed.

Betsy

In February 1988, Betsy presented herself as a client at a domestic violence center. Recently separated from an abusive man, Betsy found solace in this group of supportive women who had endured similar experiences. The group was facilitated by a counselor named Pearl, who, in addition to being director of the women's center maintained a private counseling practice in an office attached to her home.

Although Pearl's job at the center included providing individual counseling to battered women, when they had insurance and were willing to cooperate Pearl referred them to her private practice so she could collect third-party payments. More than one client was happy to help Pearl out in this way, viewing it as a way to give something back to this woman who they saw as so understanding and supportive. After all, it wasn't costing them anything. Pearl accepted whatever the insurance company paid.

Since Pearl herself was not eligible for insurance payments directly, she worked out a partnership with a licensed psychologist named Bob, who submitted the claims to the insurance company in exchange for a portion of the fee. Bob conducted an initial screening and rendered a diagnosis. Pearl then conducted the counseling sessions, for which Bob would submit bills and receive insurance payments. Sometimes called fee-splitting, this practice is fraudulent and unethical, but Bob rationalized that he was charging for clinical supervision of Pearl, not receiving unlawful kickbacks. But as far as the insurance company knew, Bob was billing Betsy for counseling services that he himself was providing.

Because health insurance is based on a medical model, insurance companies require a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM) before making payments for mental health treatment. Without informing her of what he was doing, Bob submitted a DSM code to Betsy's insurance company indicating he was treating her for "Borderline Personality Disorder." This is a relatively severe mental illness usually involving long-term treatment.

After 11 months of weekly counseling sessions with Pearl, Betsy showed one of her insurance forms to another counselor, who explained the DSM code. Betsy said this was the first time the diagnosis was explained to her, and she felt used and deceived. She called Pearly, with a copy of the diagnostic manual in front of her, and demanded an explanation. Unable to justify the diagnosis, Pearl went on the offensive, assuring Betsy she was an "expert" and directing her not to "play psychologist with me." Soon, however, Pearl backed down and offered to change the diagnosis to either "Adjustment Reaction" or "Post-Traumatic Stress Disorder," pointing out that neither label would likely result in long-term payments by the insurance company. Defending the practice, Pearl said at least one other client -- a friend of Betsy's -- also had an unjustified "borderline" diagnosis in her records for insurance reasons. Betsy inquired whether the other client had granted Pearl permission to discuss the confidential details of her case. (Of course, she had not.) Unknown to Pearly, Betsy taped these candid confessions on a telephone answering machine.

Betsy decided to terminate counseling, but not until confronting Pearl and Bob in a final joint session. Betsy used this session to vent her justifiable anger. Bob entered into a shouting match with her, telling her she was "crazy," as was the counselor who had raised questions in her mind. After going to a women's center for support, Betsy found herself exploited by two unscrupulous therapists.

Pearl was fired from her job at the domestic violence center for referring agency clients to her private practice. However, she and Bob are still practicing in the same area.

Betsy found comfort upon returning to clinicians who had counselor her prior to her involvement at the women's center. She was assured that her condition was described in their clinical records as depression secondary to marital problems, combined with stress resulting from leaving an abusive marriage. Her self-esteem shaken by the personality disorder diagnosis, Betsy consulted two other therapists, both of whom agreed the label had been improperly applied.

Betsy wrote a letter to her insurance company's fraud division, informing them of Bob's questionable billing methods. In February 1991, she received a certified letter from Bob demanding payment of $2,340.00, which she understood had been charged back to him by the insurance company. Betsy called Bob's office and firmly told him that if he continued to press her for money, he would have to answer to the state licensing board. That was the last she has heard from Bob.

Betsy says she now finds it difficult to trust mental health professionals. Added to her sense of betrayal is the fear that her estranged husband -- against whose insurance policy the fraudulent claims were filed -- could gain access to the diagnosis and attempt to use it against her in a child custody dispute as proof that she was emotionally unstable. Betsy completed her divorce and is now happily married, but says her life adjustments were made in spite of the counseling she received.

Betsy's case is a classic example of the misuse of the therapist's power. However, most counselors show more ethical concern about their clients' emotional welfare than these two did.

A legal case could be made that this incident amounts to a breach of contract by Pearl and Bob. A battered woman had sought counseling to get emotional support, not to be mislabeled and treated for a mental disorder she didn't have

Pros and cons of using insurance Some practitioners feel that labeling a client as mentally disordered or ill to satisfy an insurance company's requirement disempowers the client and perverts therapy. There is little question that, to some degree, it alters the therapeutic process from human development by means of interpersonal contact, to a cure for a mental defect under a medical model.

When deciding whether or not to seek reimbursement for outpatient counseling services from a health insurance carrier, clients should be aware that, once a diagnosis is entered into insurance company computers, it remains part of the permanent medical record, available to anyone authorized to look at the file. Many clients are unaware that reimbursement for counseling fees requires a psychiatric label, and that if they are ever asked whether or not they have been treated for a psychiatric problem, the truthful answer is yes. Since all diagnoses entered into insurance records have actuarial ramifications, as do smoking, age, weight, sex and other prior existing medical conditions or risk factors, an unnecessary record of psychiatric treatment may well be worth avoiding. By paying for counseling services directly and foregoing reimbursement, clients may literally become more "invested" in the counseling process, that is, make more meaningful therapeutic progress in relatively brief periods.

On the other hand, when a client is fully informed of the meaning of a specific diagnosis and freely consents to a treatment plan that addresses the disorder in question, using health insurance can be a perfectly ethical and legitimate choice. Clients need to be empowered to make these decisions armed with the facts. Little therapeutic change is likely when the client is not a full and active partner.

Professional grievances

Another issue raised by Betsy's experience is: to what authority can clients turn for redress in cases of alleged ethical breaches? As a licensed psychologist, Bob could have been reported to the licensing division at the state education department and perhaps faced the loss of his immediate livelihood. Betsy had to decide whether to file such a report or remain satisfied with the belief that action taken by the insurance company was sufficient.

But with Pearl, there was no decision to be made. Because she practiced in one of the 12 states that does not currently license mental health counselors, and because she holds no voluntary credentials at a national level, there was no ethics board to which Betsy could turn. Betsy's lawyer told her a malpractice suit against either Pearl or Bob would probably be unproductive because she would have to establish monetary damages, not just emotional pain or breach of contract. It seemed there was nothing Betsy could do but warn others to avoid a similar pitfall.

New York and Pennsylvania currently have legislative bills pending to remedy this problem. In albany this past November, the NYS Board of Regents voted unanimously to endorse a legislative amendment to the Education Law that would limit the practice of psychotherapy to those who demonstrate at least a minimal degree of competence and pledge adherence to a code of ethics. In Harrisburg, the Counselor Licensure Bill (HB 2009), introduced in October, would have similar effects in that commonwealth.

In jurisdictions that do not yet require licensing for psychotherapists, clients can inquire whether the practitioner has obtained voluntary certification through professional associations like the National Board for Certified Counselors, National Academy for Certified Clinical Mental Health Counselors, American Association of Sex Educators, Counselors and Therapists; or Academy of Certified Social Workers. Such bodies may hold the professionals they certify to published ethical codes, offering clients a forum for disciplinary complaints.

No amount of graduate training, even with certification and licensure, can guarantee that persons calling themselves helping professionals will be competent and act in the client's best interest. In states unprotected by licensing laws, anyone can advertise him- or herself as a psychotherapist or counselor. It is therefore left to the client to beware of the services they are purchasing and to understand the implications.

[A contributing editor for The River Reporter, Thomas Rue is a National Certified Counselor who lives and practices in Monticello.]

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