Personal Accounts: Managed Care Wars: A First Casualty

I am greatly concerned about the impact of corporate managed care on current behavioral health practices. I am concerned both as a clinician and as a sufferer of two bouts of clinical depression. The first bout occurred about 23 years ago, and the second about two years ago.

During the first episode I was too ashamed to seek professional treatment, and the depression gradually resolved itself over about a year and a half. Although I was seriously depressed, I was not psychotic. However, during this last episode I did become psychotic, suffering with marked persecutory delusions, and I required a ten-day psychiatric hospitalization. I currently continue both the therapy and the medication that brought about my recovery in order to lower my risk of relapse.

To me the second episode was strongly associated with two events in my professional life: the advent of managed care here in the central region of Pennsylvania and the discussions at the hospital where I worked about prospective mergers with other health care organizations. I firmly believe the first event was a major precipitant of my relapse into the second depression.

In the earliest planning and implementation of a managed care model here, I experienced conflict about the constraints of any model that portrays short-term interventions as meeting the needs of persons suffering from serious persisting or recurrent disorders; clearly, a continuous care model is clinically more appropriate with this population. Two-thirds to three-quarters of the hospital's clients have such conditions.

I also found it difficult to reconcile a corporate-economic paradigm with a clinical one. The managed care mentality had even changed the language I was so accustomed to. In meetings we were now using terms such as "outliers," "market share," "product lines," "penetration rates," and "assumption of risk"—but referring to risk in economic terms, not clinical terms. I thought myself transported to a foreign land against my will. I felt betrayed and angry about this dramatic shift. I also began to feel devalued as a clinician, perceiving my clinical skills as inferior to the prevailing business skills. To survive here, I would need to convert my M.S.W. to an M.B.A. And most of what I felt and thought, I internalized, which is my nature. I was, in essence, losing my clinical center.

Despite the growing dissonance, I was still functioning adequately at my job, until I returned to work from a very relaxing and enjoyable vacation. Within a few days, I became severely depressed, with prominent delusions and paranoia. These symptoms were accompanied by marked sleep disturbance, suicidal preoccupation, and seriously impaired concentration. I failed to adequately respond to psychotropic medication, including a combination of antidepressant and antipsychotic drugs.

Because of my family's increasing concern for my personal safety, I was psychiatrically hospitalized. During the ride to the hospital, I believed that I was being transported to a facility fronted by the FBI and disguised as a psychiatric unit. There I would be subjected to extreme ridicule and would be forced to admit to my many faults and mistakes. My delusions of persecution persisted for several days. I envisioned my fellow patients as disguised agents of the FBI. I believed that while I slept, these folks were plotting the next stages of my humiliation until I confessed.

With aggressive treatment, these delusions abated in a few more days. I was discharged under the care of my psychiatrist and began psychotherapy with a psychologist.

I returned to work after four weeks, experienced a wonderful hypomanic state for several weeks, and then resumed relative stability. Then I felt more depressed again and had to be off work for another six weeks. I resumed my employment at the hospital in another capacity, one that protected me from the clinical suffering that we see day to day. I am convinced that although I certainly care about clients, I am too sensitized now to the suffering of others.

This summer another blow was dealt to the hospital and its programs. Partly because of managed care and limited access to specialty care for patients, an inpatient unit and 78 positions of various kinds, including my own, were abruptly eliminated. Although I was later offered other positions, I declined to return.

Through my treatment I am trying to make sense of my earlier relapse. I portray my experience in space metaphors. Like the robot in the TV series and movie Lost in Space, whose internal alarm sensed imminent danger, my internal alarm detected the dangers of corporate managed care. Like a Jedi knight in Star Wars, I detected a disturbance in the Force, and a sinister one. Although I still cannot figure out who the equivalent of Darth Vader was in my life, or who the Emperor was, I am searching for the equivalent of Yoda, the Jedi master, who can train us to use the good side of the Force.

Perhaps someone such as the physician from a school of public health who contributed to a listserve I participate in will suffice. I am an active participant on a social work listserve devoted to managed care. I strongly concur with a message this physician placed on the listserve last fall, saying that in his 40-plus years as a clinician, never before had he "encountered a breakdown in the system of care, such a dismissiveness of human values and a disdain for ethical principles. The corporate system is characterized by the abandonment of the sick and vulnerable." He added, "Cost containment to maximize investor return is the centrality of market-driven, for-profit health care."

In retrospect, I believe the clinician in me sensed these developments coming and feared them. But I internalized my concerns and became a first casualty here. I am sure there are others, including both staff and clients.

Such a reaffirmation of the negative prevailing health care climate is an important part of my recovery. I know I am not alone in my perception of a certain reality. I have regained my clinical center. As a result, I continue to advocate (such as any good Jedi knight would do) for a more humanistic way of using resources on behalf of our clients and staff alike. We must preserve and strengthen the primacy of the therapeutic alliance in delivering behavioral health care.

A few aspects of my own care and treatment are more significant to me now than ever. One, my family, my colleagues, and my clinicians never quit believing in my capacity to recover. Second, clinical depression endures for a longer time than our professional training teaches us. Active and appropriate treatment does shorten the duration of intense suffering. Third, I am fortunate to have excellent behavioral health coverage in a preferred provider organization that allows my clinicians the autonomy and latitude to personalize my treatment.

On the basis of both my clinical and my personal background, I suggest that my colleagues expect that a robust recovery from clinical depression may take a year or more and that short-term intervention will often be insufficient to effect stabilization and prevent relapse. And I suggest that they continue to be vocal and active in expressing concerns about any managed care plan that restricts access to needed care for those with persisting and recurrent disorders. May the Clinical Force be with us.

Mr. Kensinger is on the faculty of Penn State University in Altoona, Pennsylvania, and Mount Aloysius College in Cresson, Pennsylvania, and is in private practice as a trainer and consultant. His address is Route 4, Box 856, Altoona, Pennsylvania 16601 (e-mail, [email protected]). Jeffrey L. Geller, M.D., M.P.H., is editor of this column.