(or Shout It From the Rooftops!)

I’ve been re-reading old writings and notes and emails, trying to retrace my path of the past few years.  I’m looking for patterns, for what has changed and what hasn’t.  I’m trying to see where I’ve moved forwards or backwards, where I’ve gone in concentric circles, where I’ve stayed in place or just gotten stuck.

In seeing a new temporary-therapist, I’ve had to recover familiar ground and revisit old injuries.  I’ve had to adjust my schedule, contort to fit into a new space, negotiate a fee.  And I’ve had to contend with a whole host of new feelings – ones of loss and rejection and minimization – that caught me off guard.

I’ve had to let this other person into a space that used to only be occupied by me and my therapist.  I’ve had to tell her about our relationship and things that worked well and things that didn’t.  I had to rehash the Impasse, which has always felt like a dark cloud that continued to lurk over me, occasionally unleashing a torrent of anger and rage when I least suspected it.

One of the ways we found our way out of that impasse (although we still sometimes go back in) was by writing a Manifesto.

man·i·fes·to (noun, ma-nə-ˈfes-(ˌ)tō) – a written statement declaring publicly the intentions, motives, or views of its issuer.

I had forgotten all about our Manifesto, even in the retelling of the Impasse, until I discovered it on my recent hunt.  I remember very clearly the feeling of camaraderie born out of this project – me and my therapist against the whole big bad world.  Or at least one insurance company.  We worked on it in session and over email.  It came together as a sort of gift, to each other, and as a way forward.

In my memory the language was much more eloquent, the ideas more worthy of wide-scale publication.  Now, re-reading this, years later, it’s not quite as profound and earth-shattering as I once thought.  But I re-read it with interest, looking for the nuggets of truth, perhaps buried within, that allowed our relationship to continue to move forward.  I searched for clues that may provide a path back together.  I think we each needed to state our case, individually, collectively, even if no one was listening.

Over the holidays I had the good fortune to stumble into the Park Avenue Armory and be immersed into a film exhibit titled Manifesto.  All I knew was that Cate Blanchett was somehow involved and that was good enough for me.  It was a cold, dreary day, which I planned to fill with art.  I thought I would be there for 45 minutes, maybe an hour.  Three hours later I finally had to pull myself away, having become captivated and hypnotized by the dizzying images and words and messages and ideas.

“These manifestoes show that you actually can speak up loudly — if you have something to say,” said creator Julian Rosefeldt. “Every word of these manifestoes is beautiful and full of meaning, often utopian, sometimes prophetic.  But always worth reading or listening to.  These texts are reactivated and propelled out in the world, and they’re having their own kind of life again.  Maybe there is a need, in our time again, for words.”

The New York Times explains further in its review: “None of the 50 manifestoes are presented in their entirety. Instead, parts are pulled from each, creating new texts that Ms. Blanchett delivers as dramatic speeches. The manifestoes aren’t meant to stand alone; they are meant to be in dialogue. […] Because many were written when their authors were young, before they became famous, they share a raw spirit of self-discovery and rebellion.”

I guess our Manifesto fits that definition – it certainly was written in a spirit of self-discovery and uprising against a behemoth institution.  We had visions of shouting our beliefs from the rooftops, for all to hear, even though we kept this secret, until now.  Still, there was a wild energy present, and a desire to right all the wrongs of the world and forever change the way insurers cover mental health care.  Perhaps “loud” is what has been missing from this Manifesto all along, maybe it’s time to give this baby some oxygen and let it see the light of day.

So I give you – Therapeutic Manifesto (2013):

This is a response to the request for additional information from one Insurance-Company-Who-Must-Not-Be-Named (ICWMNBN).

We offered, repeatedly, to provide ICWMNBN with a written response to these questions.  This offer was in turn repeatedly rejected by ICWMNBN, and the only indication that ICWMNBN would accept a written response was made after the administrative determination to sever benefits for the client.

We rejected a phone conference with one of your care managers for several reasons:

  1. A conference between an out-of-network provider and a care manager without permitting the client to be an active and present participant in the conference is a violation of client-centric practice.
  2. As an out-of-network provider, the practitioner has no contract with you and no obligation to respond, appeal or report to your care managers for approval of services. Services are determined by the client and practitioner together.
  3. A phone conversation also serves to conscript the out-of-network provider to collaborate as a de-facto care manager by pre-determining the number of sessions, treatment goals and plan, etc. rather than reserving that decision as the client’s sole prerogative.

Here is the information we are willing to provide, with the client and practitioner collaborating together to establish medical necessity for previously submitted claims, as well as for future claims.

First, however, we wish to make it clear that we see this inquest as a violation of the client’s privacy and therapist-patient confidentiality, and that it is a complete violation of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008.

The client’s health plan does not require pre-authorization for out-of-network, routine outpatient medical office visits, including out-of-network, routine mental health office visits.  Plan documentation provided to my client does not specify that out-of-network claims are subject to retrospective, concurrent or prospective reviews for medical necessity.

If ICWMNBN continues to defend this practice in the face of these facts and the MHPAEA, then the request for information should be made at the beginning of treatment and not nearly one year into the formation of a therapeutic relationship.  At no time did ICWMNBN disclose to the client, in the processes of choosing a plan and contracting with the insurer, that out of network services would be subject to any review whatsoever.  The client specifically factored in “unlimited sessions” before seeking out of network psycho-therapeutic services.

Neither was it made clear that a review process would be activated if “unlimited” services exceeded 20 sessions in six months or 12 sessions in six weeks (information that was disclosed by ICWMNBN to the client only after a review had been initiated).  That information should be made available in the plan documentation during annual enrollment.

ICWMNBN should also be more explicit about what types of psychotherapies are covered and what types are not.  It appears, from the questions being asked, that there is an unsubstantiated bias toward cognitive behavioral therapies (CBT) and that CBT models are given preferential reimbursement.  “Treatment plans,” “measurable goals and interventions” and “estimated length of treatment episodes” are features of CBT treatments.  This bias excludes many valid and efficacious models of psychotherapy.  If ICWMNBN does only cover behavioral, psychiatric and cognitive behavioral treatment, then that needs to be explicitly stated in the plan documentation as well.

We reject the notion that complex lives and narratives can be encapsulated in a diagnostic formulation.  We reject the notion that an Axis 1 diagnosis is required for one to need or benefit from psychotherapy.  The client is much more than the summation of any diagnostic criteria.  Such generalizations do not begin to encompass all that a client is or the unique challenges that the client faces in her life.

Further, we do not see therapy as merely a process of symptom-reduction or seeking to “cure” a diagnosis, but more so of a process of self-discovery and growth that is supportive and healing and restorative and challenging as appropriate.

If this information had been explicit in the statement of benefits, other decisions may have been made before the client and therapist alliance and clinical trust were established.  Empirically, evidence has shown time and time again that it is the relationship that ultimately heals (see Shedler, Jonathan (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist, 65(2), 98-109. doi: 10.1037/a0018378).

In the spirit of parity, we question how you can justify this request for additional information when the same request is not made from other providers who treat this patient on a regular basis for similar symptoms.  ICWMNBN needs to trust that if the client feels the need for additional sessions and if a licensed provider in good standing concurs that additional sessions are warranted, then the client should be reimbursed for these sessions.

We are asking that ICWMNBN reimburse for out-of-network, routine mental health office visits, services that are experienced by the client as essential until the client decides she is finished.

Okay, so it doesn’t quite compare with the line that moved me the most in the exhibit:

“To sit in a chair for a single moment is to risk one’s life.”
~ Richard Huelsenbeck, Dada Manifesto (1918)

But you get the idea.

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