I received an early Xmas gift this year, completely uncalled for. Delivered as it was by Billy Bob Thornton’s “Bad Santa”, I feel sure that the spirits of Will Rogers and H.L. Mencken saw to its delivery. As editor, occasionally publishers send complementary books for review (sort of like drug companies, but I don’t get pens, free lunches or useless chachkis). Gift-wrapped to my office, came “Mental Health Provider’s Guide to managed care” (published by W.W. Norton), a true piece of gutter-trash, for my satiric pleasure. When you get a hanging curve this “phat” (trying to appeal to the young/hip early career student psychologists here) over the middle of the plate, not to hit it with a full swing is just criminal.

While undergoing (awake of course) my combined root canal/colonoscopy, a real time saver in the medical department, I needed an easy read to distract myself. It was a perfect time for this work which fit right into the spirit of the experience. Painful and incredibly trite (the book that is), my amazement at the amount of incredibly obvious and banal information that could be published remains.

My first laugh came with Chapter 2 (just as the dental drill was hitting my nerve) “How to Market Yourself… to mco’s.” Yes, I realize what great concern the bachelor’s level trained staff at the mco’s have for who they refer the people who call them to. I’m sure they lie awake at night wondering if Joe Blow got to just the right psychologist. Next we’re feted with “Getting into mc Networks”, which offers a lengthy explanation of how to do just that but fails to end with the truth that the mco will lose your application anyway. We’re told that we should be careful to “follow directions carefully” and “check twice, mail once”. How fortunate that the instructions we learned in Kindergarten have been repeated for us as business professionals, since we’ve surely forgotten them by now. If only the mco’s followed the same rules.

“Provider Relations” (just the name makes me chuckle – of course just as the proctologist is making a left turn). But not before I get irritated all over again at being forced to be called a “provider” rather than a “professional” Recall that Karen Shore has covered this subject very well many years back; but bottom line, it matters what we are called. Provider is our slave name, consigned to leave us all feeling more like machines than humans. We are equivocal to inanimate hospitals, clinics etc. – we are the nameless rabble of victims to the bully of mc. With no tongue planted firmly in cheek (though I had to bite mine while thinking of this topic), we’re encouraged to read the “provider’s manual”, but no warning is issued that these are not only highly soporific documents but printed in a middle English/Latin amalgam that can only be read by Medieval scholars; in fact it may have been one of the topics studied by one of the esoteric scholars in Hesse’s “Glass Bead Game.

“Communicating with mc: Getting Services Approved” Let me just say again that this is stupid. Why we bother to approve sessions anytime before the 26th session is beyond any logic. I ask as I have previously that folks refer to the Howard meta-analysis about usage statistics in psychotherapy. Now we get a whole chapter on how to facilitate this utterly wasteful process. Lengthy instructions on how to write a “good” treatment plan never fail to amuse me. Forget about worrying about what the patient reports they want to do – can it be stated in behavioral terms understandable by a 5th grader? If so, you’re likely to get approved. But let’s face it, do we really believe most of these reports ever get read anyway? We all suspect that there is a rubber stamp machine that runs on a variable ratio schedule, occasionally spitting out denials just to make it look like the mco is doing something. And I’ve come to speculate that there are contests at mco’s (with winners no doubt receiving prizes) for the most creative way to lose or explain the loss of treatment plans sent and never “received”. Paper airplane making, runny nose wiping, wallpapering projects, origami and “how much can we shove behind the copier” have long been my fantasies for various day-time activities at these work sites.

Admittedly, with my procedures done, and with morbid curiosity I scanned the rest of the book. It remained as simple and obvious as it had begun. Look, here’s a bottom line. This book deserves no respect from me. It attempts to take seriously a topic that is ridiculous, one that I truly believe we will surely look back on 50 years from now as we do lobotomies and insulin shock therapy. Managing psychotherapy is a financial endeavor. Asking professionals to not only like but try to venerate the process is ludicrous. I understand most professionals have needed to participate in the current health care financing environment because they wanted to practice their trade and make a living. But don’t ask us to respect it or consider it a decent method of business. It’s always seemed to me like most professionals were living the last many years in WW II era Vichy France – trying hard to cooperate so they weren’t damaged or caught violating the demands of the current regime. A few people have chosen to cooperate completely with the oppressors so they could gain some temporary power and feel like big-shots. I consider it identification with the aggressor, or more appropriately being a toady to a big bully. At least you’re not one of the nameless rabble trying to scrape through during the occupation. This book is like propaganda – long on insipid recommendations for what YOU can do, and very short on responsibility of the system you’re supposed to work for.
You’re psychologists and largely nice people, and probably don’t like to read this kind of invective outside of New Republic. I started out thinking I could write something funny and satiric about this book, but it just didn’t work like I hoped. It’s too sad to be truly funny and too real to make for good satire. To me, all books are normally to be venerated just because they are books. Not this one. I will take pleasure in throwing it in the garbage now that it’s done, hopeful it won’t haunt my dreams or sell any more copies.

Now, as an antidote to my vituperation, try reading the article in this issue on Balanced Choice by Ivan Miller. It’s one way to think about a true solution to our crummy healthcare system, which is so broken, many of us feel tempted to trash the whole thing and just start again. Ivan’s answers do that and more. No, I don’t think we should or can completely abandon the healthcare system anymore. There are too many patients who can’t afford the good we can do if they had to pay for it ALL out of pocket, and without some external reimbursement, people would more and more stop therapy with a due increase in the suffering. We’re worth it, of that I’m sure.