Psychotherapy at the Price of Volunteering
THE NEW YORK TIMES, SUNDAY, SEPTEMBER 22, 2002

Insuring Privacy by Bypassing the Insurers.

By DICK AHLES

In Connecticut, you can barter four hours of volunteer work in a soup kitchen for a private hour of therapy with a psychologist, courtesy of a group know as Volunteers in Psychotherapy or V.I.P.

Not that you would be restricted to working in a soup kitchen in exchange for your therapy. You can help out in a hospital, a museum, a shelter, a library or any charity you choose so long as it is recognized as a legitimate, nonprofit organization.

V.I.P. was founded in 1999 by four psychologists and two nonprofit specialists to make psychotherapy truly private and available to anyone who needs it, according to Dr. Richard Shulman, one of the founders and the current director of V.I.P. The founders were motivated by the conviction that the treatment offered by their profession and the rules of health insurers are a bad mix.

If a person isn’t up to volunteering for four hours for therapy, he or she can work three hours and pay a $10 fee, or two hours and $25 or one hour and $40. The going rate for psychotherapy in the Hartford area is around $100 an hour.

Volunteers in Psychotherapy is located in a modest, one-room office over a restaurant on South Main Street in West Hartford Center. It is on the Web at www.ctvip.org.

V.I.P. is overseen by a volunteer board of directors, composed primarily of professional psychologists.

After a decade at a clinic operated by Hartford’s Institute of Living and Hartford Hospital, Dr. Shulman had become increasingly concerned that managed care and its financial pressures were severely cutting into the private therapy the clinic was providing. “People were shifted into short-term group therapies and pills were overemphasized,” said Dr. Shulman, who has a private practice but devotes more than 30 hours a week to V.I.P.

He was especially troubled by the rejection of two young women who said they had been sexually abused as children and were seeking therapy. “But managed care wouldn’t pay for such ‘unfocused’ or ‘exploratory’ therapy discussions,” Dr. Shulman said.

When therapy is approved, “insurers require doctors to send detailed reports about the therapy and the private life of the client every three to six sessions,” Dr. Shulman said. This doesn’t happen to patients with physical ailments and Dr. Shulman said he sees it as a way for insurers to discourage payments for therapy.

Laurie Ahearn, who heads the National Empowerment Center, an organization of recovered psychiatric patients, agreed there are problems. “With the advent of managed care and the rationing of psychotherapy,” she said, “the ability to build a trusting and empowering relationship is elusive at best, if not impossible.”

The Connecticut Association of Heath Plans, a trade association of managed-care companies, has a different view.

“It is decidedly untrue that there’s a blanket effort to keep people from going into one-on-one, long-term psychotherapy,” said Keith Stover, a lobbyist for the association. He added that essential information is not collected to discourage such therapy or invade the patient’s privacy.

“Its purpose is to help the insurer determine if an effective treatment plan is being followed, whether for a physical or a mental illness,” Mr. Stover said.

As to workers’ concerns about embarrassing information reaching employers, Mr. Stover said, “Providing such information would violate both state and federal law and Connecticut’s law against dissemination of such information is as stringent as you’ll find anywhere.”

He said a perception that employers would have access to information about an employee’s mental health care dates back to a time when large companies were self insurers and there “wasn’t a large enough fire wall between the people running the company.”

He added that most Connecticut employers “recognize the real need to provide good mental health coverage because it makes for happier, more productive employees.”

But that may not always be the case. Dr. George Allen, a professor of psychology at the University of Connecticut who also has a private practice, has found that even high-ranking employees of supposedly enlightened managed-care providers had reason to worry about their privacy.

“Over the past decade,” he said, “I’ve seen six individuals who worked in rather high-level administrative positions within the insurance industry. Without exception, all declined using their own insurance benefits to pay for services.”

In a letter he wrote to Dr. Shulman, Dr. Allen said one of the insurance executives told him that if an executive’s therapy was reported to his own insurance company, he would according to Dr. Allen “most certainly” lose his job.

“Ironically,” said Dr. Allen, who is a contributor to V.I.P., “these individuals all had the financial resources to ensure their own privacy yet they held positions in an industry that denied the same basic rights to those who were less economically advantaged.”

Had Dr. Allen’s insurance executives sought the services of V.I.P., they wouldn’t have had to worry about their privacy but they couldn’t have paid cash for their therapy even though they could afford it. V.I.P. insists that clients exchange at least the minimum one hour of charitable work and $40 in cash for an hour of therapy because, said Dr. Shulman, “giving something as a volunteer is a form of therapy in itself.”

“We’ve had people who were physically abused as kids who worked with hospitalized children, people with physical problems of their own who have worked with handicapped folks,” he added.

Those for whom volunteering is therapy come to “appreciate being valued by the volunteer agency,” he said

In 2001, V .I.P. clients received 250 hours of therapy. This year, they have already surpassed 250 hours and are on their way to more than 500 hours. Support for the nonprofit group comes from individual donors, foundations and recently, the federal Department of Health and Human Health Services

The psychologists see people with various forms of depression, anxieties, difficulties in coping with everyday life, marital and parenting problems, substance abuse and other disorders. Some clients need many hours of therapy while others require only two or three sessions, which is the number usually sanctioned by insurers before the therapist is, according to Dr. Shulman, “pressed to provide pills and not therapy.”

He doesn’t entirely blame the insurers for this problem.

“We shrinks are ultimately responsible for this,” he said. “Years ago, we fought for health insurance coverage to include the problems for which people sought psychotherapy. Many therapists and clients were happy at the prospect of a free lunch, of therapy sessions paid for by some else. But these third-party payees – employers, governments and insurance companies – eventually realized he who pays the piper calls the tune.”