By Richard Tuch, M.D.

There is a growing tendency for managed care reviewers to rely strictly on observable and quantifiable symptoms when deciding whether a patient's condition warrants continued financial backing by the insurer. Reviewers focus on the behavioral manifestations of the emotional illness--whether the patient is able to carry out the basic activities of daily living, get to work, and plan and accomplish tasks.

This overemphasis on the behavioral aspects of the patient's condition has come at the expense of any consideration of the patient's subjective distress. Unless such distress can be shown to have a demonstrable effect on the patient's ability to function, it is unlikely to be deemed sufficient to justify funding for treatment.

Misery, the psychic equivalent of physical pain, is now given little consideration when reviewers decide whether a case will be approved for continuing funding. This development alarms me and has led me to write in defense of misery as ample justification for ongoing psychotherapy, even within managed care.

Let me illustrate this troubling problem with a case that recently went to "medical review" to determine whether funding for continued care would be authorized. The patient was a divorcee in her early 40's who was quite adept at acting as though everything was fine. She got to work each day, completed her work in a timely manner, and was able to engage in enough idle chat that no one ever suspected how miserable she was. Her facade was well developed and never broke down. It was as though she held her breath for the 167 hours each week so that she could perform. Not until the l68th hour, when she passed through my waiting room door, could she relax and let down her guard enough to let out the misery with which she struggled when we were apart. Exhaling in this way provided the patient with immense relief and a chance to come to terms with what made the facade seem so necessary.

The work of therapy focused on a variety of issues--her despair that she would never be able to trust others enough to depend on them, her anticipation that if she did rely on others she would inevitably become so helplessly dependent that she would then do whatever that person asked her to do or asked her to be. Sometimes her despair caused her to wonder whether life was worth living. Knowing what it was like to feel understood, however, as she did by me, was an impetus to complete our work so that she could find in the world what she had been tasting in session.

After I had treated the patient for a while, her case was referred to "medical review" by her managed care company. When I spoke to the evaluating doctor, it became apparent that the patient's misery would play a minor role in determining whether treatment would continue to be funded. To him, the fact that she could muster the strength to get by each day was more impressive than was her misery. Being able to function was "proof" that she was not grossly impaired. The emotional price she had to pay to "get by" was not a concern of his.

I had assumed the purpose of our call was to give me an opportunity to provide additional information about the case. I was politely provided a hearing, but it became obvious that the evaluator had something else in mind. He explained that he was calling to be sure I understood how "we" worked--"we" being the managed care evaluator and me, the provider. I was being reminded that care was expected to be symptom focused and brief. Clearly, the fact that I was seeking more sessions meant that I was not complying with how "we" did things. The evaluator was suggesting that I be the one who should keep therapy from becoming a lengthier affair. To do otherwise was to place the managed care company in the potentially embarrassing position of having to say "no" to the consumer.

It dawned on me that I had misunderstood the system. I thought my role in it was a traditional one: to evaluate the case as it progressed and provide my best assessment of what was needed so that the managed care company could then decide whether it felt the condition warranted continued funding. I suddenly realized that what I was being asked to do was not even to ask for more sessions once the therapy had gone a certain length of time. The pressure was on me to bring the treatment to a close so the managed care company didn't have to be the one to do so. I began to feel confused: Whose job is whose? My choices seemed limited. Either I terminate the case prematurely, thus protecting my own interest by ensuring that I wouldn't be terminated prematurely by the managed care company or I advocate for what I believed the patient needed. Clearly we've wandered into an ethical swampland to the tune of "he who pays the fiddler . . . ."

I'm sure some readers would remind me that ambitious care isn't what managed care is all about. Don't misunderstand. I do understand the financial realities that made managed care necessary. But when I am acting as an advocate for a patient, especially one who is literally miserable and for whom I feel relief is possible, I cease to be concerned about the larger picture. I leave that up to those on the other end of the line. And if those individuals would take responsibility for deciding which treatments get funded and which don't, rather than forcing me to bring treatment to a premature close to shield the managed care company from having to say "no" to a patient, the system would stop teetering on the brink of an ethical abyss.

Furthermore, if misery is given proper consideration when decisions about funding treatment are weighed, great strides will be made toward rectifying one disturbing aspect of managed care.

Dr. Tuch is in private practice Los Angeles and is an assistant clinical professor of psychiatry at the UCLA Neuropsychiatric Institute. (Psychiatric News, February 7, 1997)