Foundations of Treatment 147
The therapist should check with each patient to determine whether demographicdifferences of many kinds—in age, weight, ethnic background, country of origin, or
religion, as well as race, gender, or sexual orientation—might infl uence treatment
(Davison, 2005; Eubanks-Carter, Burckell, & Goldfried, 2005; Helms & Cook,
1999; Higgenbotham, West, & Forsyth, 1988; McGoldrick, Jordano, & Pearce,
1996; Ramirez, 1999). If such differences are salient for the patient, the therapist
should inquire about the patient’s relevant experiences and concerns and discuss
how to shift the plans for and goals of treatment (Zane et al., 2004). For instance,
Joe, a devout Catholic seeking treatment for depression related to his unhappy mar-
riage, might explain to his Protestant therapist that, because of his religion, divorce
was out of the question. Joe and his therapist could then together devise possible
goals and strategies for treatment that did not confl ict with Joe’s religious beliefs.
Finances and Managed Care
Perhaps unfortunately, fi nances are another social factor that must be taken into
account when treating mental illness. Mental health services make up just a small
part of overall health care costs in the United States and Canada, but as the cost
of providing medical care has risen signifi cantly, external pressure to limit mental
health care spending has increased. To contain costs, health insurance companies
have developed a system of managed care, a plan that restricts access to specialized
medical care by limiting benefi ts or reimbursement. A managed care organization
tries to minimize the expense of providing health care without restricting services
that it deems medically necessary. So, for instance, to keep mental health care costs
down, a managed care organization might:
- restrict the number of days that a patient can remain in an inpatient unit, and will
no longer pay for such treatment after that time has passed;- restrict the mental health facilities where a patient may receive care (to those that
have agreed to be paid a previously negotiated rate);- pay for partial hospitalization rather than inpatient care;
- restrict the number of days a patient can remain in partial hospitalization; and
- limit the number of outpatient sessions or restrict the mental health clinicians
whose services will be covered.These limitations can harm patients, their families, and even society at large.In an effort to minimize the adverse effects of such restrictions, the U.S. Congress
in 2008 passed the Wellstone-Domenici Mental Health Parity Act. This act
requires most insurance plans to provide comparable levels of treatment benefi ts
for mental health and physical health (as well as for substance abuse). For exam-
ple, if an insurance plan does not restrict the total number of days a patient can
remain in a hospital for a medical problem, it cannot restrict the total number of
days a patient can remain in a hospital for a psychological disorder. Health insur-
ers may still limit benefi ts—but the limitations must be equivalent for physical
and mental health.
The majority of Americans who have health insurance have their mental healthcoverage handled through a managed care system (Open Minds, 1999). In response
to managed care, therapists of every theoretical orientation have worked to main-
tain the same effectiveness in fewer sessions or in less intensive forms of treatment.
Some research suggests that having a time limit on psychotherapy may accel-erate the rate of change for some—but not all—patients (Reynolds et al., 1996).
However, patients who have complex or multiple problems are less likely to benefi t
from a limit on the number of sessions (Lambert & Ogles, 2004). Further research
is needed to determine whether, for each psychological disorder short-term therapy
can provide long-term positive change without increased rates of relapse.
Managed care
A type of health insurance plan that restricts
access to specialized medical care by limiting
benefi ts or reimbursement.