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Mental Health Parity

Letter to the Editor of the New York Times

submitted 12/13/01

Mental illness can be seriously debilitating, and you (editorial, Dec. 10) and Mike Wallace (Op-Ed, Dec. 11) are right that the treatment of mental illness deserves parity with the treatment of other medical conditions -- at least in principle. 

In practice, however, parity has to be earned by a mental-health industry whose practices are not yet on a par with the rest of the health care industry. Parity in mental-health services will be achieved, and parity in payments deserved, when mental illness is rigorously diagnosed on the basis of underlying pathology, as in the rest of medicine; when proposed new therapies are based on established scientific principles; when specific treatments have been demonstrated to be effective for specific illnesses; and when practitioners routinely choose the most cost-effective alternatives. 

After almost a century of false starts, mental-health practitioners are beginning to achieve these goals, but progress has been altogether too slow. As mental-health consumers get the parity in treatment they deserve, so mental-health providers will deserve the parity in payments they seek. 

Follow-Up Correspondence

with Congressional Quarterly

As a result of the publication of this letter, I was contacted by a writer for Congressional Quarterly, which was preparing a report on the parity issue.  My comments to that reporter follow:

I want to make it clear that I believe that mental illness is real, that the mentally ill deserve the best treatment available, and that mental illnesses deserve parity in third-party payments with physical illnesses.  The problem is that mental illness has been treated with a form of benign neglect by the mental-health profession itself, so that psychotherapy simply hasn't advanced the way the rest of medical practice (defined broadly) has.  For God's sake, there is still a debate in the field over whether psychotherapy should be evidence-based.  As opposed to what?   

Frankly, with the loose standards that apply to mental health, I share some of the business community's concern that mental-health parity can become a sinkhole.  But, also frankly, I suspect that this is just a smoke screen for people who would rather not pay their employees any benefits at all -- or any salary above the Federal minimum wage, for that matter.  The situation is resolved very easily, in my view, by holding mental-health treatment up to precisely the same standards that we apply to the rest of health care.  If the diagnosis is legitimate, and the treatment scientifically based and proved efficacious and efficient, there can be no excuse for paying for it. 

As for the sob stories, I have a lot of sympathy for people with serious mental illnesses, and even not-so-serious ones, who can't get the help they need because of restrictions on mental-health coverage.  But that's not to say that there should be a blank check issued to anyone for anything.  Mental-health treatment has to be budgeted, just a physical-health treatment has to be, and in this process difficult decisions have to be made.

Of course, in my view a lot of these problems would be resolved if we had a single payer for insurance -- namely, the federal government.  That way, the risks of both serious mental illness and of serious physical illness would be spread over a huge pool, insurance would be portable, not tied to job status, and the like.  There would still be a budget -- even the Pentagon can't have every aircraft carrier it wants -- but there would be less frequent hard choices.  But I digress.

Query:  Point me in the direction of the best studies, reports, evidence, concrete real-life anecdotal examples supporting the position that mental illness is not yet rigorously diagnosed on the basis of underlying pathology, therapies have not sufficiently been demonstrated effective, and cost-effective alternatives not always chosen.

The best argument about diagnosis is one that I offered in a book recently published by the American Psychological Association, Alternatives to the DSM.  You can read the unedited draft

www.institute-shot.com/Psychiatric Diagnosis.htm

There's also an interesting argument about psychotherapy and managed care in another book published by the APA.  To read the unedited draft, go to


If you have any problem reaching these links just go to 


and search on the keywords.

With respect to treatment, there are plenty of treatments that work.  They're usually classified as cognitive-behavioral treatments, as opposed to "insight" treatments.  Division 12 (Clinical Psychology) of the American Psychological Association has a whole Task Force devoted to evaluating these treatments, and every now and then they issue a list.  And it's a pretty long list at this point.  The problem is in getting some die-hard insight-oriented clinicians, including all those psychoanalysts, to stop what they're doing and start doing something that works.  I think that it's the whole idea of all those psychoanalysts, and all their patients, spinning their wheels thinking about Mommy and Daddy that is the greatest impediment to the general acceptance of mental-health parity. 

Among treatments that "work", there are further distinctions to be made. 

First is whether there is an adequate scientific rationale for the treatment.  When someone proposes a new treatment in medicine, the first question asked is "What makes you think that would work?"  Consider a treatment like Eye Movement Desensitization and Reprocessing (EMDR), in which the patient follows the therapist's wagging finger with his or her eyes while contemplating a traumatic memory.  There's a fair amount of evidence that EMDR "works", and it's got a lot of press, especially in the wake of the incest-recovery movement, Oklahoma City, and 9/11.  But EMDR works by virtue of exposure, not by virtue of anything about eye-movements reprocessing traumatic memories.  The eye-movements are, so far as we can tell, totally superfluous.  Yet, because EMDR "works" it claims status as an evidence-based treatment.  But the theory behind it is unproved.  So, given a choice between EMDR, whose scientific rationale is weak, and a standard exposure treatment like systematic desensitization or implosion therapy, whose scientific rationale is straightforward and valid, third-party payments ought to prefer the latter over the former.

Second is whether the treatment is efficient.  In the wake of the success of the cognitive-behavioral therapies, some insight-oriented therapists have claimed that their treatments, work too.  In fact, some authorities, such as Lester Luborsky at the University of Pennsylvania (where I got my PhD) have declared a Do-Do Bird Verdict, after Alice in Wonderland, in which "All have won and so all must have prizes".  But it's not true that all therapies are equal.  The cognitive-behavioral therapies work better, and when insight therapies work it's because the therapists have brought cognitive-behavioral techniques into their practice.  Moreover, the cognitive-behavioral therapies work faster.  Hence they are cheaper.  There is even evidence, complied by David Antonuccio at the University of Nevada, Reno, that psychotherapy is at least as good as, and cheaper than, drug treatment for depression; and even when drugs work, there are reasons to think that psychotherapy can add to their effect for relatively little cost.  In a budgeted system, whether its health-care or national defense, you want the most bang for your buck.  Therefore, given a choice between an insight-oriented therapy that works a little, slowly, and a cognitive-behavioral therapy that works better, faster, third-party payments ought to prefer the latter over the former.

And the same thing goes for pre-treatment diagnosis and assessment.  Psychotherapists still rely, all too much all too often, on the same sorts of tests -- the Rorschach, the Thematic Apperception Test, the Minnesota Multiphasic Personality Inventory (MMPI) -- that they were using more than 50 years ago.  Where else in medicine do we see such a failure to develop new, more accurate diagnostic procedures?  I have problems with the MMPI, but there is no question that it is better for diagnostic purposes than the Rorschach and the TAT, which are essentially useless.  They add nothing to what is learned from "objective" tests such as the MMPI, and a competently conducted diagnostic interview.  But many psychotherapists still love their Rorschachs, and there's a huge industry built around the test.  Parity for mental-health treatment should include payments for tests that aren't valid, or that aren't efficient, any more than it should pay for ineffective or inefficient treatments.

Query: Propose a handful of key issue questions for this 25-page report.

Parity in coverage will definitely mean better mental health care, so long as mental health care is held to the same standard as physical health care.  If mental-health practitioners are merely allowed to do business as usual, they'll never alter their ineffective, inefficient practices, and the mentally ill will never get the treatment they need and deserve.

Query: Has mental health care established its credibility enough to warrant parity?

In some domains, yes.  Standardized diagnostic interviewing, and psychological testing with instruments such as the MMPI, have proved their worth in ways that the Rorschach and TAT have not.  Cognitive-behavioral therapies have proved their worth in ways that psychoanalysis has not.  In my view, managed care works to the benefit of psychotherapy, because it forces psychotherapists to demonstrate that what they do works, and once they do that, there can be no excuse for not paying for it.


Query: Is it enough to cover only the eight most severe mental illnesses?

No, no more than it would be enough to cover the eight most severe physical illnesses.  When you've got the flu, you go to your doctor, and your insurance pays for the treatment.  Your insurance pays for the treatment because the flu is a real disease, and the treatment works.  The same standards should apply to mental illness.

Query: I'm not suggesting that these are the best questions, I just put them down
as examples.

As I said, I think that mental health parity is an important issue, probably the most important domestic policy issue we have.  Certainly the most important health-policy issue.  

This page last revised 11/01/10 03:25:28 PM.