In a previous post on psychiatry and torture, I pointed out the American Psychiatric Association's official position paper on torture. It states unequivocally that psychiatrists should not be involved in torture and describes the premises for that argument. As any reader of this blog knows, I have described the impact of managed care on psychiatry including the fact that managed care has had a disproportionate effect on the field probably because of widespread biases against psychiatry, psychiatrists, and patients with psychiatric disorders and addictions. Some would cite the subjective nature of the field, but the abuses I have seen occur in areas where there is limited subjectivity such as inpatient and treatment settings where there are unequivocal and severe disorders. Obvious examples would be people with psychotic disorders who are engaged in unsafe activities due to delusions and/or hallucinations or a person compulsively drinking 1.75 liters of vodka per day despite having numerous auto accidents and nearly freezing to death because of intoxication. Every psychiatrist I know is aware of cases where these people have been denied care by an insurance company based on an arbitrary decision made by a remote reviewer who has no responsibility to the patient in question. Although many of these patients are oblivious to their plight and would be content to proceed with no treatment, many are highly distressed. They are distressed because they know that proceeding with no treatment places them at risk on several fronts and the basic act of being denied coverage causes them a great deal of distress.
That lead me to the thought: "Is this distress the equivalent of torture?" As always that depends on the definition. Post 911, the United States has used various definitions of torture including some that rationalize actual physical blows to a person as not constituting torture. Timelines of various Department of Justice memos with these interpretations are available and I will not get into them here. There are obvious problems with not calling a coercive beating torture. A more widely accepted definition is available from the United Nations:
1: For the purposes of this Convention, torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.
In this case, torture is defined as potentially mental suffering with no physical component. Since the UN is dealing with torture inflicted by states there is the expected implication of states in the process and the cases of lawful imposition of pain and suffering inflicted by states. The definition is also limited to obtaining information that a person wants to keep undisclosed or coercing them to do something they do not want to do. A more general dictionary definition from Webster's would be:
To afflict with severe pain of body or mind.
Part of the convenience to businesses denying psychiatric care is the stereotype that these are just minor medical conditions, that treatment is elective, or that treatment does not meet some arbitrary business criteria like "failing outpatient treatment first" or "we don't do medical detox in a hospital". The pain involved with mental illness is an abstract concept to anyone who has not experienced it or who has not be involved in trying to treat it. I don't think it has been studied. You won't see anyone asking the question:
How painful was it to learn that your insurance company would not fund for the treatment of your mental illness or substance abuse problem and realize that you would be losing your home, spouse, children, job, etc?
Professionals treating the patients in question also avoid the issue of psychic pain. It can be more easily dealt with as the expected anxiety or depression of an adjustment disorder rather than unnecessary suffering inflicted by a third party. Some professionals will address it as grief from the expected losses. But most often it is just glossed over as business as usual. The legal system has already indemnified managed care systems from any liability for decisions that lead to injury removing them further from the consciousness of patients, their families and the providers in question. The physicians involved are conflicted - they know they are powerless given the legal landscape and further they don't want to make any waves with the companies who might be paying them. We have culturally removed one of the most toxic factors in our health care system - the denial of care from consideration.
Like all psychiatrists, I have had to pick up the pieces when the proposed treatment plan is denied and all of the secondary problems come into play. Suddenly I am talking with a person who not only has a severe psychiatric problem and/or addiction, but they are now homeless or without a job or a family. It is the worst care scenario from the perspective of comprehensive care and it is up to me and my colleagues to piece together a suboptimal plan. The outcomes of those suboptimal plans are rarely very good. The best that I usually hope for is that they can be safe for a long enough period of time to find other resources to deal with their chronic mental illness or addiction. In some cases the expected worst case scenario occurs and if the patient is lucky they are readmitted and there is another chance to try to obtain funding from their managed care company. There is a good chance the proposed plan will be refused again.
At what point is the human suffering involved in this sequence of events recognized? At what point does a change in the system need to occur. Steven Sharfstein, MD made this decision when he was the President of the APA and he banned the participation of psychiatrists in any step of the interrogations occurring in the mid 1990s to this date. Is that a step that psychiatry should consider in managed care settings? Should we eliminate psychiatrists from sitting in a remote office and reading notes about the care of one of these severely ill patients and making a decision that favors the insurance company that they work for? Psychiatric professional societies have adapted to the cultural blindness of the culpability of insurance companies when they legitimize medical decisions by making sure that some psychiatrists are in these reviewer positions. I guess the thinking was that they could suspend their loyalty to their employer to make decisions in the best interests of patients and the profession. History has clearly showed that things don't work that way. I have had some reviewers tell me that their decisions were based on a set number of days irrespective of anything I would tell them about illness severity or complications.
I can understand the obvious counterargument to my position that the denial of care is a form of torture. It can be argued that the patient is not a passive player and that they have a "choice" about whether they continue to have severe symptoms, continue to use drugs and alcohol, or continue to harm themselves. The idea that all of these problems are based on conscious voluntary choices remains an unrealistic business approach to mental illnesses and addictions and not reality. There is also the business as usual argument. That is - this is the way we have done things for the past 30 years with the help of politicians even though it does not contain costs and it provides poor quality care. It that really enough justification for creating more stress on already distressed patients?
At what point do we all acknowledge that denied psychiatric care results in more mental pain and suffering and takes psychiatrists out of decisions that are in their patients best interest?
George Dawson, MD, DFAPA
Graphics Credit:
Graphic is downloaded from Shutterstock per their standard agreement. It is entitled "Depressed man in a tunnel" by the artist hikron.
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