Behavioral healthcare, at its heart, is a business. Practitioners care about their patients, but their work is not an act of altruism. They do their jobs for a paycheck, just like the rest of us. If a patient doesn’t pay or a state safety net doesn’t take over at a reasonable rate, the practitioner will in most cases terminate. What does a psychotherapist do with a patient who appears to be at high risk for attrition either due to reliability or financial issues? It is unlikely that the therapist will continue treatment. Under these conditions, outpatients with severe mental illness are at a disadvantage in the market. They tend to earn less than other outpatients with milder issues, and they may be less reliable in coming to sessions because of difficult symptoms. As such, problems of stability and retention for clinicians could very well be issues for the complex PTSD community and others with severe mental illnesses (SMIs), making getting care more difficult.

The business aspect of therapy is always apparent to the client when the bill comes in, although the client may not consider everything that goes on behind the scenes. It is precisely these considerations that can be behind a refusal to treat or a termination. Financial pressures on the therapist can be very high. Take a practice in New York City, for example. It is a hard place to work as a psychotherapist, whether solo or in a group. Rent alone for 300 to 400 square feet runs approximately $3000 a month. At $225 per session, a typical hourly fee (most clinicians don’t take insurance), it will take a solo practitioner 13.33 sessions out of 30, the standard weekly number of sessions for therapists, to cover office space. The remainder, $180,000 after rent, including a four-week vacation may sound dreamy, but it’s barely middle class in the city. Monthly garage parking, for example, costs around $500 where street parking is scarce. These figures represent the lower end of the profession. When it comes to making enough money to keep up with the material items and activities of the profession’s social circle, therapists will be motivated as much as anyone else to maximize their profits, and that means screening potential clients carefully.

With these sorts of pressures at hand, the elephant in the room with trauma care and other forms of outpatient care for the severely mentally ill is the price tag, as well as whether a patient is considered reliable enough to stay in treatment and maintain the therapist’s base. In the world of mental illness, these concerns can create a no-man’s-land for complex PTSD clients: the territory between the treatment of inpatients who are diagnosed with an SMI and outpatient clients who have mild diagnoses in the Diagnostic and Statistical Manual. While inpatient funding often has links to government programs, payment for mild outpatient cases is usually based on good health insurance or the ability to pay out of pocket. In contrast, someone with an outpatient severe mental illness like complex PTSD may not be able to handle major life activities, such as caring for oneself, sleeping, concentrating, thinking, communicating, and working. From the client’s perspective, that can hamper financial access to treatment, because the client is unlikely to be able to pay in cash, probably doesn’t have health insurance, or the reimbursements from Medicaid are so far below the market rate that therapists rarely if ever accept the insurance.

It shouldn’t be a surprise then that from the clinician’s perspective, treating an outpatient SMI could be a bad business decision. Like all business owners, therapists screen clients in an indirect way. It may sound unethical — perhaps it is from a medical point of view — but it is a typical business practice. In the United States, health care is for profit. It makes no sense that a therapist should take on a client who will become a money-loser. This tension between the profit-making motive and medical care can be seen in a glaring omission in an otherwise excellent book, Healing. Thomas Insel, the former director of the National Institute of Mental Health, devoted a significant amount of attention in his book to inpatients and outpatients with mild diagnoses but had little to say about problems facing outpatient SMIs. One of the reasons, I suspect, is the difficulty of corralling and monitoring a generally unregulated free market to achieve improved medical ends. For example, therapists rightly or wrongly don’t lose their licenses or get disciplined for making a business decision that excludes the severely mentally ill from receiving health care. Decisions that deny access to treatment are not considered a gross breach of ethics, because the free market mental health care industry was never designed to treat globally. No one has a right to mental wellness.

It is this lack of a right to health care in the United States that plays a role in whether outpatient SMIs receive treatment. It’s both the reality of a client’s means and reliability that make it hard to enter into a clinical relationship, as well as the clinician’s assumptions about these means and reliability. In order to make mental health care truly accessible, we need a mental health care system that serves both the outpatient severely mentally ill financially, as well as clinicians. No discussion of mental health care access should exclude how business is conducted in the psychotherapeutic relationship, as well as what the market is commanding in fees and health insurance reimbursements. For that to happen, public discussion of the mental health care system has to acknowledge more openly that the free market is an essential element in who has access to treatment and how individual markets can be addressed for improvement.

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