In the common goodness and grace of God the twentieth century brought real advance in the area of psychiatry. New drugs were discovered and various schools of counseling were developed as knowledge increased regarding the human body and how the mind actually works. But a recent trend does not bode well for patients with psychotic and emotional needs. Health insurance plans show an increasing unwillingness to pay for real counseling. The result is that more psychiatrists are prescribing medications without therapy.

A recent study showed that in more than 14,000 sessions, the percentage of visits that involved actual therapy fell to 28.9% in 2005, down from 44.4% in 1996. The use of medication rose to 83.8% of all cases, up from the earlier number of 68.6%. Authors of a recent study based on these numbers suggest there is no hard evidence yet that this has harmed patients, but they are generally agreed that drugs and therapy should be kept together. The two approaches work “synergistically,” noted one physician.

The problem is in the health plans themselves. Some plans make it much more lucrative for doctors to prescribe medications, and alternative practices and methods are always slow to get coverage. This I have found out first hand in dealing with a chronic illness that the medical community took  many years to even recognize.

More and more psychiatrists are majoring in medication management, not in counseling. This could be a good news and bad news story. Some therapies are questionable for sure, but prescribing drugs without working on very real human psycho-social problems is not the answer either.

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  1. Helen August 19, 2008 at 10:28 am

    In my experience it’s better to get counseling from a trained counselor than from a psychiatrist. Counselors have lower hourly rates and more expertise in counseling.
    The model I’ve encountered is a psychiatrist and counselor working together – the counselor’s feedback to the psychiatrist helps him/her know how the medication is working and whether to make adjustments.
    I started out trying to get therapy as well as medication management from a psychiatrist, only to realize after a while that his interpersonal skills were not up to the counseling. After that I started seeing a different psychiatrist (who I also wouldn’t rate highly interpersonally but I trust his judgment on meds) and a different person for counselor (professionally qualified). This has worked way better.
    Drugs without counseling seems like a bad idea to me because I don’t know of any cases where drugs alone have effectively addressed the complex spectrum of issues that most people with mental health disorders are dealing with. I would always recommend counseling too and also lifestyle management not involving professionals (but counselors can help guide and direct that process) that help a person achieve a more balanced life. Like, managing stress levels, getting enough sleep, exercise, diet, seeking healthy relationships and moving away from unhealthy ones.
    It certainly is unfortunate if health plans are reluctant to pay for counseling. I’m glad that mine does cover it.
    There are all sorts of ways health insurance is its own worst enemy by being more willing to cover expensive and intervention methods than cheaper and prevention methods; this is just one of them.

  2. Rick Sholette August 19, 2008 at 7:11 pm

    Hey, John:
    In the 80s I worked as a clinician and consultant for one of the largest employee assistance programs in upstate New York during the “roaring twenties” of the counseling field, when insurance was happy to promote and cover counseling (especially brief counseling). Kemper Insurance was a leader in the occupational alcoholism (later employee assistance) field and encouraged the wedding of counseling and insurance as a strategy for improving the bottom line for business, industry, and government–it was too costly to ignore problems: accidents, absenteeism, job loss, employee turnover, illness, and on and on. Paying for counseling insurance or buying counseling services directly was cheaper in the long run, so we (I think properly) argued in our marketing efforts.
    I remember having a telephone conversation with the personnel manager at Motorola Corporation near Chicago in the early 80s. I was trying to market a combination wellness and employee assistance program to Motorola, using the standard and well-documented argument that doing so made financial sense. He didn’t buy it. His argument was that the more such services were offered, the more people would use them, driving up the cost of health care on that end of the teeter-totter and eventually being costlier. In a perverted way, he was prescient: several years later, as insurance companies struggled to pay for the explosion of counseling and treatment services across the spectrum of needs (alcoholism, drug addiction, marriage counseling, etc) managed care emerged as a solution to what had become perceived as runaway mental health care costs.
    Managed mental health care said, “We will review requests for counseling and treatment and make sure you–insurance companies–are not taken advantage of. We will do that by assessing needs and monitoring services, strictly eliminating all inefficiency and ineffectiveness.” To be sure, John, managed care did help along these lines, but it also shifted important treatment decisions from the provider and insurer to the managed care operation, which was primarily motivated by profit, and has since been a headache for both providers and consumers.
    I doubt that we will ever return to the golden days of counseling and treatment as in the 80s. Doctors increasingly medicate because counseling is less affordable and available (economically) than in the recent past. The economic conditions of our nation only make matters worse for the average working man or woman. Counseling is often out of reach monetarily.
    Enter the Church: imagine local churches equipped with well-trained lay people-helpers who can draw on the best of the social sciences, Scripture, and ecclesiastical wisdom to provide counseling services to needy people from the broader community as well as from the church family. Such a ministry in Jesus’ name would both bring glory to God and good to people–the double-barrelled purpose of creation and redemption.
    What an opportunity the Church has, handed to us on the empty plate of secularism. If only we Christians can seize the day.

  3. Don August 20, 2008 at 9:07 pm

    What rick seems to be suggesting seems to be echoed in this classic Jay Adams speach.
    Response to the Congress on Christian Counseling
    A large meeting of eclectic “counselors who are Christians” was held in Atlanta on November 10, 1988. This meeting–which they called a “Congress”–was organized and led by well known integrationist psychologist Gary Collins. At this Congress Dr. Adams was presented a plaque for his “pioneering work in Christian counseling.” The following response to that mixed multitude is vintage Jay Adams. Enjoy!
    Addressing this body strikes me as an anomaly, nearly as extraordinary as the time many years ago when in Korea (which was yet a backward nation) the famous dog story writer, Jack London, was told that an entire city had gathered to see him. As he viewed the vast crowd from the top of a platform erected especially for him, he couldn’t help congratulating himself that his fame had reached so many in this far-off region. But when he opened his mouth to speak, the official in charge stopped him, saying, “Please, Sir, remove your teeth.” Somewhat taken back by the request, he nevertheless did so. The crowd applauded. Then, amidst continuous applause, for the next half hour he stood there removing and replacing his artificial teeth.
    I want you to know that tonight I’m not so foolish as to congratulate myself over this appearance. As the coordinator rightly indicated when he invited me, I have been a source of irritation to many of you. I know also that I can’t consider myself one of you, except as we are brothers and sisters in Christ. Indeed, I came not knowing why you asked me. I do know, however, as London’s experience so vividly shows, there can be any number of curious reasons for inviting someone to participate in such a gathering. Why, it even occurred to me that you might have brought me here to induce me to remove my teeth! Of course, that’s not so easy to do; you see, only false teeth can be removed. On the other hand, my presence here may only prove what I’ve been saying all along: most Christian counselors are eclectic-so eclectic, indeed, that I could be included tonight. So, since I can’t occupy the remainder of the five minutes allotted to me as London did, I want to take advantage of this occasion to do two things: give you an explanation and extend you an invitation.
    First, the explanation. Contrary to what you may think, I have not spent the last fifteen to twenty years trying to refute (or even irritate) so called Christian professionals (psychiatrists, psychologists, sociologists) like yourselves. Had I intended to do so, I assure you I would have done a better job of it! No, I have not had you in mind. My efforts solely have been to help pastors who, according to II Timothy 3:17, are God’s professionals. That’s why the approaches and arguments in my writings are not tailored to you. Rather I designed them to expose to pastors the futility and dangers of attempting to integrate pagan thought and biblical truth. Moreover, while these negative measures are necessary to alert and inform pastors, my work is fundamentally positive. I am more at home with the construction gang than with the wrecking crew. Even a superficial survey of my books reveals that my greatest efforts are positive. In them I endeavor not only to provide concrete help in specific areas but also to set forth a biblically based system of theory and practice in a usable form that may be communicated easily to any pastor out there on the front line.
    Finally, whenever I mention names of those who publicly propagate views I believe detrimental to pastoral counseling and the welfare of Christ’s church, I want you to know that it’s their opinions I am assailing, not their persons. Anyone who puts forth ideas in order to influence the church (including me) should be ready to stand the criticism of the church. The important thing for you to recognize is that there is nothing personal in my critique.
    So much for the explanation; now, the invitation. With all that is within me I urge you to give up the fruitless task to which I alluded: the attempt to integrate pagan thought and biblical truth. In his latest book Gary Collins admits, “It’s too early to answer decisively if psychology and Christianity can be integrated.” Too early? Think of the millions of hours, the more than one generation of lives, already spent on this hopeless task! Why are there no results? I’ll tell you why: because it just can’t be done. Remember God’s words: “My thoughts are not your thoughts, neither are you ways my ways” (Isaiah 55:8). What does God tell us to do to resolve this radical antithesis? Integrate? No! In that passage He commands us to forsake our thoughts and our ways and turn to His Word, which He promises will not return void.
    Counseling has to do with changing people. But, you see, that’s God’s business. There are only two ways to change people: God’s way and all others. You simply can’t build a Christian counseling system on a pagan base; nor can you incorporate pagan teachings and methods into Christian counseling. Pagan thoughts and ways are at odds with God’s. God proposes to produce fruit (love, joy, peace, self-control, etc.) by means of His Spirit through His Word. Then others come along and claim they can produce love, joy, and peace apart from the Spirit and the Word. The two proposals and the methods that go with them are essentially competitive. That’s why they can’t be integrated. If the Old Testament teaches anything, it’s this: God doesn’t bless His competition. That’s why integration won’t work. I invite you to abandon this useless endeavor. Instead, come, join the growing number of those who are discovering that the way to construct a truly Christian counseling system is to begin with biblical blueprints, use biblical brick and mortar, and find Christian workmen to construct it from the ground up. Steer clear of the ‘me too’ approaches of those Christians who emulate the world. Rather get out in front of the pack, showing that world what God by biblical counseling can do!
    At the conclusion of one of Sam Jones’ evangelistic messages an irate woman said to him, “I’ll never listen to you again. You’ve insulted me. You stroked the fur the wrong way! ” “No,” Jones replied, “I stroked the fur the right way; the cat was facing the wrong direction.” Tonight I too have been stroking fur.

  4. Bradley Cochran August 21, 2008 at 11:20 pm

    Great Post.

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