Thursday, March 30, 2006

Mental Health Parity and Insurance Costs

Parity in mental health and substance abuse coverage is a goal for many advocates for the mentally ill. Normally, insurance coverage for treatment of so-called "mental illnesses" (I'll deal with that term on another day) and addictions has it's own sets of limits, in some cases draconian. Parity in mental health and substance abuse coverage means that people have the same co-pay, deductible, and visit limitations as they do for traditional medical care.

The argument against parity has been that it would increase insurance costs significantly. The fear has been that people would sail into long-term therapy or stay in the hospital indefinitely, leaving insurance companies to pick up the tab. This article, by Goldman, et al., (there are 14 authors!) in The New England Journal of Medicine challenges that assertion.

The background is simple. In 1999, President Clinton directed the Office of Personnel Management to ensure parity for federal employees. Parity was established on January 1, 2001 for all 8.5 million enrollees in the federal system. This figure includes retirees and dependents along with the federal employees.

The authors matched 9 federal insurance plans with parity to 9 similar non-federal insurance plans without parity. They matched them on features of the plans and geographic location. They then compared the costs of the plans over the years 2000 (prior to parity) and 2001 (after parity).

From 2000 to 2001, costs of both plans rose the same amount. Had parity increased costs, the plans with parity would have increased more than the plans without parity. Because they did not, Goldman, et al., concluded that parity did not increase insurance costs.

I have a couple of of quibbles with this study. First, I'm not convinced that they matched the federal and non federal plans very well. I'd feel a lot better if they matched the plans based on the demographics of the enrollees. We know that variables such as socioeconomic class can influence rates of mental illness and substance abuse.

Second, I'm not sure that one year is enough to see a trend in costs. The major costs come from treatment of chronically mentally ill, especially in inpatient settings. That might take several years to emerge.

Finally, I'm uncomfortable with the statistical analysis. Part of it is my problem. They used a technique called "difference-in-differences" analysis, and I'm unfamiliar with it. Googling indicates that it's frequently used in epidemiological research, but I'd feel better with a parametric test, such as ANOVA. Their willingness to base conclusions on negative results furthers my uneasiness. However, they do have this to say about it:

A finding of negative results always raises the question of whether the effect of parity on use and spending was really limited or whether the evaluation lacked the necessary power to detect an effect. Two factors lead us to believe that the effect really was limited: the estimated differences between the results for enrollees in the FEHB Program and comparison enrollees were relatively small in magnitude. The sample sizes used in the analysis were large and were sufficient to show significant effects of similar policy measures, such as the effect of carving out mental health and substance-abuse care while holding the benefit design constant. (p.1384)

It's not a bad argument, but it's still somewhat shaky. On the other hand, there is an argument supporting parity which has been well documented. Providing mental health and substance abuse treatment costs brings down the costs of other medical services, especially in primary care.

Overall, this study throws the ball back into the anti-parity court. On a logical basis, it's really up to them to show that costs do increase. Goldman, et al., have shown, if nothing else, that the data is out there, just begging for analysis.

Unfortunately, I doubt we'll see any more data analysis. The belief that we need to save money on mental health treatment is very entrenched, and it seems to fall into the don't-bother-me-with-the-data-when-my mind-is-made-up category. It's like the belief that raising the minimum wage eliminates jobs. Every time we do it, the economy booms, but people still repeat that objection over and over. Still, this study is a start in a long overdue discussion.

Wednesday, March 29, 2006

Red Bull + Vodka = Bull

An interesting article in Seed Magazine, entitled, A False Tolerance for Red Bull, tests a popular misconception on college campuses. Students have been mixing vodka with Red Bull, an energy drink, believing that Red Bull moderates the effects of alcohol.

It doesn't. Drinking Red Bull does give the drinker a little energy, so it moderates such internal sensations of intoxication, as sleepiness. In the study, objective measures of reaction time and fine motor coordination still revealed impairment. The person's ability to judge their own intoxication is more impaired. There's a serious risk they'll drink more, miscalculation how drunk they are.

Mixing Red Bull and vodka may make for a good-tasting drink, but it can also raise alcohol intake. In turn, it may increase risks related to intoxication, such as drunk driving or date rape. I hope this data gets publicized on campus, not that many students will listen until it's too late.

Tuesday, March 28, 2006

"Deconstructing" Psychology

Every time I hear about "deconstruction" I feel old. Granted, I'm coming up on 60, but I still do keep up. Well, sorta. I still haven't gotten an MP3 player or a Blackberry yet.

Anyway, I encountered an article entitled, "Theorising Critical Psychology In Psychiatric Practice: Six Voices Interrupting Pathology" by Burman, et al., on the on the Social Practice/Psychological Theorizing web site. In it, the authors say,

Critical Psychology is the Practical Deconstruction of every attempt to normalise some kinds of behaviour and experience and to pathologise others.

Psychology is constructed within the horizons of capitalist society to enable that society to run more efficiently, and it constructs within that society its own images of pathology. Part of the political activity of challenging the construction of psychology is the unravelling of what we have made. The process of critique is also a process of deconstruction. It must include a practical political alliance with all those who suffer psychology and who are starting to refuse the way they have been constructed as pathological. It is a political question that calls for practical deconstruction of the theories and apparatus of the discipline of psychology. (p. 4)

This kind of nonsense really annoys me. First of all, it mischaracterizes those of us who practice in the field. We're a lot more heterogeneous than Burman, et al., let on. I characterize my politics as left of center. I've known psychologists much further left of me and some psychologists who are a little right of Atilla the Hun. The American Psychological Association (I'm not a member) has certainly taken some left-wing positions, such as support of abortion rights. To argue that, "Psychology is constructed within the horizons of capitalist society to enable that society to run more efficiently," is simply silly. Our first responsibility is to our clients. Our second responsibility is to society.

We work to help our clients function more effectively within society, but it is within the context of their goals, not ours. In some situations, we do help our clients become better workers. An employee with a personality disorder may cause chaos on the job, and we owe it to both the client and the employer to stabilize their behavior.

In other situations, we don't help the employer. I doubt there is a practicing clinician who hasn't tried to help a client work less overtime so they could be more attentive to their loved ones. That certainly doesn't help the employer.

Juggling our priorties can sometimes be a problem. We may help clients to get over losses when they have been asked to leave a social club. But if that client decides to go back there with a gun, we have an obligation to society to stop them by notifying the police and having the client hospitalized. Balancing a person's rights against society's is complicated and messy. When rights conflict, we may be forced to do what causes the least damage. Politics and power be damned.

Politics, power, and feminism always get mixed together in deconstructionist writings, and Burman, et al., are no exception:

Because models of development privilege the culturally masculine, they position women, black people and even children as culturally deficient and inferior. Their experiences are treated as mere steps on the evolutionary ladder to modern western developmental maturity. We can challenge this by pointing out the covert ways women and black people and children are considered less rational, or madder, than white middle class men.

The problem here is two-fold. First, psychology is rapidly becoming a female profession, so why culturally masculine concepts should be retained is beyond me. Second, historically, the field has been very concerned with filtering out sexual and cultural stereotypes in diagnosis and treatment. Hollingshead and Redlich (1958) were probably the first to show that people with of lower socioeconomic status are more likely to be diagnosed with more serious pychiatric illnesses.

So, it's an old problem and we continue to recognize it. We're a long way from having completed the process, but a fascinating article by Hyde (2005) deals with gender similarity and differences in a new and exciting way. This article can be found online by clicking here.

I could rant and rave about a lot of the nonsense in this paper, but I'll make one final point. There is no doubt that culture, perception, and mental health interact. Certainly, our definition of mentally ill behavior has changed over the years. However, Burman, et al., refer to psychotic speech or thought disorder as a "a construction of the psy-disciplines" (p. 6-7). That's nonsense. Anyone who has spent 5 minutes talking to a floridly psychotic person can see that there is something truly wrong. I have never encountered any evidence to suggest that a thought disorder in any society was ever truly accepted as normal or desirable.

There is such a thing as objective reality. Because reality is complex, it's often hard for us to differentiate it from our prejudices and stereotypes, especially in my line of work. But, it's there, and I believe that the closer we come to reality, the better we function. That's a big part of the way I do therapy.


Hollingshead, A. B,. and Redlich, F. C. (1958). Social class and mental illness. New York: John Wiley.

Hyde, J. S. (2005). The gender similarities hypothesis. American Psychologist, 60, 581-592.

Monday, March 27, 2006

Who is Operant and Why Does He Need to be Freed?

I mentioned in my last post that the title for my blog was drawn from one of the first psychological concepts I learned in college. My name comes from my graduate training in behavior therapy.

An operant is any overt behavior, which is potentially controlled by either stimulus, or a consequence. The stimulus is called an antecedent, because it happens before the response occurs. The consequence is either reinforcing or punishing, which means that it affects the frequency of a behavior. A free operant is a behavior that happens without systematic application of antecedents or consequences. Some might say that my views are free operants, depending on how worthy they are of being ignored. Still, it's a pleasure to write about them and to explore them myself.

So with my nom de blog, I pay tribute to my graduate training. Make no mistake about it. I hated the graduate school. After graduation, I still had to return to campus on occasion. I felt my anxiety rise the moment I walked into the psychology building. It was a tribute to the power of classical conditioning.

Nevertheless, I got excellent training there. I passed my licensing exam on the first try, and not too many people could say that. I passed because of the education I got there.

Sadly, I have to post anonymously in order to protect both my clients and my employer. I don't want my clients to worry that they might appear on the internet. The views that I post are mine alone, and not my employer's.

Sunday, March 26, 2006

Who am I?

I am a psychologist, and I practice in central Pennsylvania. I've been doing this a lot of years, having interned in the 1970's. I've taught, I've worked in institutions and hospitals, and I've done private practice. Right now, I work in an outpatient clinic in a good-sized corporation.

I hope to use this blog to discuss clinical practice. I won't be discussing "cases," because I won't violate my clients' confidentiality. Instead, I'll be talking about the science of psychotherapy and the life of a practicing psychologist.

Is psychology a science? Absolutely. It's roots are firmly embedded in empiricism. However, the practice of clinical psychology is not a science. Neither is medicine.

No medical or clinical endeavor can be a science, because healing is not systematic. The practitioner must treat the problems that come in the door, regardless of whether the research is available or not. Often, treatment decisions are based on hunches or past experience, hardly systematic or empirical. The best we can do is make each client into a one-person experiment. Sometimes, even that's difficult. We do the best we can if we want to make a difference.

A difference? Sounds like the title to this blog. That brings me to why I selected Just Noticeable Differences for the title of this blog.

When I was a lowly undergraduate, one of the first psychological concepts I learned was the "just noticeable difference," or jnd. It comes from the psychology of perception and refers to the smallest change in a stimulus that can be perceived. For example, if I compare two lines, what is the smallest difference in their length that is perceptible?

The jnd is one of the first, if not the first, empirically based psychological concept. It's still important today, as we try to construct readable gauges and other displays that reflect change.

Change is what I try to elicit from my clients. I'd like to think that I get a few jnd's of change from most of my clients.