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What About the Human Infrastructure?

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Last week a psychotherapy client called just minutes before her appointment to say she was running late because the Long Island Expressway had buckled in the recent heat wave. The road was so dangerous the police had closed it while crews made a quick repair. "I guess what they say about the infrastructure being in trouble is true," she said, wryly. Indeed, in the same week, the news media brought word that water mains were bursting in cities across America and the electric grid was so bad in the Mid-Atlantic that people were spending days without power after some big, but also typical, summer storms. Everyone seemed to be talking about how we are failing to maintain the physical networks and utilities that keep us going. But no one was talking about the other system crisis we face, the one having to do with our human infrastructure.

Just as surely as neglect will cause a bridge to fall down, failing to maintain ourselves emotionally, psychologically, educationally, and spiritually sets us up for dire consequences. And in fact, we have been neglecting our human infrastructure for decades. I know, because in my work as a psychotherapist I get to see how Americans live in an up close and personal kind of way. Just as a bridge inspector sees see the rust and rot that drivers never glimpse, I hear about the buckling and crumbling in the lives of people who struggle without adequate support.

The men, women, and children in my care are dealing with family problems including suicide, drug and alcohol abuse, job loss, evictions, and foreclosure. While the lucky ones get support from family, friends, therapy and (sometimes) medications, this safety net is frayed and full of holes. In this crisis-ridden economy, our friends and neighbors are dealing with their own stresses and, thanks to the problems in our health care system, even people with insurance have trouble accessing mental health care.

Still stigmatized in our culture, mental health care is so tightly controlled by insurers that great numbers of people are denied treatment by corporate gatekeepers who, using the vague but official-sounding term "medical necessity," deem it not worthy of payment. Those who are permitted to see a therapist are monitored closely. They often feel inhibited about using the services they are entitled to receive. So-called "care managers," who are paid to save money for insurance companies, pressure therapists by keeping fees low and demanding time-consuming reports to justify treatment. On the other end of the phone, I hear them struggling with the unkindness they are mandated to mete, according to scripts that they have been given, after hearing the harrowing tales from my client's personal lives. Medicaid and Medicare patients face even greater barriers to care because so few caregivers will work with these programs. The pay is just too low.

The effect of government and corporate policies that deny people access to mental health is quite similar to the effect of putting off maintenance on traditional infrastructure. The big difference is that instead of a structure or machine breaking, it's a person. Instead of a water main bursting, an angry husband hits his wife or a frightened senior citizen takes a drink. Instead of a school roof leaking, a youngster starts using street drugs.

Drugs and drink are two popular options for people who cannot access real mental health care but still need something to ease their pain. (I often refer to alcohol as our only legal and accessible mental health care.) Everyone who works in my profession knows that the epidemic abuse of prescription drugs like Oxycontin, Xanax, Valium and others is the direct product of the stress in our society and the absence of care for people who need it. (In my local hospital, more than half of the current caseload on the adult psych unit are oxycontin abusers.) The same is true for the abuse of street drugs and alcohol. People who have no alternatives will find a way to soothe themselves.

Sadly, caregivers have an increased need of soothing themselves, too. The squeeze put on us by the government and the insurance companies means that we often receive less -- and often a lot less -- per client hour. Major insurers have not increased the fee per session EVER since I began in the field in 1988. Some companies and Medicare offer even less per hour than I was paid as a new graduate. When you consider rent, malpractice insurance, costs of maintaining a practice, and a modest lifestyle, mental health professionals with advanced degrees are really experiencing strain. One of my students recently referred to mental health work as a mission, rather than a career.

The low pay is not just a problem for therapists. Increasing numbers of my colleagues are choosing to opt out of insurance plans, Medicaid, and Medicare entirely. Many, especially those with experience and skill, discover they can earn much more by treating only those who are able to pay two or three times the insurance reimbursement schedule out of their own pockets. Of course, this choice further limits the options available to people who are not well off, and it causes more than a little conflict in the hearts and minds of people devoted to caring for others.

The financial pressure faced by psychotherapists is a source of constant conversation in our professional community. It is especially evident in online forums where people share coping strategies and seek support. Typical is this comment recently posted:

I sincerely look forward to the time when I can simply decline to participate with insurance companies and will no longer have to accept the fees they set. But, truthfully, Medicare is worse than the worst insurance companies I deal with: Not only do they pay a lower fee, but they reject claims for no apparent reason -- as admitted to me by their own workers when I call to follow up.

Another therapist, who had made the switch to serving only those who could pay a higher fee out-of-pocket, defensively wrote: "Some of you may recoil in horror about these ethics, but not everyone is so altruistic."

These discussions initially shocked me. My social work training requires me to provide quality services to all groups, equally. But these days, clinicians often cannot make ends meet themselves, and the quality of care can only deteriorate as a result. Realistically speaking, we should not expect that a therapist who tends to our human infrastructure will happily accept being paid less than an engineer who tends to our physical infrastructure. Both jobs require advanced skills and education. Both are essential to the proper functioning of our society. Both must be maintained, or worse problems develop due to neglect. You may already being seeing this dire outcome on the roads you travel every day. I know I am seeing it in my office, hour by hour.

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