It’s Not Personality. It’s Business.

Behavioral healthcare, at its heart, is a business. It’s not altruistic. Psychotherapists do their job for a paycheck, just like the rest of us. The practitioner is likely to terminate if the patient doesn’t pay or a state safety net doesn’t take over at a reasonable rate.

Under these conditions, outpatients with severe mental illnesses (SMI) are at a disadvantage in the marketplace. They tend to earn less than clients with milder issues, and they may be less reliable in coming to sessions because of difficult symptoms. These problems of stability and retention can make getting care more difficult for people with SMIs because these clients can be less reliable consumers.

Being a therapist can be challenging in terms of the nuts and bolts of running a business. While the profit aspects of therapy are always apparent to the client when the bill comes in, the client may not consider everything that goes on behind the scenes. 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, is barely middle class in New York. Monthly garage parking, for example, costs around $500 where street parking is scarce. These figures, it should be noted, 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 as motivated 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 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 financial no-man’s-land: the territory between the treatment of inpatients who are diagnosed with an SMI and outpatient clients who have milder diagnoses listed in the Diagnostic and Statistical Manual. While inpatient funding often has links to government programs, payment for milder outpatient cases is usually based on good health insurance or the ability to pay out of pocket. Someone with an outpatient severe mental illness may not be able to handle major life activities, such as caring for oneself, sleeping, concentrating, thinking, communicating, and working. These conditions can hamper financial access to treatment, because the client is unlikely to pay in cash, have health insurance or be able to receive reimbursements from Medicaid that are high enough to compete with the market rate for outpatient therapy.

It shouldn’t be a surprise, then, from the practitioner’s point of view that treating an outpatient SMI could be bad business. Therapists do carefully screen clients indirectly for financial viability. However unethical it may sound  — perhaps it is from a medical point of view — it is a typical business practice and is in line with for-profit healthcare practices in the United States. Accordingly, no one loses their license or gets disciplined for a refusal or failing to make a good referral, leaving many of the outpatient severely mentally ill excluded from the healthcare system.

This tension between the profit-making motive and medical care can be seen in a glaring omission in an otherwise excellent book, Healing, that presented new avenues for behavioral health in the United States. Thomas Insel, the former director of the National Institute of Mental Health, devoted a significant amount of writing to inpatients with SMIs and outpatients with mild diagnoses, but had little to say about problems facing outpatient SMIs. One reason, I suspect, is the difficulty of corralling and monitoring a generally unregulated healthcare economy to achieve improved medical ends.

No discussion of mental health care access should exclude how business is conducted in private practice, particularly concerning what the market is commanding in fees and health insurance reimbursements, and who these financial structures exclude. For people who suffer from outpatient severe mental illnesses, the financial barriers are great, leaving this population with insufficient or no treatment. Accordingly, universal healthcare is not just about covering each American citizen. It is also about making it possible for practitioners to address whole classes of medical conditions that are effectively rendered untreatable by a lack of reliable health insurance. The free market in the end is bad medicine.

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A version of this essay was first published at the website of the CPTSD Foundation ©️2022