- Financially Better for Clients. This maybe counterintuitive, but paying out of pocket for many healthcare services has been shown to actually be the same or less expensive. The average number of sessions I see clients in a year is 21. Here’s the math: 21 Sessions x $159/session = $3339. That’s a big chunk of money. But…whatever is not reimbursable to you by insurance is often tax deductible. Most healthcare expenses can also be paid directly with an HSA or FSA. Additionally, more and more families are choosing high deductible, lower fee plans. Pay $5000 deductible and then insurance kicks in. That’s after you’ve paid your $833/month.
- Less Complication. It takes longer to verify insurance, verify their plan covers my services and ensure they can be seen It is a fact that every document or form that needs to be sent to insurance is an opportunity for them to avoid financial responsibility. I’ve had dozens of situations where my office manager would send in a form and the insurance company would first claim they never got it. We’d resend it. Then they claimed it was not completed correctly. Resend after corrections. Then they would claim it was incomplete. This game can last up to a year (I’m still getting payments from insurance claims filed over a year ago).
- Clinical Decisions are Not Driven By Insurance. I’ve had way too many instances where an insurance company told me or the family that the client ‘no longer met criteria for services.’ What? How the heck would they know that? It’s based on the number of sessions they allot, the diagnosis I gave and how much money has been spent. At no time does insurance actually review my notes, talk to the client or family or inquire about the clinical status. No thanks – I don’t want insurance professionals making decisions for my clients. And just in case you were thinking it, I’m not a right-wing, libertarian nut job. This is actually my progressive, liberal side coming out advocating for my clients against huge companies whose sole business model is to take in as much money as possible and avoid contractual obligations.
- Flexibity. No insurance company has ever liked hearing that I’m on-call for clients and use texting, video chat, etc. to continue treatment and support between sessions. They also are not fans of me working with parents in a consulting manner. They don’t want to hear that I provide insider knowledge of treatment programs. None of this fits within their narrow definition of what a counselor should do. I do what is necessary to create stability and promote a healthier life.
- Protection. Until there are safeguards that protect clients from being blacklisted for a preexisting condition (ACA is currently under attack from the Trump administration for this) I’d prefer not be forced by insurance companies to diagnose a client. For me to get payment, I have to provide client’s name, diagnosis code, CPT code (what service I provided), my license information, and my NPI (national identifier for healthcare professionals). If I fail to provide any of that, the claim with be denied. In my opinion, there is no reason why a company needs evidence that a client has a diagnosible condition. I totally understand requiring all the other information but diagnosis is unnecessary. At times, a diagnosis is important for the client or family to hear and understand.
For years I’ve been talking about the unethical and illegal means by which mental health and substance abuse treatment centers advertise to and treat clients. And now, finally, in one of the most accurate portrals of the industry, The Verge published a fantastic piece on the aweful practices large addiction treatment centers. From the manipulative call centers to terrible and dangerous clinical work, Cat Ferguson (freelance reporter based in California) exposed the seedy underbelly of this mostly hidden industry, predominantly in Florida. She focuses on Aid in Recovery, a sketchy hotline with a bazillion different phone numbers and websites (all of which are owned by a parent company Treatment Management Company) that funnel prospective clients (with good insurance!) to one of their affiliated treatment centers around the country. AIR is not unique. Hundreds of huge companies fight, cheat and steel every day for referrals. My one critique is that Cat didn’t pull in examples from the mental health treatment centers which are as aggressive and sketchy. Same bad actors engaging in greedy behavior to get clients.
The article reaffirms why it’s so important to work with a therapeutic placement consultant or educational consultant who knows what to avoid and how to find the most effective treatment. Not a sales pitch – just a fact that a good consultant can sniff out the industry bullshit from a mile away.
For years I have listened to parents’ tales of wasted time and money as they shifted from one therapist to another, one residential treatment program to another without experiencing the progress they anticipated. What parents don’t know costs them big time. Tens of thousands of dollars in expensive, non-evidence based treatments along with countless hours searching generic databases that don’t really help someone understand the differences in care and how to tell good interventions from bad.
Yes, this happens to be one of the services Fonthill Counseling provides but even if you do not use us, take these suggestions to heart. We offer a free consultation and will help you determine if higher level of care like residential treatment is even a good fit for your struggling teen or young adult child.
1. Professional Advisement
Chances are, if you’ve ever bought a house or had surgery, you consulted with a professional within the respective industry. So what do parents think when they start their online searching for treatment options? Do they honestly think they know how to determine the quality, effectiveness and safety of a program from reading through a website or spending 10 min on the phone with an ‘admissions counselor?’ There is WAY more to choosing any sort of therapeutic intervention than the list your insurance provides or what you find on Psychology Today.
A high quality professional advisor (aka Educational Consultant or Therapeutic Placement Consultant) will know if insurance will cover expenses AND (…and this is the important part) how to actually GET insurance to pay. They know when a kid is appropriate to remain at home and start/continue with outpatient therapy and when they are no longer appropriate for home and need a higher level of care. They will also know the positives and negatives of programs that are clinically, financially and logistically the best fit for your loved one. One program we worked with for years had lots of staff turnover which resulted in 2 suicides in close succession. We no longer refer to them. Guess what? That program does not advertise about the suicides.
Even if you are just doing preliminary search to see what might be available for your acting out son or daughter, whether you’re thinking about therapeutic boarding school, residential treatment for substance abuse or an eating disorder, or you’re looking for a treatment program for depression or anxiety, find a professional.
WARNING! Stay away from any ‘professional’ that is offering advice for residential treatment, therapeutic boarding school or a therapeutic wilderness program but does not have any clinical credentials. Look for professionals that have at least a master’s degree in counseling, psychology, social work or marriage and family therapy. Also, and this is REALLY important, make sure they are licensed in some clinical field (Licensed Professional Counselor, Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, etc.). Many, many professionals are providing advice without really having a formal, clinical background.
Every parent asking us for help starts out by saying their highest priority is ‘quality’ or ‘effectiveness.’ But once we start drilling down into details, reality mandates compromise. One of the biggest realities is cost. Cost matters… and it should. It’s not healthy, and certainly not necessary, for parents to think it’s appropriate to spend any amount to fix a problem. Residential treatment can cost between $400 per day up to $80,000 per month. Insane. What many parents don’t realize is the ‘retail price’ quoted by a treatment program admission counselor (…price is almost never posted on their website) is often not set in stone.
Let me explain. If a parent calls Fonthill Counseling and needs to find an eating disorder program in the mid-West for their college-aged daughter, it’s likely we’ll contact Timberline Knolls (pretty good program located in Illinois). If the parent calls Timberline directly, they’ll get a daily or monthly rate quoted to them with a minimum length of stay. Now, if Fonthill Counseling calls, we can negotiate a lower rate along with other accommodations (ie. single vs double room, admission date, etc.). Most programs also have ‘scholarships’ or supportive funding they can tap when their numbers are low. They’d rather have full client roster but less income per person rather than few clients and even less income since their overhead costs do not change much based on census.
But now we have to back up a bit and talk about insurance. Bottomline – insurance does NOT want to pay for residential treatment. Ever. It’s vital that if you think your son or daughter needs a higher level of care, you have your professional get a) a psychological evaluation conducted and b) preauthorization. Here is a link to more details on getting insurance to pay for treatment. If you do not submit that to insurance or if the residential treatment program fails to submit it (and they are in-network) your chances of having insurance cover treatment is very, very, very low. If your insurance covers medical inpatient and residential treatment, they are required by law to pay for mental health residential treatment. Insurance companies will argue with you on this but its the law.
Unless the client is very motivated to participate in treatment, we recommend having your professional find a transport service to transition from home to treatment. These are not thugs in black shirts that throw a bag over your kid’s head and drag them to a running van. These are often well-trained professionals using counseling skills that create enough rapport and trust to get your kid to voluntarily get into the car. Like any service, there are sketchy people trying to make a quick dime and true professionals with exceptional interpersonal skills (we’ve used Right Direction Crisis Intervention many times with great success). Insurance will never cover this but definitely worth the cost.
Why not have parents escort their own kid? Unless you have great rapport and the issues leading them to treatment have nothing to do with trust issues, running away, drugs or medically complicated issues, parents do not have the clinical skills in supporting kids during a powerless experience like transitioning from home to residential treatment.
4. Quality Control
At Fonthill, we call this ‘oversight.’ Hiring a team like Fonthill ensures through regular email, phone and treatment team meetings their is unbiased, third party oversight over the treatment plan, therapy and communication at the residential treatment program. Most of the time, we are talking with the therapist and interpreting their clinical impressions back to the parents. Since parents are not clinicians, the terms and progress may not make sense but to us, we can sift through and quickly understand how things are going. Residential programs also treat clients with greater attention to detail than those without the same oversight.
How do you know when your child is ready to leave? When can you trust the treatment program is being honest about progress? What should be set up at home, in the community or back at college to ensure your money was not wasted when they transition back to real life? In our humble opinion, the first day of intake should be the first day of discharge planning. We ensure the residential treatment program has a measurable treatment plan with clearly identifiable goals.
As we get close to discharge, as the professionals circle up and agree that he or she is ready to return home or back to campus, Fonthill Counseling will often link with a therapist, psychiatrist and case manager and make sure all appointments and documentation is set up way before. This is sometimes called aftercare, community-based living, or step-down. The final discharge meeting should just be a big hug-fest since all the prep work has already been done.
We like to have the first therapy session take place within 24 hrs of discharge. First medication management appointment should be within the first 72 hrs. Case management continues to provide that oversight and continuity, making sure the treatment plan from residential treatment is modified and extended into real life. Typically, we are providing parenting support, on-call support if something goes wrong, and linking with school personnel to help the kid get back on track.
Finding residential treatment is much larger a task than what folks realize but with a little support from a professional, you can avoid wasting resources that would be better spent on your family.
This is our second installment on how to get insurance to pay for residential treatment and therapeutic programs. Below is some great information to help you beat the insurance companies at their own game. Insurance companies count on your ignorance, laziness and distractibility to avoid paying for services they are legally obligated to cover.
With the Affordable Healthcare Act and the Mental Health Parity Act in full swing it’s time to learn how to get the most out of the insurance you pay for. We’ve included some tricks, strategies and how-to’s to help you out. Though we’re focusing on Residential Treatment for our discussion here, this info is applicable to therapeutic programs like wilderness programs, therapeutic boarding schools and intensive outpatient programs.
Ok, let’s get started with some basics…
What If I Need Additional Help?
First, read through everything below. These strategies are time consuming and require steady attention but they are not impossible. If you still don’t feel confident in holding your insurer accountable, contact us for a free consult and we’ll help you figure out how to move forward.
What is the Insurance Company’s Criteria for Residential Treatment?
…Or more importantly, how does an insurer define residential treatment? Each insurer has their own definition but most have virtually identical criteria. For our purposes, residential treatment is defined as specialized mental, behavioral health or substance abuse treatment that occurs in a residential (overnight) treatment center where the provider is responsible for clinical service, safety, shelter, and food.
Licensure differs by state, but these facilities are typically designated either as residential, subacute, or intermediate care facilities and may occur in care systems that provide multiple levels of care. Residential treatment is 24 hours per day and often requires a minimum of one physician (or psychiatrist) visit per week in a facility based setting.
What Specific Criteria Do They Look For?
Now, let’s drill down a bit more and look at some of the more common criteria requirements insurance companies are looking for when determining whether to pay for residential treatment to a struggling teen or young adult.
- Was there a sincere attempt to first use evidence-based outpatient therapy in the home community by a licensed professional before residential treatment was requested and outpatient therapy did not work? Basically, they want evidence that you tried outpatient therapy with weekly sessions (or more often) and because it was not effective, a more intensive level of care like residential treatment was justified.
- Prior to admission, did you contact your health plan for list of in-network residential treatment options? More on this later – what to do if you can not find a good option.
- Is there uncontrollable risk-taking to self or others or other dangerous behavior?
- Has there been a documentable and rapid decrease in level of functioning in one or more life domains. Another way to describe it is a decline in functioning resulting in the ability to perform self-care.
- Is there a likelihood of no improvement in current environment (ie. home or college)
- Is there a reasonable expectation that patient will improve in residential setting and be able to return to outpatient therapy for aftercare?
How to Request this Higher Level of Care?
Now that you understand the criteria, let’s talk about how to actually request residential treatment.
- Write a letter strongly recommending admission to residential treatment
- Provide copies of assessments and testing performed by a licensed professional that indicate 1) a formal diagnosis and 2) specific recommendations that list residential treatment.
- Explain how outpatient therapy has not been successful
- Explain why current circumstances make it unlikely that patient will show improvement (ie. Improvement is not likely in home setting due to social stressors such as negative peers that sell drugs but remain in the environment)
- Document unsafe, declining behaviors – show symptoms and behaviors that represent a decline from usual state and include either self-injurious or risk-taking behavior that cannot be managed outside of 24 hr care. Can your kid maintain abstinence outside of 24 hr care?
- Explain that the residential treatment program uses evidence-based clinical interventions.
- Request the residential treatment program directly contact your insurer for pre-authorization. Pre-authorization is the insurance company’s way of giving formal permission to use a higher (and more expensive) level of care. Make sure to obtain the tracking number and verification of the call from the residential treatment program. If approved, obtain written authorization confirming admission approval.
After you send off your request, your insurer should should respond in 5 days. Don’t wait that long – call them every day to find out the status of your request. Yes, seriously – call every day.
Accepted! Now Some Additional Insurance Mandates
The insurance company accepted your request (more below on what happens when they do not accept it) and a wave of relief comes over you planning for some quiet time once your kid is safely transitioned. But before you get too comfy, there are a few things you want to make sure the residential treatment program will do to ensure insurance covers as much as possible. It’s easier to ask these questions during the admissions process rather than at discharge. Here’s a list of what to look for or ask for:
- A basic physical during admission (urine screening for drug facility)
- Onsite nursing and 24hr access to med care
- Multidisciplinary assessment (also called a Biopsychosocial Intake) performed within 72 hr of admission, including information obtained from patient’s previous providers (ie. therapist, primary care physician)
- Individual therapy with a licensed therapist (ie. LPC, LCSW, LMFT) at least one time per week
- Weekly meetings with doctor for medication management
- Weekly family therapy
- Discharge plan created one week after admission which acts as a set of exit criteria
- Licensed in the state in which they are located. Some facilities are owned by huge companies in another state. Make sure they are credentialed and licensed.
Denied. Now on to The Appeal Process
Denials are just a way of life in the therapeutic treatment world but it’s certainly not the end. Here are some information on what to do when you experience a denial.
- First Thing – Do not let the denial get you mad and do not attempt to use logic, common sense or science to understand why. Insurance is a business and their business model is take in money and pay for as little service as possible – period.
- If residential treatment is verbally denied, request written denial. They must deny in writing and often will send the residential treatment program as well as the insured person a copy.
- Do not just ignore the denial and send your kid off unless you are willing to pay out of pocket and work your tail off at discharge to get the insurer to pay for it.
- How to appeal depends upon the reason for denial. The insurance company will likely list specific criteria either your kid or the residential treatment program did not meet.
- If the insurer states that residential treatment is not a covered benefit but they offer other mental/behavioral health benefits, they are required by law to pay. In Harlick v Blue Cross of California – On August 26, 2011 the court confirmed that California’s Mental Health Parity Act requires health plans to provide coverage of “all medically necessary treatment” for “severe mental illnesses” under “the same financial terms as those applied to physical illnesses,” and are obligated to pay for residential treatment for people with eating disorders even if the policy excludes residential treatment.
And It’s Still Denied – What Next?
If you submit an appeal with additional information and site the law but still are denied or hear nothing, you can request an independent review from your state’s regulatory body that oversees insurance compliance. It’s amazing how quickly insurance companies can ‘find missing paperwork’ or reverse a denial when regulators and attorney’s get involved.
- Send a certified-mail cover letter describing the dispute
- Provide all relevant evaluations, assessments and testing you already sent to the insurer
- Submit a doctor’s letter stating care is medically necessary
- You can also hire an attorney that specializes in insurance issues like this. They are often worth their specialist price tag.
Plan B – If You Can Afford It
If residential is denied and you don’t want to push the insurer for whatever reason, you can pay out of pocket for room and board and try to get the clinical services covered. This approach is often what is equivalent to out-of-network coverage. The insurer is more likely to cover outpatient therapy, group therapy and medication management (virtually the same as if client was living at home and going to therapy).
You can also request that the residential treatment primary therapist get a single case agreement which forces the insurer to pay at in-network rate and you only owe the copay, as usual.
What if Our Family Member is at Therapeutic Boarding School?
With the growth of therapeutic boarding schools, we’ve received a ton of questions about how insurance pays for the clinical aspects of these hybrid programs. Here are some tricks we’ve picked up over the years:
- Think like the insurance company – they want to hear your son or daughter is being referred to as a patient and not a student.
- Make sure to request a physical assessment is done at admissions. This promotes the perspective that he/she is a patient and not a student. Remember – we want the insurer to understand this is a therapeutic program, not as much an academic program.
- We also want to ensure the program is keeping daily records such as treatment plan updates, nursing and medical notes and service notes – health plans will want copies. We want to be documenting progress as well as setbacks.
When we conduct placement services, we always request the therapeutic program develop a treatment plan with some specific exit criteria. The first day of treatment is the first day of discharge planning. Some plans will want exit criteria so err on the side of having the program provide it early on. It’s also a good clinical practice to give the providers a clear target.
In Which State Should Insurance Regulators Be Notified if Insurance Refuses to Cooperate?
The state in which treatment is being provided is where insurance regulators should be contacted if your insurance company refuses to play nicely. The state in which you live may be where your insurance is attached, but legal oversight for provision of service and insurance regulation is in the treatment state.
Can Insurance Pay for Services Retroactively?
Theoretically, yes. Practically, it’s pretty difficult and will require regular attention and contact with the insurer. They will likely ‘lose’ applications, claim forms and anything else you send. If you get insurance to agree to pay for residential treatment or other therapeutic services after treatment has started, you can request for retroactive coverage. It’s best to write a letter (and send it certified mail and keep a copy for your records) stating why you didn’t understand or it was not stated clearly in a policy that treatment was covered.
Will Insurance Cover Partial Hospitalization Programs (PHP)?
Partial Hospitalization Programs or PHPs is typically a level of care designed for individuals who need structured mental health, behavioral health or substance abuse programming but do not need 24-hour supervision (ie. inpatient or hosplitalization). Many hospitals and residential treatment programs offer partial hospitalization or day treatment services. Good PHPs are designed to provide support, education, medical monitoring and accountability during the hours of the day often identified as most troublesome for patients. Patients participate in therapeutic groups, structured activities and discharge planning similar to those offered in the inpatient and residential programs. Many patients who have been in an inpatient or residential program can “step down” to this level of care because it continues to provide a high amount of structure and support.
Insurance generally covers PHP at a per diem rate (daily rate) but will not cover overnight which the hospital or treatment program may charge extra for. Make sure to clearly understand how the treatment center charges for PHP before signing up. Also make sure insurance covers it and what portion it covers.
So we covered several of the topics and tricks that can help you navigate the insurance company maze when it comes to paying for residential treatment. If you need additional help, contact us today – email@example.com
Many years ago I had the pleasure of visiting The Renfrew Center just outside of Philadelphia, PA. At first, I wasn’t sure if this was a gigantic private residence with it’s ancient stone farm house, stables, and quintessential barn. Definitely one of the more beautiful suburban locations for a treatment center I’ve seen. I had my tour of the grounds which look more like an upscale farm (in a good way), talked with the Executive Director about mental health under a giant oak tree, and got to know the program schedule as young women shuffled in and out of the various buildings. Below are more details on Renfrew with my Final Thoughts at the end.
The Renfrew Center is headquartered in has been serving women with eating disorders and behavioral health issues since 1985. As one of the nation’s first residential eating disorder facility, with 16 locations throughout the country, Renfrew claims to have worked with more than 65,000 women since their founding. The Renfrew Center has experienced it’s most significant growth in the last decade and a half have with the additional of programs across the country.
The Renfrew Center offers a full continuum of care that supports patients well beyond a residential stay. This comprehensive range of services available at most of their locations, includes day treatment, intensive outpatient and outpatient programs. The services are tailored for each patient and with her referring therapist to develop treatment plans and goals based on her unique needs.
Renfrew maintains continuity in philosophy and approach throughout the individual’s treatment, while facilitating timely transitions from one level of care to another in order to maximize treatment and insurance benefits.
Residential services are only offered in their Philadelphia, Pa and Coconut Creek, Fl locations.
Renfrew works with women over the age of 14 suffering from anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified (EDNOS) and related mental health problems.
Residential – $8050 per week
They work with most insurers so a significant portion of services may be covered.
Employees on multiple sites give Renfrew some terrible grades for working conditions, diversity of the work force, and work-life balance. Most notably were many comments on Renfew’s seeming focus on profit and not much focus on treatment. They also described poor, untrained supervisors that did little to organize chaotic situations.
Clients on the other hand often report having a positive experience and feeling somewhat nurtured. There were dozens of reports from clients going back to Renfrew multiple times for support. This could be viewed as good or bad.
The New York location stood out with many, many negative reviews which highlights an ongoing theme among larger providers like Renfrew – when it comes down to actual effectiveness of a program, everything has to do with the clinicians at specific locations and very little to do with the corporate handlers up above.
Here is a link to their online contact form which is probably the best way to get ahold of them.
Oh how I wish programs like Renfrew could just slow down and focus more on quality. I’ve known too many therapists over the years who think poorly of Renfrew’s clinical integrity to feel comfortable referring clients that come to Fonthill. That said, it doesn’t mean women struggling with an ED should avoid Renfrew. I think programs like this have a place in the menu of options, especially if you want treatment close to a major metro area like Philadelphia. Just make sure to make a decision on more than what the admissions folks at Renfrew tell you. Look up reviews, talk with outpatient eating disorder specialists (like Dr. Joanna Marino in Washington, DC) or placement specialists (…like Fonthill ) and do your homework. It’s expensive and takes a huge amount of time to go to Renfrew so don’t rush in.
Since paying for therapeutic treatments like residential treatment, intensive outpatient program and therapeutic boarding school with insurance is a big topic we’ve broken this into a few different posts. Today, we’re starting with the basics of the health care act that tightens up the requirements for insurers. Historically, insurance paid for outpatient services and residential treatment was only for more affluent families. But thanks to the mental health parity act, insurers are not more responsible than ever for paying for higher levels of care.
What’s the Mental Health Parity Act?
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires many insurance plans that cover mental health or substance use disorders to pay for coverage for those services that are no more restrictive than the coverage for medical/surgical conditions. Basically, if they pay for medical stuff, they have to pay for mental health and substance abuse stuff – that’s the ‘parity’ part.
What Does it Cover?
- Copays, coinsurance, and out-of-pocket maximums
- Limitations on services utilization, such as limits on the number of inpatient days or outpatient visits covered
- Coverage for out-of-network providers
- Criteria for medical necessity determinations
MHPAEA does not require insurance plans to offer coverage for mental illnesses or substance use disorders in general, or for any specific mental illness or substance use disorder. It also does not require plans to offer coverage for specific treatments or services for mental illness and substance use disorders. However, coverage that insurance plans do offer for mental and substance use disorders must be provided at parity (the same) with coverage for medical/surgical health conditions.
The original MHPAEA was enacted in October of 2008. The main purpose of MHPAEA was to fill the loopholes left by the previous Mental Health Parity Act was legislation signed into law on September 26, 1996 that requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical benefits offered by a group health plan.
What if My Plan is Not in Compliance?
Before escalating things and contacting state or federal officials, contact Fonthill to see how to ‘encourage’ the insurers to provide appropriate coverage (look for future blog posts on how to communicate and educate your insurers for coverage). If you still have concerns about your plan’s compliance with MHPAEA, you can contact the Feds or your State Department of Insurance. You can contact the Department of Labor at 1-866-444-3272 or http://www.dol.gov/ebsa/contactEBSA/consumerassistance.html. You can also contact the Department of HHS at 1-877-267-2323 ext 61565 or at firstname.lastname@example.org or your State Department of Insurance at http://naic.org/.
Check back next time when we explore some tricks to getting insurance to pay for treatment – it’s what the insurance companies don’t want you to know.
The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, offers a common language and standard criteria for the classification of mental disorders. Basically, it’s the organized language of disorder. Often referred to as the therapist’s bible, it’s used, or relied upon, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policy makers together with alternatives such as the International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO). The DSM is now in its fifth edition, DSM-5, published on May 18, 2013.
The DSM evolved from systems for collecting census and psychiatric hospital statistics, and from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, although also removing those no longer considered to be mental disorders.
The International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO), is the other commonly used manual for mental disorders. It is distinguished from the DSM in that it covers health as a whole. It is in fact the official diagnostic system for mental disorders in the US, but is used more widely in Europe and other parts of the world. The coding system used in the DSM is designed to correspond with the codes used in the ICD, although not all codes may match at all times because the two publications are not revised synchronously.
While the DSM has been praised for standardizing psychiatric diagnostic categories and criteria, it has also generated controversy and criticism. Critics, including the National Institute of Mental Health, argue that the DSM represents an unscientific and subjective system. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from ‘normality’; possible cultural bias; medicalization of human distress. The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically totaling over $100 million.
Many mental health professionals use the manual to determine and help communicate a patient’s diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US also generally require a DSM diagnosis for all patients treated. The DSM can be used clinically in this way, and also to categorize patients using diagnostic criteria for research purposes. Studies done on specific disorders often recruit patients whose symptoms match the criteria listed in the DSM for that disorder. An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found the former was more often used for clinical diagnosis while the latter was more valued for research.
The current version of the DSM characterizes a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated with present distress…or disability…or with a significant increased risk of suffering.” It also notes that “…no definition adequately specifies precise boundaries for the concept of ‘mental disorder’…different situations call for different definitions”. It states that “there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder” (APA, 1994 and 2000). There are attempts to adjust the wording for the upcoming DSM-V.
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category, “idiocy/insanity”. Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives stating that “the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation” and pointing out that in many towns African-Americans were all marked as insane, and the statistics were essentially useless.
The Association of Medical Superintendents of American Institutions for the Insane was formed in 1844, changing its name in 1892 to the American Medico-Psychological Association, and in 1921 to the present American Psychiatric Association (APA).
Edward Jarvis and later Francis Amasa Walker helped expand the census, from 2 volumes in 1870 to 25 volumes in 1880. Frederick H. Wines was appointed to write a 582-page volume called “Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880)” (published 1888). Wines used seven categories of mental illness: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania and paresis. These categories were also adopted by the Association.
In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the APA developed a new guide for mental hospitals called the “Statistical Manual for the Use of Institutions for the Insane”. This included 22 diagnoses and would be revised several times by the APA over the years. Along with the New York Academy of Medicine, the APA also provided the psychiatric nomenclature subsection of the US general medical guide, the Standard Classified Nomenclature of Disease, referred to as the “Standard.”
World War II saw the large-scale involvement of US psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. A committee headed by psychiatrist Brigadier General William C. Menninger developed a new classification scheme called Medical 203, that was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. The foreword to the DSM-I states the US Navy had itself made some minor revisions but “the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present day concepts of mental disturbance. This nomenclature eventually was adopted by all Armed Forces”, and “assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty.” The Veterans Administration also adopted a slightly modified version of Medical 203. In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD), which included a section on mental disorders for the first time. The foreword to DSM-1 states this “categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature.” An APA Committee on Nomenclature and Statistics was empowered to develop a version specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the VA system, and the Standard’s Nomenclature to approximately 10% of APA members. 46% replied, of which 93% approved, and after some further revisions (resulting in its being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of “personality disturbance”, generally distinguished from “neurosis” (nervousness, egodystonic). In 1952, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was widely influential in the medical profession. In 1956, however, the psychologist Evelyn Hooker performed a study that compared the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a hero to many gay men and lesbians, but homosexuality remained in the DSM until May 1974.
In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued that mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was merely another example of how society labels and controls non-conformists; from behavioral psychologists who challenged psychiatry’s fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA’s listing of homosexuality as a mental disorder. A study published in Scienceby Rosenhan received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.
Although the APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968), it decided to go ahead with a revision of the DSM. It was published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I. The term “reaction” was dropped, but the term “neurosis” was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, although they also included biological perspectives and concepts from Kraepelin’s system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions appearing disconnected from reality). Sociological and biological knowledge was incorporated, in a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded.
An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool.They found that different practitioners using the DSM-II were rarely in agreement when diagnosing patients with similar problems. In reviewing previous studies of 18 major diagnostic categories, Fleiss and Spitzer concluded that “there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories”.
1974: DSM-II (7th printing)
As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate against the APA’s convention. At the 1971 conference, Kameny grabbed the microphone and yelled, “Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you.”
This activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations.
Presented with data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of “sexual orientation disturbance”.
In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also a need to standardize diagnostic practices within the US and with other countries after research showed that psychiatric diagnoses differed markedly between Europe and the USA. The establishment of these criteria was an attempt to facilitate the pharmaceutical regulatory process.
The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language (which would be easier to use by federal administrative offices), rather than assumptions of etiology, although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as “neo-Kraepelinian”). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislativemodel. A new “multiaxial” system attempted to yield a picture more amenable to a statistical population census, rather than just a simple diagnosis. Spitzer argued that “mental disorders are a subset of medical disorders” but the task force decided on the DSM statement: “Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome.” The personality disorders were placed on axis II along with mental retardation.
The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced, while some were deleted or changed. A number of the unpublished documents discussing and justifying the changes have recently come to light. Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless “neurosis” was included in some capacity; a political compromise reinserted the term in parentheses after the word “disorder” in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of “sexual orientation disturbance”.
Finally published in 1980, the DSM-III was 494 pages and listed 265 diagnostic categories. It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry. However, Robert Spitzer later criticized his own work on it in an interview with Adam Curtis, saying it led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems.
When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:
Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalisability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator…
In 1987, the DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, and significant changes in criteria were made. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. “Sexual orientation disturbance” was also removed and was largely subsumed under “sexual disorder not otherwise specified”, which can include “persistent and marked distress about one’s sexual orientation.”Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated that for at least some disorders, “particularly the Personality Disorders, the criteria require much more inference on the part of the observer.”
In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multicenter field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required that symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. Some personality disorder diagnoses were deleted or moved to the appendix.
2000: DSM-IV-Text Revision (TR)
A “text revision” of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD. The DSM-IV-TR was organized into a five-part axial system. The first axis incorporated clinical disorders. The second axis covered personality disorders and intellectual disabilities. The remaining axes covered medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-V, was approved by the Board of Trustees of the American Psychiatric Association (APA) on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in twenty years, and the Roman numerals numbering system has been discontinued to allow for greater clarity in regard to revision numbers. A significant change in the fifth edition is the proposed deletion of the subtypes of schizophrenia. During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.
The DSM-V is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, “there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries” but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning,” although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.
Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.
In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step (“Axis IV”) for outlining “Psychosocial and environmental factors contributing to the disorder” once someone is diagnosed with that particular disorder.
Because an individual’s degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM’s standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptomology may nevertheless experience comparable distress or disability in their life.
Welcome to Your Axis
The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:
- Axis I: All psychological diagnostic categories except mental retardation and personality disorder
- Axis II: Personality disorders and mental retardation
- Axis III: General medical condition; acute medical conditions and physical disorders
- Axis IV: Psychosocial and environmental factors contributing to the disorder
- Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children and teens under the age of 18
Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder,borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder,dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.
WARNINGS (kind of)
The DSM-IV-TR states, because it is produced for the completion of federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”. The APA notes diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis or label may have different causes or require different treatments; for this reason the DSM contains no information regarding treatment or cause. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered “illnesses”.
The DSM-IV does not specifically cite its sources, but there are four volumes of “sourcebooks” intended to be APA’s documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials. The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.
How do We Know This is Reliable?
The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. It was argued that a science of psychiatry can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about a diagnosis with a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with “tweaking” the diagnostic criteria. Unfortunately, neither the issue of reliability (accurate measurement) or validity (do these disorders really exist) was settled. However, most psychiatric education post DSM-III focused on issues of treatment—especially drug treatment—and less on diagnostic concerns. In fact, Thomas R. Insel, M.D., Director of the NIMH, has recently stated the agency would no longer fund research projects that rely exclusively on DSM criteria due to its lack of validity.
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, “little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology.”
The DSM’s focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.
Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists’ criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology. Another example is a strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts such as depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that “Instead of replacing ‘metaphysical’ terms such as ‘desire’ and ‘purpose’, they used it to legitimize them by giving them operational definitions…the initial, quite radical operationalist ideas eventually came to serve as little more than a ‘reassurance fetish’ for mainstream methodological practice.”
A 2013 review published in the European archives of psychiatry and clinical neuroscience states “that psychiatry targets the phenomena of consciousness, which, unlike somatic symptoms and signs, cannot be grasped on the analogy with material thing-like objects.” As an example of the problem of the superficial characterization of psychiatric signs and symptoms, the authors gave the example of a patient saying they “feel depressed, sad, or down,” showing that such a statement could indicate various underlying experiences: “not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychic anxiety, varieties of depersonalization, and even voices with negative content, and so forth.” The structured interview comes with “danger of over confidence in the face value of the answers, as if a simple ‘yes’ or ‘no’ truly confirmed or denied the diagnostic criterion at issue.” The authors gave an example: A patient who was being administered theStructured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a “conversational, phenomenological interview,” a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: That the patient didn’t “recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question,” or the experience didn’t “fully articulate itself” until the patient started talking about his experiences.
Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as “culture-bound”, whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Kleinman’s negative view toward the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. One of the results was the development of the Azibo Nosology by Daudi Ajani Ya Azibo as an alternative to the DSM to treat African and African American patients.
Medical Model + Financial Conflicts of Interest: Follow the Money
It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalization of human nature, which may be attributed to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half have had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. The same article concludes that the connections between panel members and the drug companies were particularly strong in those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry. In 2005, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had “allowed the biopsychosocial model to become the bio-bio-bio model” referring to a significant focus on biology (medical model) vs social and psychological influences.
However, although the number of identified diagnoses has increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients. William Glasser (founder of Reality Therapy and Choice Therapy), however, refers to the DSM as “phony diagnostic categories”, arguing that “it was developed to help psychiatrists – to help them make money”. In addition, the publishing of the DSM, with tightly guarded copyrights, has in itself earned over $100 million for the American Psychiatric Association.
Consumer v Client: Terms of Resentment
A “consumer” is a person who accesses psychiatric services and may have been given a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, while a “survivor” self-identifies as a person who has endured a psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). Some individuals are relieved to find that they have a recognized condition that they can apply a name to and this has led to many people self-diagnosing. Others, however, question the accuracy of the diagnosis, or feel they have been given a “label” that invites social stigma and discrimination (the terms “mentalism” and “sanism” have been used to describe such discriminatory treatment).
Diagnoses can become internalized and affect an individual’s self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result. Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, and/or against the DSM system in general. The Mad Pride movement has been particularly vocal in its criticism of the DSM. Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple “comorbid” diagnoses) or chronicity.
Psychiatrist Allen Frances has been critical of proposed revisions to the DSM-5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, it will “medicalize normality and result in a glut of unnecessary and harmful drug prescription.” In a December 2, 2012 blog post in Psychology Today, Frances lists the ten “most potentially harmful changes” to DSM-5:
- Disruptive Mood Dysregulation Disorder, for temper tantrums
- Major Depressive Disorder, includes normal grief
- Minor Neurocognitive Disorder, for normal forgetting in old age
- Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
- Binge Eating Disorder, for excessive eating
- Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
- First time drug users will be lumped in with addicts
- Behavioral Addictions, making a “mental disorder of everything we like to do a lot.”
- Generalized Anxiety Disorder, includes everyday worries
- Post-traumatic stress disorder, changes opening “the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.”
- are they more like theoretical constructs or more like diseases
- how to reach an agreed definition
- whether the DSM-5 should take a cautious or conservative approach
- the role of practical rather than scientific considerations
- the issue of use by clinicians or researchers
- whether an entirely different diagnostic system is required.
In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Approximately 14,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen otherAmerican Psychological Association divisions have endorsed the petition. Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.
We hope this history of the DSM provides some thought-provoking information you can use to become a more educated consumer or advocate for someone with mental health issues.
You may have recently heard of Timberline Knolls for the high-profile admission of Ke$ha on Friday, January 3, 2014. Or maybe you heard of Timberline Knolls when Demi Lovato was raving about it to MTV when she was discharged several years earlier. Both of these and many other celebs are drawn to Timberline Knolls for their quiet, discrete environment with a good reputation for getting young women healthy.
We take reviews from the internet lightly since they could have been written by competitors (yes, that really happens), written by staff posing as program alums or written by actual alums. Unfortunately – there’s just no way to know for sure so be cautious when considering the reviews. Most of the negative reviews for Timberline Knolls across these sites indicates pretty good clinical program, really nice setting, but super high pricing which may not be very transparent (not currently listed on their site) and significant problems with the Timberline Knolls administration for various issues.
Who They Serve
They admit women ages 12 – 60’s to extremely discrete care (lots of celebrities). Timberline Knolls recognizes that recovery from eating disorders, addiction and the other conditions is a lifelong process for women. Women require different tools as they move through different phases of life. Their customized program addresses the unique treatment needs of women at various stages of life.
Many adult women come to Timberline Knolls after having been in recovery for many years. They offer programming tailored to the specific needs of mature women, including those of mothers with children at home. Many clients come to them having been triggered by complicated life events like a death in the family, divorce or significant career challenges.
Residents live in separate lodge settings based upon their age. Adolescent girls attend school at the state-approved Timberline Knolls Academy. They benefit from the tight integration between the classroom and a therapeutic living environment that supports their social, developmental and clinical needs. Check out their video here.
LocationTimberline Knolls (40 Timberline Drive Lemont, Illinois 60439) is located on 43 wooded acres just a few miles southwest of Chicago, less than a half-hour’s drive from either O’Hare or Midway Airport. An interesting side-note: The campus received recognition for its beauty from the American Institute of Landscape Architects. The tranquil grounds contain a lake and reflecting ponds, an historic art studio, comfortable contemporary residential facilities, and outdoor activity fields.
Residents are housed in one of four residential lodges, (Oak, Maple, Pine and Willow), which are staffed 24 hours a day with nursing and clinical support staff. Timberline Knolls also employs on-campus security staff 24 hours a day to protect the safety and privacy of both residents and staff.
Fees, Insurance and Financing
$875 per day. The daily rate is inclusive for all clinical, educational, psychiatric, behavioral/milieu, nursing, and expressive therapeutic services on a 24 hour, 7 days a week basis. Individual, family, and group therapies are included. It also includes all meals and lodging. The daily rate is based on a tuition model of monthly billing. Non-included services are off-site medical services such as pediatrics, gynecology, dentistry, dermatology, hospitalization, urgent care, emergency care, urine/blood/lab work, etc., and medications. If any of these services are required, the specific provider of those services will directly invoice the parent(s)/guardian(s) or their insurance.
If applicable Timberline Knolls works with a client’s insurance company (some in-network, some out-of-network) to get as much of the fees covered. Admissions counselors will help clients investigate their benefits.
If insurance is not an option and out-of-pocket is out-of-reach, contact Timberline Knolls and ask about financing.
Timberline Knolls had a bumpy start when they started in 2005. The original founders were two pretty shady characters who have since been replaced by reputable investors that seem to be focused on providing a good quality program to upper and middle class women. Most of the feedback we gathered from online and colleagues was that they do a descent job working with the clinical issues but could be a lot more upfront about expenses. They also received several negative marks for having difficult admin staff. These issues could be more about personality (clients as well as the staff) and less about policies that impact every client.
Overall, we encourage perspective clients to take a tour and consider the program. It’s best to higher an educational consultant or case manager to go with you. They will ask detailed questions you may not think to ask or just feel way too uncomfortable to ask. This is a decision you should not make alone.
When your struggling teen or young adult is acting out and traditional therapy and medication just has not been enough, it may be time for a therapeutic wilderness program. Before you start googling programs, read through our handy guide that includes not only the cost of therapeutic programs but also all the hidden costs that programs may not divulge (or even know about) and strategies on how to afford these expensive interventions.
Financial costs of support for troubled child is not free and is usually not cheap (actually, it’s pretty costly). Many savvy parents that place their troubled teen in therapeutic wilderness programs receive financial aid and/or assistance to cover the expenses of the placement. The following are items that pose a significant financial expense for parents considering the placement of troubled teens in therapeutic wilderness programs:
- Therapeutic Wilderness Program: These programs range anywhere from $200 to $500+ per day and the programs usually last 30 – 90 days. Many wilderness programs will charge an additional upfront fee for gear and supplies and some have an application fee of a few thousand dollars. If they provide individual and group counseling, your insurer may reimburse you a portion of your out-of-pocket expenses following discharge. Programs generally do not voluntarily provide the information needed so consult a case manager that knows how to navigate the process. BEWARE: With the rise of client need and fees sky-rocketing, lots of programs have sprouted up like mold after a rainy week. Do your homework and make sure the program is insured, make sure staff are happy and have been there for years and, finally, make sure they are available to any other professionals working with you. Continuity is essential when a family is experiencing turmoil.
- Transportation: If you are working with a case manager/educational consultant, they may encourage use of a therapeutic transportation service if your child has a history or is suspected of acting out when they find out about going to the program. These transport services help transition and transport a struggling teen/young adult safely to a wilderness program, when he/she may be unwilling to cooperate with parent(s) requests to go. The transport fees usually range from $2000 to $4000. Airfare is usually an addition to this charge. Price of transport fee and airfare can vary on time and location of pick up. A good transportation service has highly trained transporters with a clinical background. They normally work in teams of two from door-step to program. BEWARE: Some transport ‘companies’ are not companies but individuals who saw an opportunity to make big money. Make sure the transport company is insured, has references and loads of experience. This, ideally, should be set up by your case manager.
- Case Management + Educational Consultant / Placement Fees: Often parents will receive the wilderness program’s information from a case manager or educational consultant. These professionals generally work directly for the parents and receive no financial compensation from the wilderness therapeutic programs they recommend. Their fees range from $150/hr up to $10,000 per project. Some are paid to simply ‘place’ children while some are more therapeutic-oriented and conduct (or recommend) an assessment prior to giving placement recommendations. Some parents will receive placement recommendation from a placement service that does not charge. Usually these services will be receiving financial kick backs and/or compensation from the therapeutic wilderness programs they refer to. Many of the wilderness programs that accept placements from such services may charge the parents an upfront admissions fee ranging from $1500 to $5000. Some or all of this fee, may go to the placement service that was said to be offering free advice to the parent(s). Good case managers can often negotiate a program or treatment center down in their fees so they may end up paying for themselves in the discounts they find you. BEWARE: Some professionals may charge simply to ‘place’ your child. This does not include an evaluation by a licensed professional and does not really take into account whether residential treatment is actually recommended for their unique needs.
- Additional Travel and Additional Placement Costs: Most parents eventually travel to the wilderness program for family meetings or come out to pick up their teen at graduation. In some cases, teens are recommended to go on to more therapeutic treatment in a boarding school type atmosphere to help internalize changes before returning home from the wilderness program. Costs for these programs are usually at a lower rate, ranging from $100 to $350 per day. These rates largely depend on the amount of intensive therapy and school program offered. See Fonthill Counseling’s blog about Therapeutic Boarding Schools for more info.
- Total Cost: $2500 – $10,000/month. This sounds expensive but if you figure that an attorney costs $350/hr if your child gets into more trouble, you may actually be saving money in the long run.
When considering the above information, it is easy to understand why many parents may want to request 1) support from a case manager and 2) financial aid for therapeutic wilderness programs. Here are some of the financial aid options that some parents may consider for therapeutic wilderness programs:
- Educational Loans: Parents may often consider or be encouraged to seek an educational loan for financial aid for wilderness programs. These loans are specifically designed to cover all of the costs involved in any type of educational placement of a child. Often the interest rates for these types of loans can be very affordable. An educational loan can cover all of the above mentioned charges if set up accordingly.
- Behavioral Health Loans: There are financial institutions that specialize in providing loans to families that need support defraying some of the out-of-pocket expenses of treatment. They often lend $500 – $100,000. Repayment often is expected 30 days after the loan has closed (no more borrowing is needed). Some companies can expedite the approval process if there is serious health risk and funds are needed asap. The interest rates are lousy but, for a last ditch option, it may have to do – expect 7% – 18%. Here are some examples: Clark Behavioral Health Financing and American Healthcare Lending (actually just acquired Clark BHF).
- School Districts /Courts/DSS: Some state laws require school districts and/or courts to be responsible for cover all and/or reimburse for all or some of the financial expenses of placing a teen in a therapeutic wilderness program. Please contact your local school district office for more information. Some parents seek the advice and help of an educational attorney. These are attorneys that fight for the school district and/or state to pay for or reimburse expenses of wilderness programs and other placements. All of the above charges may not be covered; please seek their council for more detailed information.
- Grants / Reduced Rates: Though our case managers and educational consultants do it all the time, parents can directly contact programs and ask for financial grants and/or a reduced rates. Usually financial grants and reduced rates are based on the income of a family.
- Family / Close Friends: It’s not always the first or best option but don’t forget to think about asking for help of a close family member or trusted friend. In these situations, a family member or friend that is providing the financial aid may be the one recommending and encouraging the wilderness placement. We always recommend that the loan be formalized in some sort of written contract to make it clear how much will be borrowed, when and if it will be paid back and any other terms of the loan.
Please always consider consulting a case manager or educated professional before making final placement decisions with a therapeutic wilderness program. A great program that fits your child’s needs can be a life saver while the wrong placement could set treatment and your family back years at significant financial cost.
The Affordable Health Care Act (aka Obamacare) has been ramping up over the last few months and goes into full-throttle (Health Insurance Marketplace enrollment starts October 1, 2013). Here are some of the important changes the healthcare law impacts.
The Affordable Care Act will expand mental health and substance use disorder benefits and parity protections for 62 million Americans. Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy, prescription drugs. It also covers services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more. The healthcare act also includes a huge Medicaid/Medicare expansion to provide coverage to millions more Americans currently without insurance. Here are just a few other bullet points of the healthcare act going into effect soon:
• National goals have been set to identify and reduce mental health care disparities in the U.S.
• More federally-qualified mental health care facilities will be made available and funded.
• There will be an increased focus on telemedicine, which will facilitate mental health services and collaborative efforts from a distance, through the use of telecommunication technologies.
• Additional funding will be allocated to mental health organizations, such as SAMHSA.
• State Health Homes will be made available for individuals recovering from substance abuse and mental health disorders.
• School-based mental health programs will be initiated for child mental health care.
• Grants will be allocated exclusively for training more mental health care professionals.
• No-cost and low-cost preventative screenings will include mental health services.
• Mental health benefits will be included in the Medicaid expansion.
Most health plans must now cover preventative services like depression screening for adults and behavioral assessments for children at no cost. All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.
Starting in 2014, health insurance plans will not be able to deny clients customers coverage or charge extra for pre-existing health conditions including mental illness.
Let’s Talk Access
Access through for those un- or under-insured is through Exchanges. Exchanges are set up through state websites designed to make it easy for people to find health coverage. Each state will have one. The District and 16 states, including Maryland, are running their own exchanges. The rest are either partnering with the federal government or, as in Virginia’s case, relying on the federal government to operate their exchanges. To find the correct site, go to www.healthcare.gov.
To learn more about how the Affordable Healthcare Act may impact services with Fonthill Counseling, please contact us with specific questions or concerns.