Cost-effectiveness studies have shown when people are able to have long-term therapy, the economic savings from decreased use of general medical services, emergency room visits, hospitalisation, and increases such as in job productivity, and the ‘intangible’ increases in well-being and quality of life are justified.
Psychotherapy as a treatment must take into account the controversies and problems to the profession of psychology at a time when managed health care is imposing limitations and challenges to the practice of mental health care. Because of the problems of health care resources that are being experienced in the field of psychotherapy, research concerning costs and benefits has become a pressing concern. Many issues of Cost Effectiveness Analysis and Cost Benefit Analysis of psychotherapy are related to problems of assessing its efficacy. For example, effects of psychotherapy include reduction of suffering and pain and enhancing well-being. These effects are often difficult to measure and difficult to value in monetary terms (Buckwalter, 2000; Clay, 2000; Danulaoff, Erard, Hyman & Pallas, 1994; Derksen, 1999; Glen, Gabbard & Lazar; 2002; Kavanaugh, Keller, Westhoff, Rohner, Studt, 1997; Spiegel, 2002; Hunsley, 2002).
There are many competing pressures for health care resources, of which psychology is one. But the slice of the health insurance pie dedicated to psychology is diminishing. For example, one American study showed that “mental health dollars” paid out by insurance had decreased by 54% since 1988, whereas “general health dollars” had only declined by 7.4% (Buckwalter, 2000). As a result, studies in cost-effectiveness and cost-benefits of psychotherapeutic treatment have become necessary as one of the ways to address this alarming trend.
The disconcerting areas surrounding current managed health care with respect to psychotherapy have been the subject of many papers and books (Buckwalter, 2000; Hunsley, 2002; Kavanaugh et al. 1994). For example, it is maintained that the positivistic, anti-subjective view in psychology has been used to support the “…denial of subjectivity and the unconscious, focussing on target symptoms and excluding underlying characterological or causative issues” (Buckwalter, 2000:1). Kavanaugh et al. (1994) call the approach of the managed care policy a bio-reductionist way of conceptualising human behaviour in which the profession of psychology has been reduced to an “industrialisation of the health care professions”. By this is meant that this profession has been functionally redefined as a craft in which the ‘practitioner’ is considered interchangeable “…with any other craftsperson who is equally well-trained and has demonstrated competency with particular treatment applications for certain diagnostic conditions”. Psychologists and other professionals are designated as “providers” and “vendors” using the vernacular of industry (Kavanaugh et al. 1994: 2).
Several deeply concerning issues surround these redefinitions and policy formulations. Among these are the loss of distinction between ‘craft’ and ‘profession’ and the consequent aspirational goals and ethical standards of conduct intended to serve as guides in the professional and scientific activities, not to mention the loss to the members of society it serves (Kavanaugh et al.1994). For example, the ethical psychotherapist-patient relationship is violated by the health care demands for disclosure of confidential information such as fees charged and disclosure of diagnosis (Buckwalter, 2000; Kavanaugh et al.1994;). Secondly, the unique clinical relationship between psychotherapist and patient, as a treatment ingredient is not appreciated or acknowledged. A third issue is that participation in the health care system requires that the psychologist and patient follow the treatment plan considered “appropriate and necessary” as set down by the practice guidelines, or that the current model of symptomology, pathology and aetiology are followed. Requirements such as these eliminate services such as “prevention”, which can address psychological difficulties that would otherwise manifest as ‘physical complaints’, “problems in living”, which do not generally fit into diagnostic categories and which may develop into expensive diagnostic conditions. They also eliminate treatment of choice. (Kavanaugh et al.1994). This latter aspect is especially significant in this study as it was noted under the section above dealing with personality change that long-term psychodynamic therapy is the treatment of choice for the personality (Derksen, 1999; Pervin, 1994). In this respect, it has been maintained that based on scientifically established foundations, psychological treatment has advanced to the stage where it is acknowledged that treatment needs to address the specific situation of the patient, be “maximally sensitive and responsive” to the unique clinical relationship, treatment plans need to be flexible so that they may adapt to the unique person and circumstances. An important point is that diversity and choice of treatment also allows for development of theory and refinements of therapeutic techniques (Derksen, 1999: 4).
Among these techniques is that of the psychodynamic approach, which is of indefinite length. It is the oldest, most studied and most widely practiced form of therapy (Derksen, 1999) Cost-effectiveness studies have shown when people are able to have long-term therapy, the economic savings from decreased use of general medical services, emergency room visits, hospitalisation, and increases such as in job productivity, and the ‘intangible’ increases in well-being and quality of life are justified. (Clay, 2000; Derksen, 1999; Glen, Gabbard et al. 2002; Kavanaugh et al.1994; Keller et al.1997; Pomeranz in Clay, 2000; Spiegel; 2002). Studies have also shown that in addition to reductions in health care costs, the decreases were large enough to cover the costs of psychological interventions. Further to this, studies have also indicated that the costs of mental health to the total health costs of countries as a whole are considerably high (Hyman et al. 1994). Some of these studies are referred to in the following paragraphs.
In a report commissioned by the Canadian psychological Association, estimates suggested that in 1998 the disability health costs in Canada associated with depression alone exceeded those associated with hypertension and were comparable to disabilities associated with heart disease, diabetes and back problems (Hyman et al. 1994).
A study by the German Society for Analytical psychology in Berlin examined the effectiveness of long-term analyses 100 sessions in the treatment practice. It included the stability of treatment results by a follow-up study 6 years after the end of therapy, and it evaluated the aspects of cost effectiveness. ICD diagnostic classification included patients suffering from affective disorders, such as bipolar, recurrent depressive episode and cyclothymia; neurotic and somatoform disorders such as, phobic disorder, anxiety disorder, compulsion disorder, stress reaction and somatoform disorder; behavioural disturbances with physical symptoms such as eating disorder and sexual dysfunction and personality disorders such as, specific personality disorder, complex or other personality disorder and abnormal habits. A follow-up six years after termination of treatment yielded positive results showing that firstly, patient self-assessment was that they experienced very good improvements regarding physical or psychological distress, general well-being, life satisfaction, job performance, partner/family relations and social functioning. Secondly, psychometric tests supported the self-assessments. Thirdly, health care utilization indicated that more than 50% of the patients reported a substantial reduction in frequency of doctor visits compared to visits prior to psychotherapy. Data recorded by cost carriers showed a reduction in objective work disability of 50%, a reduction in hospitalisation by 87.5% before and after therapy, and reductions in drug intake and insurance claims (Keller et al. 1997).
Clay (2000) cites several studies that show the clinical and economical cost effectiveness of psychotherapy. Her study includes focus on the pressure exerted by managed-care companies to push the prescription of drugs, and the problem of health plan budgets, which focus on expenses in the current year. It is maintained that this kind of focus provides a short-term advantage for using medication and permits medication to be prescribed over very long periods of time. Even in cases where medication is warranted for example, with schizophrenia or bipolar disorder, patients are being steered towards medication only, despite the fact that psychotherapy would benefit them. It is also noted that patients often relapse when medication stops. By contrast, although psychotherapy requires a greater upfront investment, it is maintained that the cost of relapse when medication is stopped and the cost of ongoing medication, as compared to the long term benefits and the reductions in relapses outweigh the initial costs of therapy. Pomeranz (Clay, 2000:4) cites the example that “If you can get with four months of psychotherapy the same benefits you get from a year and a half to two years of continuous medication, you begin to break even after about a year’s time even though it’s more expensive upfront to provide psychotherapy”. Further losses cited in this study are lost productivity, salaries, taxes and community services whereas an important benefit as a result of therapy is that people are taught skills (Clay, 2000).
In a paper for the APA Commission on psychotherapy which drew on 21 studies conducted between 1986 and 1997, Glenet al. (2002) showed that patients treated by psychotherapy are better off than 80% of untreated patients; that family therapy for patient’s with schizophrenia reduces relapse by the same extent as does anti-psychotic medications; and that longer length of psychotherapy is associated with better outcomes. The studies also showed that psychotherapy is cost effective. For example, patients with severe psychiatric disorders and substance abuse reduced hospitalisations, medical expenses and work disability in 88% of studies. Further benefits in other studies were a decrease in the uses of psychiatric inpatient services, emergency room care, appointments with other medical specialists, and work performance improved. One study showed that increased psychotherapy for U.S. military dependents resulted in a net savings of $200 million over 3 years through a decrease in hospitalisation. This paper included a study that indicated that because the payments for outpatient therapy are generally higher, this places psychotherapy out of reach of those people in greatest need for therapy (Ibid.). This latter point is particularly relevant in a discussion querying the percentages of health care resources dedicated to psychotherapy and the cost of long-term psychotherapy.
Spiegel (2002:2) maintains that “To say that there is no benefit … derived from a carefully structured human interaction is to deny the possibility of social effects on the individual” adding that human beings have profound psychological effects on one another. He cites the benefits of psychotherapy that have already been mentioned above, adding further costs such as those of heart disease and co-morbid substance abuse for patients with untreated depression, and social costs such as decreases in self-respect. According to Spiegel (2002) It is relatively easy for health care managers to restrict psychotherapeutic services, which they do by cutting down numbers of visits, increasing paper work, and only paying therapists with less training.
In the final example of cost effectiveness, psychotherapy studies have shown that generally, therapy aids in remission of symptoms, healing processes are speeded up, and it provides coping strategies and ways for dealing with future problems (Lambert, 1994). According to an examination of studies on recovery from Personality disorder, Derksen (1999:41) estimated that long-term psychodynamic therapy would result in 50% of recovery after 123 sessions, while 100% recovery could be expected after 384 sessions (about 5.1 years). He contrasted 5.1 years of long-term therapy (an improvement factor of 4.7 times) versus 24 years with natural history (which he calls a natural improvement, which may be possible over time). He added that studies have shown that even before complete recovery, 1 or 2 years in psychotherapy decreases the need for hospitalisation and emergency room visits. He cites that in dollar cost terms at about $100 per session, 123 sessions would cost $12 300 to bring 50% of patients to recovery, which would result in significant decreases in costs to society “… attributable to decreases in hospitalisations, emergency visits, the aftermath of suicides, automobile crashes, and other impulsive actions, as well as lost earnings and other indirect costs of illness. It should also diminish the hidden negative effects upon other family members, especially the children, which are hard to estimate accurately” (Derksen, 1999: 41).
About Leslie
Leslie Zimmermann is a Jungian Analyst trained in the philosophy and psychology of C.G. Jung in Zurich and is based in Johannesburg. She offers a range of services, which she integrates, to meet the needs and aspirations of people. In a word, her work is in the service of wholeness. Wholeness includes both our vulnerabilities and our strengths, becoming conscious of our own unique mix of these, honoring our own unique way of functioning and with this knowledge and confidence, contributing as only we each can in our own way, to this evolving world we find ourselves to be a part of.
Besides having a Diplomate qualification in Analytical psychology, which qualifies me to write about the theory and practice of dream interpretation, I also have an Honours degree in Applied Psychology and a Masters degree in Research psychology, which qualify me to write about theories of human development, personality, abnormal psychology, social psychology, sociology and ethics. Also, theories and knowledge pertaining to sleep and dreams from a perspective of neuropsychological and biological systems.
Leslie specializes in Analytical Psychology, Voice Dialogue, Life Coaching solutions for business executives. Consulting and coaching for family owned and home-based business
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Member: SAPC (South African Psychoanalytic Confederation); AGAP (Association of Graduate Analytical Psychologists, Switzerland); SAAJA (Southern African Association of Jungian Analysts); IAAP (International Association for Analytical Psychology); International Association for the Study of Dreams