Hypothetical*

Let’s say there’s a shrink. Let’s call the shrink Marriette, just for the purpose of simplifying this story. Let’s say that Mariette is a highly paid Manhattan shrink. And let’s say that for a number of years a patient of hers, who I shall refer to here as Zauren, has paid Marriette out of pocket and sought reimbursement from Zauren’s insurance company. Let’s call that plan, Loxford, just for identification purposes.

OK, now, let’s say that Zauren, due to circumstances beyond her control, suddenly has a new insurance company. Let’s call the new insurance company, Flemblem.

Zauren was sad that she was no longer on Loxford, but then she began looking into which of her current healthcare providers are Flemblem network providers, she was delighted to discover that Marriette IS a Flemblem network provider! Oh fortuitous delight! Imagine, after all these years of paying Marriette directly, and through the nose, Zauren could finally experience the joy of having her health insurance company pay Marriette directly!

Let’s say, then, hypothetically, that the next day, Zauren took the train into Manhattan to see Marriette. But when Zauren walks in, Marriette has a surprise for her, and it isn’t a birthday party.

Marriette has a letter in her hand, from Flemblem, telling her that she is Zauren’s provider, and per the contract that Marriette signed with Flemblem, Marriette must treat Zauren under the terms of the contract, which say that Marriette is to be paid by Flemblem, with a copay by Lauren.

Marriette is not happy.

Marriette demands to know why Zauren is no longer a member of Loxford.

“Not by choice.”

Marriette informs Zauren that Flemblem doesn’t pay even close to what Zauren was paying out of pocket.

“Oh?”

Marriette tells Zauren that there is no way that Marriette can accept such a pittance for her services.

“I understand. So, why don’t you terminate your contract with Flemblem and become an out-of-network provider the way you are with Loxford? Seems simple enough.”

Marriette tells Zauren that Marriette cannot go off of Flemblem because Marriette has another patient who is on the Flemblem plan.

“I’m sorry…what? You take what Flemblem gives you for this other patient, but you won’t take it for me?”

Marriette offers an obtuse reason for needing to not rock the boat with the other patient. She suggests perhaps Zauren might not mind paying out of pocket and NOT submitting it through Flemblem.

WHAT?

Zauren gets up to leave. Clearly, this is not going to be resolved in this manner, Zauren thinks. Clearly, Marriette is under a legal obligation to take Zauren’s insurance, but she is refusing to do so. But just as clearly, Zauren understands that she cannot MAKE Marriette continue to see her as a patient if she does not want to, for any reason, so long as it is not an illegal reason, which this is, but what difference does that really make when one is being told by one’s shrink that another patient’s needs are more important to said shrink, and that said shrink is willing to make insane and illegal financial demands of her?

Let’s say that Marriette encourages Zauren to stay anyway to talk about the hurt and betrayal Zauren feels. Let’s say that Zauren stays for 10 more minutes and then leaves and takes a day to think about it, and to call her insurance company to ask if a provider is permitted to pick and choose which patients said provider will see on the plan and to ask her patients to pay out of pocket and not submit it through insurance.

Let’s say that Zauren realizes, after a day of moping, that she hasn’t got time for the pain. And Zauren summarily terminates her relationship with Marriette over the phone – by leaving a message – and asks Marriette to not call her back because there is nothing more to say.

Then let’s say that Marriette disregards Zauren’s request and demands a face-to-face meeting. And Marriette bolsters her “case” for a face-to-face meeting by pointing out that Zauren has a history of “executing” relationships summarily, and this is just another example of that sort of pathological behavior.

Finally, let’s just say that Zauren just says no to emotional manipulation by one to whom she entrusted her mental health.

Not that any of this happened necessarily.

But let’s just say that it did. What do we think of this?

YC

[*edited for Zauren/Flauren disambiguation]

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27 Responses to Hypothetical*

  1. Anonymous says:

    I suppose that without the years of positive work with said shrink you would have just shot her and been done with it. A hundred years from now we will look back on that profession with laughter and derision.
    Olddude

  2. LI Ashtangini says:

    I think somehow Zauren became Flauren? And that at best Mariette is a money grubber and at worst highly unethical.

  3. Sharper says:

    It looks like Marriette would be manipulating and using Flauren's emotional weakness to work in Marriette's favor. She must think that her fancy occupation in a fancy city can outsmart her patients for her own financial gain. Pretty sad. I'm sorry that Flauren was betrayed in someone she trusted. If that really happened, that is.

  4. Susan says:

    Manipulation is a pathological syndrome too.

  5. laksmi says:

    we're confused about zauren and flauren. otherwise, totally your choice what you do. that is, hypothetically.

  6. DebPC says:

    It's called abandonment and although it probably isn't technically illegal it is against the APA Code of Ethics and is definitely grievable, if you were to so choose.

    ANd I think "closure" is bullshit. We were taught you should always have closure with a client. Fine, if the client wants a wrap-up session. But speaking of ethics, how dare we as clinicians demand a client pay for a session because we ourselves feel some need to summarize all of the progress our client has made because of our wonderfu work. I'm just saying…

  7. Anonymous says:

    That bitch!

  8. Karen says:

    Let's say that Zauren writes a letter to Mariette stating that she is terminating their doctor-patient relationship because she has issues with Mariette's suggestion that she be paid "under the table." And perhaps, while Zauren is at it, she could include a letter she intends to send to Flemblem informing them of her decision to cancel Mariette as a provider because of that proposition.
    At any rate, I'm sorry to come to the conclusion that Flauren's relationship with Mariette has not choice but to end. It has become adversarial and therefore it would appear that Mariette's services will not be able to be provided objectively.
    p.s. If you do shoot her, be sure you cover your tracks. Or better yet, somehow figure out a way to frame the other Flemblem patient.

  9. Anonymous says:

    I had almost exactly the same conversation a few years ago with my shrink. I was seeing him, I changed jobs, I had new insurance, I saw his name, I said great and blablabla exactly the same thing. Then he was very patronizing with "I can SEE that you would WANT to use your insurance benefits. But blablabla psychobullcrap whatever let me treat you like a 5 year old etc etc." I was like, I do understand from your perspective that it's all about the money, but you could do a better job of not making it so obvious. The end was very near that day.

  10. Yoga Chickie says:

    Sorry about the confusion with Flauren and Zauren and whatever else!! I am amazed you all caught those…much better proofreaders than me…

    Does ANYONE want to side with Marriette? ANYONE??? (Not that I want you to…)

  11. karen says:

    Okay, I'll bite. I'd be curious to talk with Marriette. Anything that really pisses me off makes me curious. I'd wonder what she had to say about this whole deal. And then I'd decide what my next step would be.

  12. Lisa says:

    I'm a longtime lurker on your blog, and in addition to being a yogi am also a therapist. I'm not going to side with Marriette, but would like to digress for a moment to tell people who are making disparaging comments about our profession and "fancy offices" a couple of things….

    Being a therapist is pretty darn hard work, believe it or not. 3,000 hours of non-paid work are required before I can even sit for the licensing exam. I think what I do is worth $120 an hour, but the insurance companies will only pay me $50. For the privilege of working with them, I have to diagnose my patients with mental diseases that stay on their records, and then fight with a high school graduate at the insurance company to justify why my treatment plan is the way to go. For every $50 hour I work with a client, I spend 2 hours on the phone or doing paperwork. Using insurance for mental health services isn't good for my clients and it's not good for me — obviously it's cheaper for my clients, but the psychological and long term impact of working from a disease model isn't worth it, in my opinion. Obviously another thing that needs to get fixed in our healthcare system.

    Okay, having said that, I know you'd just like to forget this, but I really do think you should report this hypothetical situation so other clients don't have the same situation.

    #1: It's insurance fraud to do what she was proposing to do – she can lose her license for it, and should. If she had convinced you to do it, it would have been a jail term.

    #2: She may not abandon a client for purposes of pay – it's unethical, she can lose her license for it, and should.

    If she is a Licenced Clinical Counselor, social worker or Marriage and Family Therapist, she gets reported to the state licensing board. If she is a Ph.D. psychologist, she gets reported to the American Psychological Association. Please report her. She makes us all look very bad.

    Lisa…

  13. Yoga Chickie says:

    Karen…I'll bite back…what would you like to know? Since this is a "hypothetical", I can try to answer as if I were "Marriette".

    Then…perhaps Lisa already addressed what you might be wondering…about the difficulties of practicing as a psychologist when people denigrate the profession and when insurance companies pay you "reasonable and customary", except that it is NOT reasonable and NOT customary in your particular city or in this particular decade (or perhaps century)?

    I do feel for clinicians who are underpaid. But Marriette, whose practice is established, could easily go off the plan. Simple solution, no?

  14. Lisa says:

    Yes. She should not be on any plans at all. What I do is slide my fee for anyone who I really want to work with and who can't afford it. I'd rather slide to $50 on MY terms and not have to answer to anyone or do paperwork than to be under the rules of the insurance company. I do this often.

    Having said that, a therapist friend of mine tried to get OFF panels and found it frustratingly difficult to do…I don't really know the whole story, but as long as there were people who had contacted her under the panel, she couldn't get off, and then by the time they were gone, there was another client, etc. etc. In other words, if you (hypothetically) WANT to see her using this insurance, she CAN'T get off the panel. My understanding, but I'm in California, so it might be different…..

  15. Yoga Chickie says:

    Yeah…I remember she had trouble getting off the Loxford panel. But in this case, she doesn't want to get off the Flemblem panel because of this other patient. I am horrified even writing that. It's like having to admit that she likes some other patient better than me. It's like reminding me of years and years of sibling rivalry. Looks like Zauren might need a shrink to deprogram from Marriette.

  16. karen says:

    I'd just be curious to hear her perspective and look at her face as she explained it, Lauren. I don't have any specific questions except: "What's your take on what's going on here?" I understand you talked to her about it already, and that it was contentious. Like I said, I'd just be curious to hear what she had to say. And if I felt something ("I feel like you like this person more than you like me because you are cutting her this slack, insurance-wise,") I'd say it because I'd want to see Marriette's reaction. That's all. I wouldn't go to make my case, I'd go to ask her about her perspective, because I don't understand it.

  17. laksmi says:

    Well, Karen, I might not get printed on this, but I think Flauren wrote the question that Mariette posed, which seems valid: And Marriette bolsters her "case" for a face-to-face meeting by pointing out that Zauren has a history of "executing" relationships summarily, and this is just another example of that sort of pathological behavior.
    That's the part that made me curious, and to me, that's the more interesting part. Flauren/Zauren already knows that what Mariette did was wrong, and knows what she's going to do about it. But is there some (please note that that says 'IS there some', NOT 'there is some') validity to the question that Mariette posed about Flauren's relationships. Not asking for an answer here, just bringing that question up again, as it may have some validity.

  18. Karen says:

    First Karen here. As an employee benefits professional, my entire problem with this is the ethics of what your therapist suggested.
    And as a holder of not one, but two college degrees, I'm not going to go into my feelings concerning Lisa's assertions regarding insurance companies and their employees or risk management procedures.
    The question really is, how could you ever trust this person again?

  19. laksmi says:

    yes, Karen. It's amazing that mariette would DO this, let alone say it to someone else, especially to Zauren. POOO on mariette.

  20. Anonymous says:

    I would suggest that you not get bogged down in the permutations of this relationship but rather focus on the foundations of the relationship and whether there is a point in continuing the rather chiropraticlike, "you might get better but it will take the rest of your life" approach. Your smart and there is thousands of years of people dealing wit the human condition and only a minute portion of them require years of expensive "buy a friend" as a treatment modality. Do it yourself and give the money to a ex crack whore who has real problems and a kid who will know real suffering. I say this without meaness.
    Oldduder

  21. Yoga Chickie says:

    First off…I didn't know there were two Karens…maybe even three if one of the ones who commented is not DZM.

    Second, yeah, Laksmi has a point, and let's call a spade a spade: she has experience with this side of me, this side you might call "Ze Executionah".

    With online friends, as I believe Cody pointed out in his latest (last?) post on his blog, you can just disappear and it's as if it were all a dream…none of this really happened. In fact, now that I know that my 12-year old has a YouTube persona and people who he converses with back and forth, as they discuss Green Day and Billie Joe Armstrong, I would like to share Cody's astute observations with him. Or at least, I would like to tell him that it if someone hurts his feelings online, he can make the whole thing go away, pretty much, by simply disappearing from the situation.

    That said, that has nothing to do with the shrink/patient relationship. As Debpc points out (and she is a recent graduate of a PhD program in clinical psychology, so this is fresh in her mind), closure is good, but it need not be demanded, and when it is it is often self-serving for the shrink.

    In Zauren's case, Marriette put a pin in the long-term trust relationship between them. It's as if Marriette suddenly told Zauren that Zauren MUST believe that the world is flat or else their relationship could not continue. Zauren could not possibly sit there and accept therapy from a shrink who insists that the world is flat and insists that Zauren agree with that mis-statement of fact.

    But yeah, Laksmi, it is an interesting topic for another shrink if Zauren should ever decide to start with another shrink.

  22. karen says:

    DZM here (small "k" karen comments in this thread).

    I'm with lax re: what's interesting in this whole dealio: the relationship execution comment. I'd be so curious to hear Marriette's ideas about how I summarily 86 relationships.

    And of course the follow-up question might be how she thinks treating me differently from another patient is fair. And maybe I'd probe to see if she's messing with me to see if my sense of injustice and outrage might incite me to 86 another relationship. And then maybe I'd even say I felt hurt, instead of just angry.

    See? All of this is speculation. LOL! Really I'd simply be curious to see what happened if I actually talked with her…

  23. Susan says:

    I always thought one went to a shrink because one had a "problem". A problem that one needed to sort out because it was interfering in their ability to be a successful person in the world. A problem that was keeping them from having relationships, or from going outside, or from drinking truckloads of vodka…or depression.

  24. Tracy says:

    i think Mariette needs her own shrink.
    oh..wait, she probably already has one! silly me~

  25. Lisa says:

    Old Dude: Sounds like maybe YOU have had a bad experience from this profession. That does not mean that you can generalize to all counselors and assume that we are all trying to get people to come talk to us for the rest of their lives. I myself left a much higher paying profession to go back to school and do this because I felt called to help.

    Karen the 1st: I realize I'm doing the same thing I'm accusing Old Dude of doing. I didn't mean to imply that EVERY person working the risk management at insurance companies is a high school graduate only — however, that has been my experience. I've not dealt with an insurance company that cares for my clients like I do, or even allows me to care for them the way I think I should. Sounds like you might be one of the good ones – I'm thankful there are some.

  26. Yoga Chickie says:

    DZM-Karen…"the follow-up question might be how she thinks treating me differently from another patient is fair."

    Discussed it. She said the other patient was on it first. I am not sure how that answers the question, but that was her answer.

    " And maybe I'd probe to see if she's messing with me to see if my sense of injustice and outrage might incite me to 86 another relationship. And then maybe I'd even say I felt hurt, instead of just angry."

    She wasn't messing with me, intentionally, at least. She is dead serious. I told her I was hurt. I don't remember registering anger, at least consciously, until she called me the next day to chide me for 86ing the relationship without a "closure" conversation. That made me feel manipulated and repulsed.

    Susan, I like to think that I am a better person for examining myself each week for 15 minutes short of an hour with the help of someone who is trained to help people examine themselves.

  27. Anonymous says:

    i have had the experience of having a counselor (couples) offer to meet for a final closure conversation at no charge. she might have offered that if she truly wanted to be helpful and you could request it if you decide you want it. but i don't think it's pathological to feel you just don't want to continue in these circumstances.

    Even a pattern of moving on when you feel a relationship has reached its limit is really a style,not necessarily a problem every time you do it. sometimes it may be appropriate, sometimes a sort of anticipatory abandonment when you feel someone may betray or disappoint you. you may beable to learn to get what you need from the person instead, in some situations, which may be more satisfying.

    here, if zauren hasn't said it she could explicitly tell mariette she could only continue if treated the same as the other subscribing patient, and cld ask mariette why zauren, not mariette should be responsible for mariette's problemswith insurance companies. then it becomes clear that if there is any 86'ing it is being done by mariette.

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