Depression, HMOs, and Waiting

• The Chemistry of Hugs by Jim Brody, 2/26/97
  
  

Sally's early 20's and very pretty but sad. She has the light hair and blue eyes once noted by Kagan to be associated at times with shyness. Her lifetime thought is that of taking blame but never credit for events. Her husband left her for an older woman, one who owns a business and has some money to spend. He also made Sally's appointment with me, complaining that she never said what was on her mind. He led her, in separate cars, to my door and drove away as soon as she was in my office.

We got along pretty well in our first session and suggested some constructive steps for her. One element involved her taking a low dose of sertraline to soften her unrealistic guilt about his actions ("Something's wrong with me if he acted this way.") and perhaps boost her assertiveness and self esteem.

I called her physician who agreed with my recommendations but refused to call in a prescription. He insisted on seeing her himself. I relayed his message; she called him for an appointment and was given one 10 days in the future. She agreed to the delay because, with his approval, her health insurance would cover a portion of my modest fee. Two weeks elapsed. My answering machine blinked a red "1"; her message was that her physician didn't think she needed help, that her feelings were natural and would dissipate on their own.

Thus, his interests and hers and mine were in conflict. He was allied with her health carrier; however, she likely didn't know of his financial interest in her not getting assistance. She, one more time in her life, accepted the burden, the responsibility for her feelings while accommodating other people.

I wonder how many times, by tolerating a delay of 1-6 weeks before a session, the client moves from hurt and indignation to resignation. So many of the "enablers" tolerate incredible amounts of rudeness, cheating, and disrespect in daily life. There are rare instants, when pushed sufficiently, the meek rebel but for just a moment. Like a wave, the protest builds, spreads, but then sinks into the sand, and they are again accepting of their lot. That initial urge to complain, to fight, to get even can be tremendously positive; the delay in help loses that motivational boost. Apathy sets, the agency saves money, and the client stays in their sad carton.

NOTES:

The accountants have several reasons to make a client wait for service. First, by hiring a minimum number of therapists, delays become inevitable because of peaks and valleys in demand. Hiring economics likely dictate taking on the staff required to handle the low points plus a little more, so that peaks are delayed into future slack intervals. Delivering treatment is a cost for the agency if income has been paid in advance; you make money by not giving treatment. There are many tales of physicians spending their first years on the golf course because they made more money by being absent. Second, some companies (including state agencies) explicitly demand income immediately but delay costs to the maximum possible interval. The notion is that by delaying payment, there is some chance that interest can be earned or payment will not have to be made.

There is also a symbiotic relationship between organized health care and the patients. Health organizations take a little bit from a lot of people. Like any parasite, they work best if they do not annoy or cripple the host. Patients also can have a parasitic relationship by collecting more benefit than costs.

"Cheater" is a strategy wherein one member of a species always takes help from other members but never reciprocates. "Sucker" gives assistance even if there is never a return. Assistance and the costs of rendering it are measured in reproductive fitness; thus, the costs and gains are significant. Computer simulations show that Cheater always wins in competition with Sucker, Sucker always goes extinct against Cheater. Cheater initially wins but then loses against "Tit for Tat" in which the rule is "be nice until someone fails to reciprocate, then be nasty." (However, Cheater still wins if there is no repeated series of contacts. See Dawkins R, The Selfish Gene, for a discussion of other instances in which alliances develop along with T4T, even between presumed adversaries.)

Alliances might develop between each patient and the insurer but not between patients directly. There is repeated contact between patient and agency but not between patients. Thus, T4T applies for the patient/agency relationship but not for that between patients wherein Cheater tactics win. Each patient may visualize his health plan as "me and Blue Totem against the other Blue Totem members." Thus, the patient may tolerate being cheated on the smaller things but try to take a larger advantage on more catastrophic illnesses, while letting other policy holders pay the inflated costs.

I suspect a lot of "enablers" are glued in "Sucker Mode." There may be subtle advantages to the Sucker tactic if it allows a symbiotic relationship with a Cheater. (e.g., the patient skips psychotherapy but gets free medication samples from the physician.) A possessive Cheater may take too much advantage personally but will defend the Sucker from predation from other Cheaters. Submissive Cindy enjoyed being in the front of lines whenever Hulk escorted her. His large, tattooed friends assured her food and shelter when he was in jail. "The meek shall inherit the earth" (also a K-selection rule? See postings below on K/r-Selection.)

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