Behavioral Health Back On Defense

Lindsay Clancy's case has put behavioral health strangely back in comfortable territory - defense. The industry has been on defense more than a pee wee football team that keeps fumbling snaps. It's been since the 1960s—fighting for coverage and parity and a seat at the big kids’ policy table, like the awkward 11-year-old sitting with the toddlers at Thanksgiving. There was a time not that long ago in 2008 when hospitals had to defend every claim, argue that the man with severe depression really did in fact need to be hospitalized, even if he didn't want to hurt himself or others. For those new to healthcare, I'm not making that up - insurers used to deny payment for hospital psych admissions unless you had actually tried to hurt yourself.  The defensive struggle has continued since - battling for coverage, arguing that people in the throes of addiction shouldn’t have to wait for pre authorization and even as the nation's mental health crisis had seemingly put behavioral healthcare on offense, the sector has returned to playing defense as insurers and investigators start looking to sack businesses doing too much therapy without progress and at unsustainable costs....And now, as the industry reassesses its position and realigns like a Big 12 football team without a conference (like Sword’s digital pain services acquiring Headspace talk therapy, or UHS’s inpatient facilities acquiring Talkspace), the psych community is back defending itself in, of all places, the courtroom…The Clancy trial has elevated the issue of the psych professional's influence over decisions we make in our lives after the therapy session ends, and it's emphasized what so many already knew that women need more help, not less, not just after the baby comes but in the years after. But what will be striking to me is how documentation within the therapy session notes likely becomes a lot more defensive in nature, protective, and written for an unusual audience - the coroner, insurer, regulator, an AI bot and, perhaps most amazing, a jury of peers, which seems like the opposite of what the psychiatric documentation is supposed to do. Isn't it for the patient's benefit and for the next psychiatrist and therapist? A guide, a log, a story and a reference point to help make progress. Increasingly I wonder if therapists will start documenting not just what they said, but what they’ll need to prove should something go wrong. The size of the notes will expand but will their value diminish?  AI’s interpretation of documentation may muddy the story, even lose the nuanced gains the therapist made. Defense is all well and good, and documentation matters perhaps until it misses the point and hampers the healthcare worker who's just trying to listen, guide, and make sense of all the noise inside our brains, to help the working woman with kids and cancer manage her depression a little better, so she can go to work and raise a family. I’ve myself been on defense most of my parental life like that time in 2008 when I was changing Tommy’s explosive diaper while my 3 year old daughter Sophie was washing her dolls in the toilet with the spatula, and my 5 year old Jack was running naked kicking a football down Trout Brook Drive, which for a kid is like I-95. I was on defense, failing miserably, unable to get on the other side of what in my mind was a crisis. It of course was not, not like real mental health crisis. But had something gone really wrong – and I suppose it almost did had wildman Jack been hit by a truck, what would my case be—Tommy’s poop was messy? I surely barely had the time to navigate their childish albeit hilarious behavior, much less document my every defensive move. Therapy, like life, is messy and so to is our fluctuating behaviors–therapy is not transactional and not solved in one fell swoop, it lives in a gray area that policy makers like to challenge, but it’s hard to capture all the nuance in a note while juggling the actual art of the therapy. Therapy is not a lab test or CT scan that usually gives you the answer. It’s a 3 yard gain followed by a 2 yard loss. And so defending therapy’s value in society and health policy, and now legal circles, is incredibly complicated.  If only the industry had a secondary solution to take the ball back….