Although I’m usually a big fan and praise your blog endlessly, this recent post [“Helping Head,” 6/17/11] isn’t a “like.” Eating disorders are treatable to full remission. In fact, the pervasive idea out there that people just struggle endlessly and that treatment doesn’t really work is self-fulfilling and even dangerous. Please consider re-considering. There’s new science on this!

Without irony, I can say that treatment for eating disorders is effective. In other words, I agree with you, except that the word “effective” has a hook in it.

“Effective” is the word most favored by drug companies because it implies no guarantees, solutions or cures, just that the treatment in question produces results that are better than no treatment at all.

Unfortunately, it does not mean completely effective, or effective for everyone, all the time. (And it also may cause dry mouth, constipation, etc., etc.).

The result is that people who commit their resources to such treatment (which is usually very costly) must work hard to monitor its effectiveness and know enough to stop it if and when it doesn’t help.

Here’s a common scenario—imagine you’re an uninsured parent of 3 kids, one of them has a dangerous eating disorder, and tens of thousands of dollars have gone into her second residential treatment. Under observation, she’s gained weight to the point of medical stability, but the moment she goes home on a pass she binges and purges and there’s been no progress in the past 3 weeks.

If you keep her in the program, you won’t have enough money to send your other kids to college or pay for another course of residential treatment if/when it’s necessary. The staff tries to be helpful by telling you that treatment works, it’s what they recommend, and when it doesn’t work quickly, they recommend more because they believe in what they’re doing.

What they don’t do, and have never been trained to do, is look for and identify the signs of an impasse, accept the fact that treatment sometimes stalls, and help you conserve your resources.

Emotionally, your daughter’s (partial) treatment failure may have you wondering what she, you, your wife, or the program did wrong. The answer may well be…nothing. Treatment works, but not always, and it’s no one’s fault. After all, it was effective, just not enough, and the possible side effects include bankruptcy.

If you begin any treatment with the strong belief that what ails you is curable and everything’s going to be OK once you accept “scientifically effective” treatment recommended by trained professionals, you face the possibility of draining yourself, your bank account, and your resolve in order to achieve something that, while possible, is not guaranteed.

While eating disorders can be treatable, it’s better to approach any course of treatment with the attitude that it might not take right away (if ever), it will be a struggle, you’re the one who needs to decide whether and when it’s working, and that, even if it doesn’t produce the desired results, you should always be proud of making the most of whatever treatment’s available, even if that includes shutting it down.

People should never give up hope in their ability to overcome illness by getting treatment and living their lives in spite of whatever disability remains. However, they should never make their hope dependent on the good ol’ effectiveness of treatment, particularly if it comes up short in the long run.

STATEMENT:
“I’ll try any treatment that has a reasonable chance of working and I’ll spend anything if I believe it’s necessary, but I must always do my own assessment of whether it’s working and conserve resources if it isn’t.”

When my daughter got dangerously thin, I knew she had an eating disorder and forced her to see a therapist, but she didn’t get better and I couldn’t get her to follow a meal plan or stop running 5 miles a day. Now, however, she knows she can’t return to college until she gains 20 pounds and gets permission from her doctor, so she’s willing to accept more help. I wonder how treatment can help her if she’s being forced into it. My goal is to find a way to get her to see the need for treatment.

Fortunately, as described above, treatment for eating disorders and other problems involving destructive behaviors don’t depend on a patient’s having insight and motivation. Unlike the old joke about the number of psychiatrists required to change a light bulb, it’s not necessary for the light bulb to want to change. That’s because, once people are exposed to a new routine and strong incentives to form better habits, their attitudes often follow.

With eating disorders, the effect of malnutrition on the brain makes it extra hard for patients to reason clearly. Once their weight normalizes, their thinking improves, at least partially, and the vicious circle reverses.

So don’t waste time persuading your daughter to see things more reasonably; you’ll get frustrated, she’ll dig in her heels, and you’ll have a harder time getting her to attend a residential or day program.

Instead, keep your mouth shut, open the car door, and convey your willingness to help her do what she needs to do to get back to college and her running. It’s very likely that she can get healthy again, but she doesn’t need to be reminded of that since she refuses to admit she’s sick in the first place.

Later, if she slips up on her meal plan when she gets home, you may well want to adopt whatever incentives seemed to work in the hospital to keep her going on her healthy behaviors. Again, less talk and less emotion are usually better. There are eating goals that you impose, there are consequences, and there’s your belief that they’re for the best and don’t need to be talked about.

In the long run, you hope that negative behaviors will lose their grip on her health and her values, but in the short run, you do whatever you think works. You’re the parent, and it’s your job to do what you think is best and create a customized treatment plan so effective that she’ll eventually be as willing to change as that light bulb.

STATEMENT:
“It’s agony to see my daughter starving herself and then insisting that she’s doing what’s best for her health. I can’t stand the lying and cheating. My job, if I’m going to be effective, is to do what seems to work and keep my feelings out of it.”

I decided recently to listen to my friends and family and see a psychiatrist about my depression, but I don’t know whether I’ve made the wrong decision, or whether I’ve just chosen the wrong doctor. Basically, I decided to get help because I feel helpless, but my doctor wants me to do a lot of the work myself and doesn’t really help that much. It’s not just he wants me to ask myself a lot of questions (and answer them—if I had the answers, would I really be paying him?—but also deal with my insurance company and read up on the medication he suggests (he tells me about them, sure, but he says I owe it to myself to read up on them on my own, and that doesn’t make sense to me since he’s a doctor, knows everything about the pills, and he could just tell me himself). My goal is to figure out whether therapy is worth it, or whether I’m just getting help from the wrong source.

I hate to sound like your psychiatrist, but ask yourself what you have a right to expect from treatment, given what you know about its limits and your resources for paying for it.

If you want, you can spin things positively by saying that you’ve heard about good new treatments that can really help and that you’ve got great insurance that you pay a ton of money for. Of course, you’d probably be full of shit.

You don’t need to do months of research to know that no treatment has yet been acclaimed as a cure for mental illness or any other life- or personality-related problem.

Plus nothing you’ve read (or probably haven’t bothered to read) about the effectiveness of any current treatment implies that it works 100 percent of the time or that the treatment, if medical, is safe from possible side effects.

In addition, every method of “screening” for depression that you’ve heard about involves a questionnaire, right, rather than a blood test or scanning machine, which means that the burden for enduring, measuring and tracking the results of a trial of treatment falls, inevitably, on you the patient. And those are unfortunate facts of life whether you’re rich or poor, smart or stupid, board certified or not.

That’s the next problem: you’re not rich. And while you bristle at having to deal with insurance limits, you can’t afford insurance that would give you unlimited mental health treatment because it doesn’t exist. All insurance puts a limit of some kind on the amount of treatment you get and, unless you know what that limit is, you’ll use up your resources too quickly and have no idea about what, if anything, entitles you to more.

In addition, insurance limits your doctor’s fees and the amount of time s/he can afford to spend on a visit, so don’t fall for the professional who is ultra-amiable until your money runs out. Instead, look for someone who gives you what you most need in as little time as possible. In other words, beware smiles and frills because they may drain your limited resources.

Depressed people like yourself also tend to get negative and helpless ideas, which make them act negatively and passively, which makes them yet more depressed. That’s why mental health clinicians will push you to challenge your negative assumptions, learn more positive ways of thinking about your problems, and put the breaks on the depressive cycle.

It’s a cognitive kind of psychotherapy and is very helpful, although it’s often unpleasant in the beginning because you need to clamp down on your natural instincts. It’s a mental workout to make your non-depressive muscles stronger. No pain, no gain.

So yes, therapy of all kinds can be worth it, but you’ll be the one doing much of the work, not because someone else is slacking, but because mental illness sucks and both treatment and the resources to pay for it require careful management—by you.

Now you just have to decide what’s harder—doing the work or doing nothing. It might not be what you want to hear, but there’s no psychiatrist out there with a better offer.

STATEMENT:
Here’s a statement to keep you positive about a negative treatment process. “It’s hard having an incurable illness and knowing that the treatments are iffy, take a long time, and can easily use up my insurance before helping me, but I owe it to myself to give every reasonable treatment a try and become and good resource manager because that’s what I have to do.”

I’ve been in therapy for five years, and while I like my therapist a lot, I’m moving soon (my girlfriend got into grad school on the west coast), so I’m ending my treatment with her. She asked me recently though whether I was going to continue my treatment in my new town or whether I thought I’d taken it far enough, and I realized I honestly don’t know. She had some suggestions in terms of determining when and why to end therapy, but to be honest, they didn’t really help. I’ve been in therapy long enough that I don’t really remember how I coped beforehand, and while I feel much less tormented than I did when I began therapy, I’m not sure if my state of mind will crumble once I’m no longer getting help. How do you think one can determine when therapy has run its course, or whether there’s more to be done?

There’s a simple way to figure out how much talking psychotherapy you need: imagine paying full fee for it.

Before you crunch the numbers, ask yourself why you started therapy in the first place. Forget self-improvement, introspection, or generally pondering your bellybutton. Figure out what’s so bad about the way you feel and/or handle your life that you need to continue to spend lots of time and money on changing it.

Having failed to solve your problems over the past 5 years, you should wonder whether you can realistically expect a cure in the next year (no way) or whether you need maintenance treatment to keep you from slipping backwards (which is what you’ve been wondering all along).

At the same time, go back to the original question and ask yourself how much you can afford to spend on treatment each year and whether you should hold a few sessions in reserve for use in emergencies.

Unless you’re rich, don’t waste time worrying about how stopping treatment will make you feel. Instead, try stopping and see what happens. Even if you miss your therapist’s support, lose confidence, and re-experience your nervous stammer, suck it up, give it time, and the earth will continue to turn.

Next, think of therapy as a course that’s supposed to give you a specific marketable skill in exchange for your hard-earned debt. Don’t think like a college kid; you’re not there to party, please your parents, or become cool. If the first few sessions don’t deliver what you need, drop the class.

If you do have ample insurance coverage for therapy, don’t let it make you forget basic resource management skills. For one thing, many insurance policies are stiffening the limits on outpatient psychotherapies and are about to force you to do the above.

For another, being an active manager protects you from unnecessary dependence and time-wasting. Give your therapy specific goals, then examine how close to those goals you’ve come.

If therapy is more about discussion, then save the insurance hassle and start a search for a fun hairdresser. You can get your hour of talk and never have a bad hair day.

STATEMENT:
Here’s a statement that keeps you focused on making the best of limited resources instead of going for all-you-can-eat and then feeling deprived and abandoned. “I like psychotherapy and feel it’s been good for me, but it’s time, before it eats up more time and/or money, to think hard about how badly I need it, how well it’s working, how much is necessary, and how much I can afford to pay for it. The more I answer these questions for myself, the less likely I am to depend on experts to tell me what I need.”

I’ve been depressed for some time and could use some treatment, but my insurance has a big deductible, so I’ll be paying everything out of my pocket, which isn’t deep. My goal is to get treated for the least amount of money.

I’ll assume from your tone that depression isn’t making you suicidal or putting you at immediate danger of losing your job and/or family because, if it is, you need to forget about the cost of treatment and value the cost of your survival.

If depression is putting your life/work/family in danger, get a psychiatric evaluation, in an emergency room if necessary. Do not pass go, do not collect $200 (no matter how much you need it).

If that isn’t the case, there’s lots you can do to reduce the amount of money you spend on treatment…if you’re willing to spend some time, do some research, and use your common sense.

While the above question is quite short, the answer is anything but; looking for a treatment on any budget is a serious, involved process, so we have an involved, serious answer. Behold, our five step process that will help you with your depression without hurting your wallet.

Step one is telling your primary care physician (during a brief visit or even email) that A, you’re feeling low, B, you don’t have any physical symptoms (no fever, no weight loss), and C, you’d like to get some tests to rule out a physical cause of depression, like thyroid disease.

Tests will reveal if you’re feeling low because your glands, not your brain, are problematic.

Assuming your glands are good and your brain isn’t, step two is considering the options other than antidepressant medication, which, because it’s medication, always has a higher risk than non-medical therapies.

I’m guessing that medication is probably the last thing on your mind. It’s important to think about it upfront, however, because sometimes depression doesn’t wait for psychotherapy to work before causing severe pain and/or damage to your life, and medication always increases the odds for a better and faster (and sometimes cheaper) recovery.

Step two then, (postponing the issue of possible pills), is considering psychotherapies, including the how-do-you-really-feel-about-that kind. Many people assume this is the only kind since it gets lots of airtime on TV, where it uncovers exciting and unexpected changes of heart and inspires tears and plot reversals.

Despite what TV tells you, however, not everyone with depression needs psychotherapy. Psychotherapies are better at helping you manage depression than cure it, so it’s not surprising that many people with depression have had a number of psychotherapies.

Before considering a feelings-focused therapy, ask yourself and the people who know you whether there’s an issue you need to talk about. Remember, sharing your feelings with a professional is most effective if you haven’t done it before or your confidantes are unsupportive bozos and bartenders.

So, while the bad news is that psychotherapy is not a cure, the good news is that you don’t have to pay for it unless you think there’s a kind that’s worth trying. Either way, you save!

Your job is to figure out whether you (still) need one or more of them. If you want to save money, do your homework. It’s that, or pay a professional to do it for you.

If you decide that a feelings-focused psychotherapy is necessary, you may get a bargain at a state-subsidized community mental health center or a psychotherapy teaching institution. Don’t assume you should see a therapist every week, because you may get just as much bang for your buck by making the meetings less frequent.

You haven’t completed step two, however, until you consider other psychotherapies, particularly cognitive behavioral therapy or “CBT”, which is a good option if your negative thinking (caused by depression or being human) is making you more depressed.

Read books on the negative thinking caused by depression and anxiety (like The Feeling Good Handbook by David Burns) and decide whether you need to do thought exercises to stop your negative feelings from becoming negative beliefs or actions. If you find it useful, look for a therapist who “does CBT” or “DBT”, a form of CBT that focuses on thoughts of self-worthlessness and the desire to injure oneself.

Please note: we’re not recommending all kinds of self-help. In fact, if you see a self-help book about “healing the inner hurt,” run the other way as if it were on fire. If Dr. Phil recommends a book, we forbid it.

Step three is taking a break from the books and tuning up your diet and lifestyle. Exercise is a powerful antidepressant (the way you feel afterwards, not during, anyway). Vitamins and omega three fatty acids help, and, despite what most people think, drinking and drugs don’t, so learn to abstain.

Finally, read up on antidepressants while ignoring the eye-witness accounts of horrors and miracles. Consider the risks (fairly low, despite what Scientology says) and possible benefits (positive, but delayed and very iffy). Then, if you decide that the risks of staying depressed are worse than the medication risks you’ve read about, ask your primary care physician for an “antidepressant medication trial.”

Remember, you’re conducting a trial, not taking a cure. Note, quantify and record your symptoms and possible side effects over the next few weeks. (There are programs on Google that can help you do this). You’re the one who decides whether the new medication is doing more good than harm.

If a couple medication trials haven’t worked, the very last possible step, number five, is to get a referral to a psychiatrist and give him/her a list of the medications you’ve tried, the doses, how long you took them, and the good and bad things you noticed. You can find a psychiatrist on the cheap at the same clinics we sent the feelings-focused types to.

Follow these steps, and you’re on the road to dealing with/managing your depression. It’s not a cure or an easy answer, but it’s a start, and hopefully this is all the information you need to start on a good path to treatment without paying a pretty penny.

STATEMENT:
Here’s a statement of purpose that will counteract depressive helplessness and pessimism. “I don’t know why I’ve been feeling depressed and I may never know, but I know how to find any causes that are worth finding and to try the cheapest treatments first. I expect to run into a lot of dumb ideas about depression because many people want to believe they have the answer and an easy way to control it. Whether or not I can control it, I know that, by doing the research myself and using professional help whenever I think it’s necessary, I can do a good job of taking care of myself.”

I have a 30-year-old patient whom I’ve been seeing in weekly psychotherapy for 6 months and he had a terrible history of sexual and physical abuse and years in state care. Amazingly, despite all his trauma and several prior failed treatments, he settled into a trusting relationship with me. He tells me I’m the first person he’s bonded with, and he’s been able to stop using cocaine, and, for the first time, sees some hope for himself. The problem is that he just got a new job, and I’m not covered by his new insurance plan. He wrote me a letter telling me how much he feels his recovery depends on continuing the treatment we’ve started and I feel professionally obliged to put his welfare ahead of my financial needs, but I’d like to get paid. My goal is to do right by my patient, and not trigger the feelings of abandonment that underlie much of his negative behavior, but I’m not sure how long I can afford to see him for nothing.

There are many therapists who believe the best thing you can do for a troubled patient like this is to “be there,” providing the steady acceptance and secure relationship that they need for healing. I’m not one of them.

The sad fact is that the healing power of currently available treatments is vastly over-rated and a good example of false hope and the harm it can cause.

What’s wrong is that our treatments, in terms of demonstrated effectiveness, are all rather weak, and it shouldn’t be surprising; we do our best, but life, such as it is, is a bitchmonster from hell. You can’t undo the past, change personality, stop drug cravings, or even guarantee that you’ll be available next week.

Look where you’re going with this treatment and “mind the gap,” as they say on the London Underground, because, as ideal a healer as you seem right now, there are many ways this dynamic could get tripped up.

For example, unexpectedly, you and/or your treatment rub the patient the wrong way. It may be that you fail to live up to an impossibly high ideal or that you have a bad day and say the wrong thing. When that happens, trust disappears and with it, your patient’s rationale for healing.

You try to stay calm, remain empathetic, and ride out the storm while resenting having your personality dissected for an unpaid hour. If your anger shows, it gives your patient more reason to feel victimized and find a therapist who can help him recover from his latest trauma/treatment.

Another common outcome is the “Bill Murray Morass,” whereby he continues to feel strongly that treatment is beneficial and can’t imagine living without it, and you, and this continues for many years, while you continue to feel responsible and indispensable. “What About Bob?”, indeed.

You and “Bob” could argue that treatment has benefited his control over negative impulses, but it has also fostered a sense of dependency and fragility that will surface if, God forbid, you should die first, or, more likely, he just changes his mind.

So don’t buy into his idea of your precious relationship. If he liked you, it proves he has the capacity to like another therapist. There are many fish in the sea, many therapists in his insurance directory. If he depends on that positive feeling to stay sober or maintain a positive idea of the future, he’s in trouble, and so are you.

Your goal is for him to build up ideas for staying sober and fighting off despair that are not dependent on a single relationship or good feeling, and that can stand up to rejection and depression. In other words, you want to “be there” for your patient, but you don’t want to be the only thing between him and oblivion. Don’t beget a Bob.

STATEMENT:
Our relationship has been positive, but it’s important for you to manage negative beliefs, despair, and anger when you’re not feeling closely supported, and our stopping treatment gives you just such an opportunity. You have the capacity to form a positive relationship, so I’m confident you’ll do well in shopping around for a new therapist. Meanwhile, it’s good for you to focus more on the ideas than on the individual, because it’s your own ideas and the way you use them that will give you strength to manage yourself. I’m confident that this will work out well.”

I have a new patient who’s a young woman, college freshman, who was sent to therapy by her parents after her roommate turned her in for cutting her arms and drinking too much. After a fair amount of discussion, I started her on a medication trial and explained to her that these pills take a while to work (if they work at all), but it didn’t sink in, because after a week she’d had enough with feeling tired and hungry, especially because she still felt depressed and anxious. Not long after that, she declared that therapy in general was a waste of her time and she could stop drinking and self-mutilating on her own. Part of me thinks that it’s not my job, or anyone’s job, to sell her on treatment if she’s not ready, but I admit, there’s a softy side of me that doesn’t want to let her off the hook just so that she can really hurt herself or get kicked out of school. My goal is to get this kid to give treatment one more chance.

It’s tempting to tell a young woman with obvious problems that she should stay in treatment, but don’t. This is not the time to listen to your softer side. Of course you wish she would feel better and stay positive, but first, you and she must accept your lack of control.

If psychiatric treatment—medication or psychotherapy—were more reliable and effective, maybe it would be worthwhile to give such advice. More often than not, however, the first trial of treatment doesn’t work or causes side effects and patients who are already angry and disappointed about their life expectations are then quick to feel that their negative beliefs have been redeemed.

Your goal isn’t to get her to stay in treatment; it’s to give her tools to make rational and positive decisions about treatment. You don’t want her treatment decisions to depend on her positive relationship with you (see: above Bob) or an initial positive result. You want them to depend on her own ability to weigh risks and benefits and do what’s right.

It’s easier to help her think realistically about treatment if you crush false hope up front. You are obviously well aware that treatments of any kind rarely bring about a “cure.” I’m often reminded, when patients cite a pharmaceutical add touting a particular medication as “effective,” that the scientific meaning of the word is the opposite of its meaning in plain English.

In the language of science, effective means “better than nothing,” not “helpful most of the time.” Life is tough and so are most psychiatric problems. Unfortunately, so is your patient’s attitude.

Ultimately, you want her to know that, while you don’t care which decision she makes, you do care a great deal that you make she makes that decision rationally. Being soft won’t work, so be hard, or really, be honest, not emotional or sentimental.

STATEMENT:
Here’s a speech for encouraging her to take good care of herself and use treatment appropriately. “I wish I could tell you that treatment will ease your pain, but it often doesn’t. Given the fact that depressive feelings often come from genes and that we don’t have a cure, it’s not surprising that they tend to come and go and then return, even when a medication or other treatment has been very helpful. So the main goal of treatment isn’t to make you feel better, but to make you stronger and better able to tolerate your condition, much as if it were diabetes. You can get stronger by choosing the right psychotherapist or therapy or 12 step group and also appropriate friends and readings, because the right choice can make you stronger, and the wrong choice won’t. Medication is worth trying if your symptoms are hurting or threatening to get you canned. There’s a risk that each medication will cause side effects or won’t work, but you don’t want to make a choice about meds because you love or hate them. You want to weigh the risks of not taking them and the possible benefit of their working. If I were in your position, I’d definitely be trying them, but it’s your call.”

For years, I’ve talked to a friend of mine about my problems who’s also a counselor, and during that time, he’s urged me to seek professional help. I used to brush off that advice, mostly because this friend lives in another city and only ever really talks to me on the phone when I have problems, but in the last few months, I’ve begun to consider taking his advice. I don’t know what to say when I call to make the appointment, however, because I haven’t the faintest how to explain the unknown in my head (which is the main issue that frustrates me). I want to scream, but don’t know why or what. Do you have any advice as far as how to ask for help when I’m not sure what I’m really asking help for?

Remember, funny feelings in your head cause fear, which causes funny feelings, which cause fear, which create a spiral that will flush you down the toilet of needless worry. The first thing to do then is shut up and think about whether you need help.

If you’ve had funny feelings in your head for years, they’re not about to kill you; they’re not telling you to kill yourself or anyone else, and they’re not annoying you to death. Plus, they’re obviously not getting in the way of at least one long-term friendship.

So, taking all that into account, you have time to use your usual problem-solving methods to determine whether or not your weird head sensations are a big deal. You can try exercising and going on vacation, to see if you get better.

The big question isn’t what you say when you ask the shrink for help, but what you say after forming your own decision about why help is necessary. After all, you can’t shut up your worrying friends until you know your own mind.

There are several criteria for deciding when to seek help that apply to most situations, like if your problem gets in the way of making a living or being a good guy, or if your problem causes too much pain.

Assume, of course, that you haven’t been able to solve the problem without help, and throw in one special-knowledge exception: get help if the problem might be a sign of an illness that you might cure and/or prevent if you had expert advice. Then come to your own conclusion about whether you need help and then stand by it.

If you don’t need help, don’t bother to tell your friend to shut up. Let him/her know, if you need to talk about the problem, that you’re satisfied with your own way of managing it, and he’ll probably shut up on his/her own.

On the other hand, if you decide you do need help, shut up about your helplessness. Tell your doctor what the matter is and why you think it’s necessary to talk about it. Then the advice you get will be more focused and less patronizing, so you’ll actualy want to shut and listen to it.

STATEMENT:
“My symptoms are subjective and I don’t know anyone else who has them, but they hurt and distract me a great deal, so I want expert advice on what I can do about them that I haven’t already tried. I don’t care if the experts explain them away or tell me they’re in my head. That just means no one has an answer, and I have the answer I need (though the answer I want would include a cure). Then I know it’s not cancer, I’ve done my best, and it’s time to accept pain and move on with my life.”

After graduating from college last spring, my son moved to a new city for graduate school. The problem is that his psychiatrist, the one he credits with saving him from severe depression and turning his life around, did not make the move with him, and my son doesn’t want to talk to anyone else. The fix so far has been phone sessions, but this doctor is not covered by my son’s meager student insurance, so his father and I have been footing the bill, and that bill is staggeringly enormous. We love our son and want him to be well, but between our own expenses and the money we’re putting towards his graduate education, our goal is to get him to look for a new, local doctor without making him relapse.

Severe depression is scary and hard to control, so it’s not unusual that recovering survivors cling tightly to whatever may have made the bad symptoms go away, including anything from the lucky underwear they had on when the cloud lifted to, of course, their shrink, particularly if he or she is nice to talk to.

On the other hand, it’s also hard for parents to stress a kid who’s gone through depression, because it’s not just the kid that fears a relapse. That’s why you don’t want to tell your son and the therapist that it’s time for them to shut up.

Your goal, however, isn’t to protect him from stress or make him feel good, but to teach him how to deal with depression effectively, and superstitiously clinging to good luck charms isn’t the way to do it.

Instead, encourage him to make the most of his resources by bravely figuring out what he really needs, and what he can do without. Treat him as the agent of his recovery, the expert of his own experience, and the client who seeks useful ideas from many sources, including new therapists, all while debunking the therapeutic impact of nurturing/”special” relationships.

Yes, suggesting change will raise his fears and your own, but it’s your job to do that while offering him reasons for beating the fear and methods for managing it. Also, of course, don’t act frightened; sure, you can admit to fear and talk about fear, but not show fear, or else everyone will be so afraid as to soil their lucky underwear.

You’re there to convince him that facing fear will pay off; it’s for his own benefit in the long wrong, not just so you can make it easier to pay off your bills.

STATEMENT:
“Of course you need a doctor to help you manage depression, but our resources are needed for your education, so we can’t waste a cent. Find a doctor who is covered by your insurance. Don’t use that person for comfort and understanding unless it’s necessary; remember, we’re your friends and you have a dog and we’re all free. Ask yourself what you learned from your old doctor that helped you manage your negative thoughts and/or symptoms more effectively and look for someone who has similar ideas. Also, if you want to learn more about coping with depression, join a group of strong depression survivors. If you want to learn how to correct negative thinking, read a book and take a course. Use your doctor to get what you can’t get elsewhere. Whether we’re managing depression or diabetes, that’s how we can keep the costs of treatment under control.”

We don’t like to get political, and everyone’s entitled to their own views (at least I think so—he’d probably tell you you’re just wrong), but this is not an entry about politics; at its core, the health care debate is about health care, and as a doctor, not a Democrat or Republican, this is his medical point of view. We’ll return to normal cases on Thursday.
-Dr. Lastname

One thing you learn as a parent is that there’s never enough time, money, or resources to provide perfect safety and security for your family. Worse, if you hold yourself responsible for providing it, you’ll go nuts the first time something goes badly wrong and you can’t control it. You’ll blow everything on something that can’t be helped, feel like a failure, and have nothing left, financially or emotionally, for those who need you.

As such, compromising on how you spend your resources is as much a part of good parenting as is nurturing, although it often makes you feel terrible. So it is with health care systems.

Democrats sometimes emphasize the nurturing part of this process, our shared humanitarian desire to provide more care, while Republicans sometimes emphasize the tougher part of this process, our desire to make sure that treatments work and are well delivered. But at the heart of good management there is always an unavoidable need to make good compromises, and that’s what I think needs more attention and reform. Not fewer denials from the insurance companies, but denials that are more fair and decided upon more ethically.

That might sound harsh, but remember, we will never have enough money for everyone to have unlimited access to the most expensive treatments, and if we focus too many resources on patients’ problems that aren’t likely to get better, we’ll leave ourselves broke and with nothing to give those who might really benefit.

Making resource decisions on a case-by-case basis is called utilization management, and it’s done by most managed care insurers and many public care systems. Without utilization management, too much care goes to the person who is first in line or has the best advocate, leaving the rest on a waiting list.

It’s the job of the utilization manager to review a patient’s case on behalf of the insurance company and judge whether the requested treatment is medically necessary and therefore eligible for coverage. It’s never easy for a utilization manager to say “no” to requests for care, but the process is better than the alternative.

For a managed system of health care to work, the resource decisions of utilization managers must ultimately have integrity and inspire respect, like the decisions of judges. They must be impartial, arise from clinical and ethical principles, stand up to scrutiny, and undergo revision through an appeal process. Yet this is not the case.

Currently, this process of utilization management has insufficient safeguards protecting medical/clinical resource decision-making from being overly influenced by business incentives. For instance, there is nothing to stop an insurance company (or government, or hospital) executive from saying to utilization managers who work for him or her, “we have too many patients in the hospital today, you need to tighten up on your admissions reviews and not agree to so many admissions.”

It should be unlawful for non-clinical executives to urge utilization managers to take its financial condition into account when making resource management decisions—it’s certainly unethical—but it happens all the time.

And if insurers believe a particular reviewer is too “lenient” in making decisions, it can steer these decisions to another reviewer the company thinks is tougher and less likely to consider a costly treatment as necessary. Almost always, the insurer pays the salary or fees for the managers who make these decisions, as well as for “the higher court” of managers who review appeals of these decisions.

So the insurer can always choose utilization managers to make decisions that it, the insurer, thinks are best, and if there’s a dispute, they’re also paying additional managers—the second tier of judges—who make the final call. Naturally, most executives and utilization managers strive to be fair; but the lack of safeguards has an insidious and negative effect on the decision making process.

So here’s what I think doctors and patients need to do. Accept that utilization management is unavoidable and needs to be done right, working together to protect the integrity of the decision-making system.

Let me tell you, my fellow doctors: our leadership on this is needed and has been sorely missed. And let me tell you, my patients: you can’t avoid an oversight system, so put your energy into insisting that it get fairer and more impartial, not limitless. It needs a common set of regulations, publicly arrived at, and a method of funding that guarantees the independence of its judges, at least at the appeal level.

There’s no avoiding compromise, not in health care decisions, not in life in general. We need to clean up the utilization management system by which compromises are now made. We should aim for systems that make good, ethical compromises, not that give perfect care or that punish the current crop of resource wasters. And then our reforms will be lasting and create a system that does the right thing.