Tag Archives: Managed Care

Trichotillomania


The diagnosis of Trichotillomania (TM) is synonymous with the act of recurrently pulling one’s own body hair resulting in noticeable thinning or baldness.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 674)  Sites of hair pulling can include any area of the body in which hair is found, but the most common sites are the scalp, eyelashes, eyebrows, and the pubis area.  (Kraemer, 1999, p. 298)  The disorder itself is categorized in the DSM-IV-TR as an “Impulse Control Disorder Not Elsewhere Classified” along with disorders like Pathological Gambling, Pyromania, Kleptomania, and Intermittent Explosive Disorder.  Although TM was previously considered to be a rare disorder, more recent research indicates that prevalence rates of TM may be as high as 2% of the general population.  (Kraemer, 1999, p. 298)  This prevalence rate is significantly higher than the lifetime prevalence rate of .6% that is cited as a potential baseline among college students the DSM-IV-TR.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  The condition appears to be more common among women and the period of onset is typically in childhood or adolescence. (Kraemer, 1999, p. 298)  As is customary with most DSM-IV-TR diagnoses, the act of hair pulling cannot be better accounted for by another mental disorder (like delusions, for example) or a general medical condition.  Like every disorder in the DSM-IV-TR, the disturbance must cause significant distress or impairment in functioning.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 675)

Alopecia is a key concept that must be understood in order to complete the differential diagnosis of TM.  Alopecia is a condition of baldness in the most general sense.  (Shiel, Jr. & Stoppler, 2008, p. 14)  Other medically related causes of alopecia should be considered in the differential diagnosis of TM, especially when working with an individual who deny pulling their hair.  The common suspects include male-pattern baldness, Discoid Lupus Erythematosus (DLE), Lichen Planopilaris (also known as Acuminatus), Folliculitis Decalvans, Pseudopelade of Brocq, and Alopecia Mucinosa (Follicular Mucinosis).  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  Comprehensive coverage of these medical conditions is beyond the scope of this article – all of the aforementioned confounding variables can be eliminated by a general practitioner.

There are a number of idiosyncratic features associated with TM that bear mentioning.  Although the constellation of features covered here is not sufficient to warrant a diagnosis in isolation, they can aid in the differential diagnosis process.  Alopecia, regardless of the cause, has been known to lead sufferers to tremendous feats of avoidance so that the hair loss remains undetected.  Simply avoiding social functions or other events where the individual (and their attendant hair loss) might be uncovered is a common occurrence.  In cases where individual’s focus of attention is on the head or scalp, it is not uncommon for affected individuals to attempt to hide hair loss by adopting complimentary hair styles or wearing other headwear (e.g., hats, wigs, etc).  These avoidance behaviors will be the target of exposure and response prevention later in this article.

In addition to avoidant behavior and elaborate attempts to “cover it up,” individuals with TM frequently present with clinically significant difficulty in areas such as self-esteem and mood.  Comorbidity, or the presence of one or more disorders in the addition to a primary diagnosis, is the rule not the exception in the stereotypical presentation of TM.  Mood disorders (like depression) are the most common (65%) – anxiety (57%), chemical use (22%), and eating disorders (20%) round out the top four mostly likely candidates for comorbidity.  (Kraemer, 1999, p. 298)  These comorbidity rates are not overly surprising since they parallel prevalence rates across the wider population – perhaps with the notable exception of the high rate of comorbid eating disorders.  We can speculate about the source of comorbidity – one possible hypothesis is that a few people who suffer TM also suffer from a persistent cognitive dissonance associated with having happy-go-lucky personality trait which leads them “let the chips fall where they may.”  They are individuals prone to impulsivity, but they are subdued and controlled the shame, guilt, frustration, fear, rage, and helplessness associated with the social limitations placed on them by the disorder.  (Ingram, 2012, p. 269)  On the topic of personality, surprisingly enough, research suggests that personality disorders do not share significant overlap with TM.  This includes Borderline Personality Disorder (BPD) despite the fact that BPD is often associated with self-harming behavior.  (Kraemer, 1999, p. 299)

Differentiating TM from Obsessive-Compulsive Disorder (OCD) can be challenging in some cases.  TM is similar to OCD because there is a “sense of gratification” or “relief” when pulling the hair out.  Unlike individuals with OCD, individuals with TM do not perform their compulsions in direct response to an obsession and/or according to rules that must be rigidly adhered to.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  There are, however, observed similarities between OCD and TM regarding phenomenology, neurological test performance, response to SSRI’s, and contributing elements of familial and/or genetic factors.  (Kraemer, 1999, p. 299)  Due to the large genetic component contributions of both disorders, obtaining a family history (vis-à-vis a detailed genogram) is highly recommended.  The comprehensive genogram covering all mental illness can be helpful in the discovery the comorbid conditions identified above as well.

There is some suggestion that knowledge of events associated with onset is “intriguing, but unnecessary for successful treatment.”  (Kraemer, 1999, p. 299)  I call shenanigans.  There is a significant connection between the onset of TM and the patient enduring loss, perceived loss, and/or trauma.  Time is well spent exploring the specific environmental stressors that precipitated the disorder.  Although ignoring circumstances surrounding onset might be prudent when employing strict behavioral treatment paradigms, it seems like a terrible waste of time to endure suffering without identifying some underlying meaning or purpose that would otherwise be missed if we overlook onset specifics.  “Everything can be taken from a man but one thing: the last of human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”  (Frankl, 1997, p. 86)  If we acknowledge that all behavior is purposeful, then we must know and understand the circumstances around onset if we will ever understand the purpose of said behavior.  I liken this to a difference in professional opinion and personal preference because either position can be reasonably justified, but in the end the patient should make the ultimate decision about whether or not to explore onset contributions vis-à-vis “imagery dialogue” or a similar technique.  (Young, Klosko, & Weishaar, 2003, p. 123)  If such imagery techniques are unsuccessful or undesired by the client, a psychodynamic conversation between “internal parts of oneself” can add clarity to the persistent inability of the client to delay gratification.  (Ingram, 2012, p. 292)  Such explorations are likely to be time consuming, comparatively speaking, and should not be explored with patients who are bound by strict EAP requirements or managed care restrictions on the type and length of treatment.  Comorbid developmental disabilities and cognitive deficits may preclude this existential exploration.  I employ the exploration of existential issues of origin in the interest of increasing treatment motivation, promoting adherence, enhancing the therapeutic milieu, and thwarting subsequent lapses by anchoring cognitive dissonance to a concrete event.

TM represents a behavioral manifestation of a fixed action patterns (FAPs) that is rigid, consistent, and predicable.  FAPs are generally thought to have evolved from our most primal instincts as animals – they are believed to contain fundamental behavioral ‘switches’ that enhance the survivability of the human species.    (Lambert & Kinsley, 2011, p. 232)  The nature of FAPs that leads some researchers to draw parallels to TM is that FAPs appear to be qualitatively “ballistic.”  It’s an “all or nothing” reaction that is comparable to an action potential traveling down the axon of a neuron.  Once they are triggered they are very difficult to suppress and may have a tendency to “kindle” other effects.  (Lambert & Kinsley, 2011, p. 233)

There are some unique considerations when it comes to assessing a new patient with TM.  Because chewing on or ingesting the hair is reported in nearly half of TM cases, the attending clinician should always inquire about oral manipulation and associated gastrointestinal pain associated with a connected hair mass in the stomach or bowel (trichobezoar).  Motivation for change should be assessed and measured because behavioral interventions inherently require a great deal of effort.  Family and social systems should not be ignored since family dynamics can exacerbate symptomatlogy vis-à-vis pressure to change (negative reinforcement), excessive attention (positive reinforcement), or both.  (Kraemer, 1999, p. 299)

What remains to be seen is the role of stress in the process of “triggering” a TM episode.  Some individuals experience an “itch like” sensation as a physical antecedent that remits once the hair is pulled.  This “itch like” sensation is far from universal.  Some clinicians and researchers believe that the abnormal grooming behavior found in TM is “elicited in response to stress” with the necessary but not sufficient condition of “limited options for motoric behavior and tension release.”  (Kraemer, 1999, p. 299)  Although this stress hypothesis may materialize as a tenable hypothesis in some cases, it’s by no means typical.  Most people diagnosed with TM report that the act of pulling typically occurs during affective states of relaxation and distraction.  Most individuals whom suffer from TM do not report clinically significant levels of anxiety as the “trigger” of bouts of hair pulling.  We could attribute this to an absence of insight regarding anxiety related triggers or, perhaps anxiety simply does not play a significant role in the onset and maintenance of hair pulling episodes.  Regardless of the factors that trigger episodes, a comprehensive biopsychosocial assessment that includes environmental stressors (past, present and anticipated) should be explored.

The options for treatment of TM are limited at best.  SSRIs have demonstrated some potential in the treatment of TM, but more research is needed before we can consider SSRIs as a legitimate first-line treatment.  SSRIs are worth a shot as an adjunct treatment in cases of chronic, refractory, or treatment resistant TM.  I would consider recommending a referral to a psychiatrist (not a general practitioner) for a medication review due in part to the favorable risk profile of the most recent round of SSRIs.  Given the high rate of comorbidity with mood and anxiety disorders – if either is anxiety or depression are comorbid, SSRIs will likely be recommended regardless.  Killing two birds with one stone is the order of the day, but be mindful that some medication can interfere with certain treatment techniques like imaginal or in vivo exposure.  (Ledley, Marx, & Heimberg, 2010, p. 141)  Additional research is needed before anxiolytic medications can be recommended in the absence of comorbid anxiety disorders (especially with children).  Hypnosis and hypnotic suggestion in combination with other behavioral interventions may be helpful for some individuals, but I don’t know enough about it at this time to recommend it.  Call me skeptical, or ignorant, but I prefer to save the parlor tricks for the circus…

Habit reversal is no parlor trick.  My goal isn’t to heal the patient; that would create a level of dependence I am not comfortable with… my goal is to teach clients how to heal themselves.  Okay, but how?  The combination of Competing Response Training, Awareness/Mindfulness Training, Relaxation Training, Contingency Management, Cognitive Restructuring, and Generalization Training is the best hope for someone who seeks some relief from TM.  Collectively I will refer to this collection of techniques as Habit Reversal.

Competing Response Training is employed in direct response to hair pulling or in situations where hair pulling might be likely.  In the absence of “internal restraints to impulsive behavior,” artificial circumstances are created by identifying substitute behaviors that are totally incompatible with pulling hair.  (Ingram, 2012, p. 292)  Just like a compulsive gambling addict isn’t in any danger if spends all his money on rent, someone with TM is much less likely to pull hair if they are doing something else with their hands.

Antecedents, or triggers, are sometimes referred to as discriminative stimuli.  (Ingram, 2012, p. 230)  “We sense objects in a certain way because of our application of priori intuitions…”  (Pirsig, 1999, p. 133)  Altering the underlying assumptions entrenched in maladaptive priori intuitions is the core purpose of Awareness and Mindfulness Training.  “There is a lack of constructive self-talk mediating between the trigger event and the behavior. The therapist helps the client build intervening self-messages: Slow down and think it over; think about the consequences.”  (Ingram, 2012, p. 221)  The connection to contingency management should be self evident.  Utilizing a customized self-monitoring record, the patient begins to acquire the necessary insight to “spot” maladaptive self talk.  “Spotting” is not a new or novel concept – it is central component of Abraham Low’s revolutionary self help system Recovery International.  (Abraham Low Self-Help Systems, n.d.)  The customized self-monitoring record should invariably include various data elements such as precursors, length of episode, number of hairs pulled, and a subjective unit of distress representing the level of “urge” or desire to pull hair.  (Kraemer, 1999)  The act of recording behavior (even in the absence of other techniques) is likely to produce significant reductions in TM symptomatlogy.  (Persons, 2008, p. 182-201)  Perhaps more importantly, associated activities, thoughts, and emotions that may be contributing to the urge to pull should be codified.  (Kraemer, 1999, p. 300)  In session, this record can be reviewed and subsequently tied to “high risk circumstances” and “priori intuitions” involving constructs such as anger, frustration, depression, and boredom.

Relaxation training is a critical component if we subscribe to the “kindling” hypothesis explained previously.  Relaxation is intended to reduce the urges that inevitably trigger the habit.  Examples abound, but diaphragmatic breathing, progressive relaxation, and visualization are all techniques that can be employed in isolation or in conjunction with each other.

Contingency Management is inexorably tied to the existential anchor of cognitive dissonance described above.  My emphasis on this element is where my approach might differ from some other clinicians.  “You are free to do whatever you want, but you are responsible for the consequences of everything that you do.”  (Ingram, 2012, p. 270)  This might include the client writing down sources of embarrassment, advantages of controlling the symptomatlogy of TM, etc.  (Kraemer, 1999)  The moment someone with pyromania decides that no fire worth being imprisoned, they will stop starting fires.  The same holds true with someone who acknowledges the consequences of pulling their hair.

How do we define success?  Once habit reversal is successfully accomplished in one setting or situation, the client needs to be taught how to generalize that skill to other contexts.  A hierarchical ranking of anxiety provoking situations can be helpful in this process since self-paced graduated exposure is likely to increase tolerability for the anxious client.  (Ingram, 2012, p. 240)  If skills are acquired, and generalization occurs, we can reasonably expect a significant reduction in TM symptomatlogy.  The challenges are significant, cognitive behavioral therapy is much easier said than done.  High levels of treatment motivation are required for the behavioral elements, and moderate to high levels of insight are exceptionally helpful for the cognitive elements.  In addition, this is an impulse control disorder… impulsivity leads to treatment noncompliance and termination.  The combination of all the above, in addition to the fact that TM is generally acknowledged as one of the more persistent and difficult to treat disorders, prevents me from providing any prognosis other than “this treatment will work as well as the client allows it to work.”

References

Abraham Low Self-Help Systems. (n.d.). Recovery international terms and definitions. Retrieved August 2, 2012, from http://www.lowselfhelpsystems.org/system/recovery-international-language.asp

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Frankl, V. E. (1997). Man’s search for meaning (rev. ed.). New York, NY: Pocket Books.

Ingram, B. L. (2012). Clinical case formulations: Matching the integrative treatment plan to the client (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Kraemer, P. A. (1999). The application of habit reversal in treating trichotillomania. Psychotherapy: Theory, Research, Practice, Training, 36(3), 298-304. doi: 10.1037/h0092314

Lambert, K. G., & Kinsley, C. H. (2011). Clinical neuroscience: Psychopathology and the brain (2nd ed.). New York: Oxford University Press.

Ledley, D. R., Marx, B. P., & Heimberg, R. G. (2010). Making cognitive-behavioral therapy work: Clinical process for new practitioners (2nd ed.). New York, NY: Guilford Press.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.

Pirsig, R. M. (1999). Zen and the art of motorcycle maintenance: An inquiry into values (25th Anniversary ed.). New York: Quill.

Shiel, W. C., Jr., & Stoppler, M. C. (Eds.). (2008). Webster’s new world medical dictionary (3rd ed.). Hoboken, NJ: Wiley Publishing.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York: Guilford Press.

Ethical and Legal Issues in Diagnosis


There are certainly some potential issues that need to be addressed when balancing desires of managed care and the ethical diagnosis and treatment of individuals entrusted to our care.  First among my concerns are situations where an individual is in obvious need of treatment but the necessary treatment falls outside of managed care coverage.  This may occur because they do not fit the standard illness category or because treatment recommendations fall outside of what the managed care organization deems the best course of action.  “Many insurance carriers will not pay for treatment that is not defined as an ‘illness’ for which treatment is medically necessary.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 427)

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This may tempt a clinician to engage in some unethical and inaccurate diagnosis practices in effort to get the client the help they need.  I believe most clinicians would do this out of what they consider to be the best interest of the individual clients themselves.  However, “the road to hell is paved with good intentions.”  (Kristian Delaney, personal communication) “Under no circumstances should clinicians compromise themselves regarding the accuracy of a diagnosis to make it ‘fit’ criteria accepted by an insurance company.”  (Corey et al., 2007, p. 427-428)

Personally, I see some benefits to managed care that I think we as practitioners sometimes choose to neglect.  Honestly, even if therapy was covered just by my insurance, EAP (managed care) usually provides 6 sessions every year with zero deductible.  We use them every year without fail, and there are some situations where we use them “just because they are there…”  If they cost us anything, even a deductible… we probably wouldn’t utilize the sessions.  Although I think the short sessions do frustrate some practitioners, especially those who have to deal with extremely complex situations in as little as 6 sessions… I think the primary source of frustration is the paperwork!  From what I gather, submitting paperwork for reimbursement to some of these managed care organizations (Magellan, etc) is a real pain.  I don’t understand why they have to make it so difficult… I don’t think there’s any situation where we should spend more time on paperwork than we do with clients.

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Reference

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th ed.). Belmont, CA: Brooks/Cole.

Evidence Based Practice


Evidence-based Practice (EBP) is based on three pillars: “looking for the best available research, relying on clinical expertise, and taking into consideration the client’s characteristics and preferences.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 446)  The suggestion is that we, as practitioners, should strive to provide minimum amount of treatment that gives maximum benefit in the least amount of time… as supported by the managed health care system that has been “the driving force in promoting empirically supported treatments (EST).”  (Corey et al., 2007, p. 443)

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Where the EST system falls short is the fact that there can be a wide variation in presentations within one specific categorical diagnosis.  I agree with the premise that “this approach is mechanistic and does not take into full consideration the relational dimensions of the psychotherapy process.”  (Corey et al., 2007, p. 443)  What if, for example, the recommended treatment modality is obviously not sufficient to effectively treat an individual client?  What if, at the close of the 5th or the 6th session, the client has made little or no progress as a result of the ESTs?  Despite the focus on “best available research,” there is no single identified treatment method that works for everyone.  When EST fails, is the system flexible enough to recognize its shortcomings?

The concept of EBP and EST are in fact theory laden, but I question whether ever practicing clinician subscribes to that theory.  It is generally acknowledged that a practicing clinician should anchor his or her methodology to a theory… but if that theory differs from the 3rd party payer, I suspect that the clinician would be better off working outside of the managed care system.  My question is this… is that even possible today?  Can you effectively run a private practice and not accept EAP or managed care as a 3rd party payer?  If we choose not to accept those types of clients, isn’t that discrimination in its own right?

I am in support of the general underlying premise of EBP and EST, lowering costs and raising the quality of care should be something we should all aspire to.  However, I fail to see how force feeding a theoretical system on practitioners is in any way conducive to raising the quality of care… it would appear that it is 100% focused on lowering costs.  After all, lower costs are quantifiable (measured in $), and the relative quality of care is subjective.

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Reference

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th ed.). Belmont, CA: Brooks/Cole.

Eating Disorders = BIG BUSINESS


“Weight discrimination and the resulting obsession with thinness are rampant and recalcitrant.  I believe that, in order to make any kind of a dent in this field, we all need to combat these pernicious influences.”  (Netherton, Holmes, & Walker, 1999, p. 412)  Amen.  The weight of the media, the “diet food industry,” and the purveyors of a “healthy lifestyle” propagate this issue… without a doubt.  Losing weight is BIG BUISINESS, and there are huge profits to be made for those that offer obese people the glimmer of a stereotypically thin body.

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I also appreciated the acknowledgement on the pressure exerted by managed care.  Eating disorders appear to be particularly “deep seated” and ill suited for half a dozen one hour sessions.  Correcting inaccurate perceptions, relabeling cognitions of visceral and affective states, and redrawing boundaries… this kind of work takes time… more time than managed care often provides.  This is yet another example of the effect managed care will continue to have for as long as it is the primary method of seeking out psychological assistance.

I was suitably surprised at the long-term mortality rate… suggested to be over 10%.  (Netherton et al., 1999, p. 399)  With a roughly 1 in 10 shot of succumbing to starvation, suicide, or electrolyte imbalance; you would think this particular set of disorders would get more research attention.  The fact that there is still limited epidemiological data is frustrating… perhaps the difficulty obtaining the data is related to the relative secrecy and shame associated with the disorders themselves?

Like the BM text, NHW jumps on the multi-determined etiology bandwagon.  It’s hard to disagree with since biological, familial, sociocultural, and personality factors all seem to be plausible.  The differences in family characteristics were particularly interesting.  “Bulimic families tend to be characterized as disengaged, chaotic, and highly conflictual and as having a high degree of life stress.”  Conversely, “anorexic families tend to be characterized as enmeshed, overprotective, and conflict avoidant.”  (Netherton et al., 1999, p. 400)  That’s a strange clinical picture that seems to suggest that there might be a single underlying biological cause for EDs in general, but that familial and personality factors may play a role in its manifestation.

The list of comorbid disorders we need to consider during the assessment process is long and fairly inclusive.  “Depression, anxiety disorders, dissociative disorders, substance abuse, and personality disorders” are on the forefront of the disorders we should be checking for.  (Netherton et al., 1999, p. 401)  Furthermore, NHW suggest we assess treatment history, as well as suicide attempts and self mutilative behaviors (cutters).

Pharmacological interventions employing antidepressants have been particularly successful.  This text only cites 3 studies that have employed SSRI class antidepressants, but they report “significant improvement with 60-80 mg dosages (of Prozac) compared to placebo.”  (Netherton et al., 1999, p. 407)  I think I am going to dig deep into some more recent research to see of this trend holds up, there has to be more than three studies on it by now.

I like the idea of a behavioral contract… not just for eating disorders, but for any disorders which involve “behavior.”  I am inclined to agree with the statement “the contract provides structure and predictability.  Expectations, rewards, and consequences are delineated so that all people involved (patient, treaters, families) know what is expected at all stages of treatment.”  (Netherton et al., 1999, p. 407)  My question is this… realistically, what “consequences” are there if we are dealing with outpatient treatment?

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Evidence Based Practice (EBP) and Managed Care


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Evidence-based Practice (EBP) is based on three pillars: “looking for the best available research, relying on clinical expertise, and taking into consideration the client’s characteristics and preferences.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 446)  The suggestion is that we, as practitioners, should strive to provide minimum amount of treatment that gives maximum benefit in the least amount of time… as supported by the managed health care system that has been “the driving force in promoting empirically supported treatments (EST).”  (Corey et al., 2007, p. 443)

Where the EST system falls short is the fact that there can be a wide variation in presentations within one specific categorical diagnosis.  I agree with the premise that “this approach is mechanistic and does not take into full consideration the relational dimensions of the psychotherapy process.”  (Corey et al., 2007, p. 443)  What if, for example, the recommended treatment modality is obviously not sufficient to effectively treat an individual client?  What if, at the close of the 5th or the 6th session, the client has made little or no progress as a result of the ESTs?  Despite the focus on “best available research,” there is no single identified treatment method that works for everyone.  When EST fails, is the system flexible enough to recognize its shortcomings?

The concept of EBP and EST are in fact theory laden, but I question whether ever practicing clinician subscribes to that theory.  It is generally acknowledged that a practicing clinician should anchor his or her methodology to a theory… but if that theory differs from the 3rd party payer, I suspect that the clinician would be better off working outside of the managed care system.  My question is this… is that even possible today?  Can you effectively run a private practice and not accept EAP or managed care as a 3rd party payer?  If we choose not to accept those types of clients, isn’t that discrimination in its own right?

I am in support of the general underlying premise of EBP and EST, lowering costs and raising the quality of care should be something we should all aspire to.  However, I fail to see how force feeding a theoretical system on practitioners is in any way conducive to raising the quality of care… it would appear that it is 100% focused on lowering costs.  After all, lower costs are quantifiable (measured in $), and the relative quality of care is subjective.

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