The Cost-Effectiveness of Psychodynamic Therapy: The Obstacles, the Law, and a Landmark Lawsuit

ABSTRACT

Psychotherapy, especially dynamic psychotherapy and psychoanalysis, has been poorly supported by insurance although the Mental Health Parity Act mandates benefits for mental health care at parity with other health care and The Affordable Care Act lists mental health care, including psychotherapy, as an Essential Health Benefit. Limiting insurance support for psychotherapy turns away very ill, especially poorer patients who forego treatment and incur increased medical costs and disability. Patients with personality disorders, chronic anxiety depression, chronic illness and comorbidity require extended, often intensive, psychotherapy for optimal recovery. Brief cognitive-behavioral therapy is seen as a “gold standard” and “most evidence-based” although its research protocols study subjects not typical of most patients and who achieve only short-lived improvements. Research finds psychodynamic therapies to be highly cost-effective, equal to other efficacious therapies in improving symptoms, and also superior in improving maladaptive interpersonal relationship patterns, a high-risk factor for mortality. Knowledgeable attorneys and expert witnesses were key to the 2019 successful class action lawsuit against United Behavioral Health for declining to cover research supported generally accepted standards for mental health care and for a subsequent California state law mandating sufficient insurance coverage. To defend it in legal and policy arenas, providers and advocates for psychodynamic psychotherapy should familiarize themselves with its supporting research and the laws that demand its provision.

KEYWORDS:

• Mental Health Parity Act
• Affordable Care Act
• insurance
• class action lawsuit
• United Behavioral Health

Acknowledgments

The presentation of psychotherapy research and related data in this article is expanded and updated from an analogous discussion in an earlier paper (Lazar, 2018).

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Notes on contributors

Susan G. Lazar

Susan G. Lazar, M.D., has presented and also published widely on the cost-effectiveness of psychotherapy, including the special place for psychodynamic therapy, in book chapters and articles. Her publications include coauthoring a 1997 American Journal of Psychiatry cover article The Economic Impact of Psychotherapy: A Review, two edited and coauthored special issues of psychiatric journals including the Psychoanalytic Inquiry 1997 supplement Extended Dynamic Psychotherapy: Making the Case in an Era of Managed Care as well as the Psychodynamic Psychiatry 2014 special issue Psychotherapy, The Affordable Care Act, and Mental Health Parity: Obstacles to Implementation, the volume Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness, and the 2018 article The Place for Psychodynamic Therapy and Obstacles to Its Provision in Psychiatric Clinics of North America. She chaired the group that formed The Coalition for Psychotherapy Parity and coauthored its document Clinical Necessity Guidelines for Psychotherapy, Insurance Medical Necessity and Utilization Review Protocols, and Mental Health Parity which is available on the website of the Coalition, psychotherapyparity.org.

Dr. Lazar served as a consultant to The Mental Health Work Group of The White House Task Force for National Health Care Reform in the Clinton administration and was instrumental in the inclusion of psychotherapy as a medically covered service without arbitrary limitation in the bills considered by Congress at that time. She is a Supervising and Training Analyst at The Washington Baltimore Psychoanalytic Society and Clinical Professor of Psychiatry at The George Washington University School of Medicine and The Uniformed Services University of the Health Sciences, Member and former Chair of The Committee on Psychotherapy at The Group for the Advancement of Psychiatry (GAP), Member of the American College of Psychiatrists, and Distinguished Life Fellow of the American Psychiatric Association.