Cover Story

Historically, practitioners have balked at taking on patients with personality disorders (PDs), often considering them untreatable. While that's beginning to change due to new, more hopeful research findings on PD treatment (see page 46), negative attitudes persist among insurers, many of whom still fail to reimburse for PD treatments.

As justification, insurers say there isn't enough research showing treatment efficacy for Axis II disorders (the group in the Diagnostic and Statistical Manual of Mental Disorders that includes PDs), especially relative to Axis I disorders. And PDs remain an unpopular research topic because of the lingering stigma that they are untreatable, say experts.

"For the most part, insurers think personality disorders are a lost cause--something they don't want to cover," says psychologist James Pretzer, PhD, of the Cleveland Center for Cognitive Therapy, who offers practitioners training in treating PDs.

What's more, Axis I symptoms are usually more apparent to the patient and their families, and more likely to put them in crisis, so patients often come to therapists complaining of problems like depression and anxiety, which can be symptomatic of an underlying PD, says Pretzer.

But because of insurer coverage, therapists often bill only for treatment of the Axis I disorders, Pretzer says. And even though this practice is ethical because those Axis I disorders are real and evident, Pretzer adds, it doesn't provide the most effective treatment for the PD itself.

"It's rare for a person with a personality disorder to seek treatment when they don't also have an Axis I problem, and it goes much better with the insurance company when you look for reimbursement for that Axis I disorder," Pretzer says. "However, there's so much more to what these patients are dealing with."

The bottom line is, even though insurance company policies vary, most don't want to provide long-term treatments, and PDs require long-term care, says psychologist Jeffrey Young, PhD, of Columbia University. The main reason therapists typically bill--and are reimbursed--for Axis I disorders is companies assume that Axis I problems can be alleviated over a relatively short time, in a set number of sessions, says Young.

However, "Even if you get 20 sessions on the basis of an Axis I disorder, you still don't have enough sessions to work on the Axis II problem," Young says. "It's unlikely you're going to take a lifelong problem and solve it in 20 sessions, but with ongoing therapy, that problem is likely to come under control."

Potential benefits of treatment

What insurers may not realize is that treating PDs doesn't just benefit the patient and public health, it benefits the companies as well, says Pretzer. For example, people with untreated PDs tend to need frequent health care because they experience stress and because--given their typically impaired social skills--they often have damaged personal relationships and can't turn to family or friends for help in health crises.

Treatment can help break that pattern, research suggests. For example, several empirical studies have pointed to the efficacy of dialectical behavioral therapy (DBT) for borderline personality disorder (see page 46). According to the research of psychologist Marcia Linehan, PhD, of the University of Washington, borderline PD patients who undergo a course of DBT treatment, which includes psychotherapy and behavior modification training for up to two years, spend far fewer days in hospital and visit emergency rooms far less frequently than those who don't. That indicates cost-savings for insurers.

"It's just plain financially foolish to not treat personality disorders," Pretzer says. "If a whole year of therapy prevents one major hospitalization, that's going to be a good deal for the insurance company."

Future prospects

Indeed, a small but growing number of insurers are beginning to consider long-term treatment plans for borderline patients, says Young.

A case in point is the experience of psychologist Catherine Forneris, PhD, of the University of North Carolina at Chapel Hill. A DBT program Forneris manages offers patients treatment twice a week over 18 months to two years, she says. After that, patients still need weekly sessions with therapists, but they seldom visit the hospital's emergency room or require inpatient hospitalization for psychiatric issues, according to Forneris's patient surveys.

"When I talk to insurance companies, I discuss how our course of treatment can reduce the number of days the patient spends in the hospital, the amount of prescribed psychiatric medication and visits to the emergency department," says Forneris. "That's a big savings because a day in the hospital can cost about $1,000."

However, attaining reimbursement for PD treatment remains an uphill battle, say those involved. Not only is the reimbursement problem rooted in the stigma surrounding PDs, but it's also a result of managed care's ongoing efforts to cut costs by limiting services wherever they can, says Russ Newman, PhD, JD, APA's executive director for professional practice.

"Personality disorders become a good target for cuts because of the prejudice that these patients aren't going to get better," he says. "Alternatively, there's an assumption that because it's not a critically life-threatening situation, it's not debilitating. But that's just not the case. These disorders have a really limiting effect on all facets of a patient's life: career, family and general stability."

And while all PDs are equally limiting, payment for treatment of PDs besides borderline, such as antisocial or narcissistic PD, is a particularly long shot, says Young, because the treatments have only been anecdotally proven effective.

"Treating personality disorders other than borderline is very difficult because often these patients don't have severe Axis I symptoms; instead they have very low-level chronic Axis I symptoms," he says. "Their disorders are just as disruptive as borderline, but because you don't have the drastic Axis I problems and no proven treatment, no one is willing to pay."

Without more proven treatments, the prospects for treating PDs will remain grim, many in the field believe, so they are pushing for more research.

Ways to help

Although researchers are still studying the cost-effectiveness of treating PDs, psychologists can, in the meantime, take steps to help patients get the treatment dollars they need. For example, it's helpful to choose limited, feasible goals to maximize your time with patients, says Pretzer.

Most importantly, therapists should operate under the assumption that the insurance company has the patient's best interests at heart and would respond to well-considered arguments about the need to subsidize long-term treatment, Forneris says.

Newman adds it's important to make the best case possible to the insurance company about the valuable treatments available, and, when it is an employer-sponsored plan, there may even be times when it's appropriate to register a complaint with the employer as to the insurance company's handling of a claim. He also says psychologists should contact APA and their state psychological associations if they encounter egregious insurance company practices, allowing APA to track the situation and perhaps communicate with the company.