The Trap of Medical Necessity


When I worked in community mental health in North Carolina, I would try to help individuals and families by providing Medicaid or State-funded services from a moving smorgasbord of options. The system was in constant flux, especially in the era of ‘mental health reform’ at the legislative level. Some treatment options during my time included ‘Community Support,’ ‘Intensive In-Home,’ ‘Multisystemic Therapy,’ and more. Of course, the approved interventions, duration, and reimbursement rates changed seemingly every few months for these service options. One thing did not change – in order to provide such services, it must be proven that the treatment was “medically necessary” for the consumer / client.

Part of the process of proving medical necessity was the assignment of (at least one) diagnosis to an individual. Sometimes a psychiatric nurse practitioner might spend 30 minutes in an interview, or a Qualified Mental Health Professional would review an intake assessment, make a best guess of diagnosis out of the DSM-IV TR, and have that diagnosis signed off on by somebody with a higher credential. Within relatively little time, somebody as young as 6 years old could have a label affixed to them by a stranger. Such a label, indicating a disorder or psychiatric illness, might follow this individual through their entire lifespan, influencing how others view and treat them, and even eventually impacting how that person views their self.

In order to help suffering individuals trying to make sense of the hurts in their childhood and dysfunctional family systems, we were forced to provide a psychiatric diagnosis in order to get approved for services and ultimately receive financial reimbursement. Through the chaining of treatment to a medical / disease model of mental illness, I believe we risked contributing to long-term stigma and self-fulfilling prophecies in the lives of consumers – the very people we wanted desperately to help. To their credit, my co-workers would try to choose relatively benign diagnoses, such as Adjustment Disorder (unspecified, 309.9) or Mood Disorder (not otherwise specified, 296.90). But as legislative changes continued, certain diagnoses were not extreme enough to warrant the approval of treatment. Mental health providers were and still are incentivized to emphasize the negatives and downplay strengths in order to get treatment approval.

As one step in the right direction, I believe a category of “psychological necessity” needs to be recognized. A qualified counselor should be able to advocate to an insurance company or government agency that it is “psychologically necessary” for an individual to receive certain kinds of treatment. We need to stop forcing consumers through the funnel of disease model psychiatry in order for them to receive help.


One thought on “The Trap of Medical Necessity

  1. It seems like the trap of medical necessity is a logical result of the application of methodological naturalism.

    Ultimately, if government is paying for the diagnosis and cure, the rigid application of the 1st amendment (as interpreted in the 20th and 21st centuries) requires the scope of the diagnoses and treatments to be limited to the natural possibilities.

    The wine of supernatural causes and treatments cannot be contained in the wineskin of the natural (thus the winskins supported by government cannot contain the proper diagnosis and treatment).



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