An Action Research Project

“involvement ... transforming human relationships.”

My Research for the Taos Tilburg PhD program

Ignacio Martin-Baro said, “No knowledge can be true if it has not attached itself to the task of transforming reality, but the transformative process requires an involvement in the process of transforming human relationships.”

 

QUESTION:      What is the power of clients and therapists in relation to Blue Cross Blue Shield (BCBSMA) over issues that affect client well-being, client privacy, client-therapist relationships, treatment methodologies, and therapist pay? 

 

Therapists are concerned about the introduction by Blue Cross Blue Shield of Massachusetts (BCBSMA), the state’s largest health insurer, of a measurement device, the TOP.  The TOP is a form of “outcome and effectiveness measurement”, which they say is necessary to address gaps in the quality of mental health care delivered.  They want us to administer this test to our clients.  They are pegging our rate of reimbursement to compliance, and projecting other uses for it in the future, like judging therapist effectiveness.

 

The TOP asks clients 72 intimate and personal questions including questions about sexual orientation, income, sexual activity, substance use, and HIV status.  The test is to be administered every 3 months, independent of the clients’ perceptions of their own needs and the needs of the client - therapist relationship.  It can take most of a session.  It assumes its own scientific validity and that of the DSMIV.

 

Some of the objections to the TOP and its implementation include 1.its vast invasion of client privacy, 2.its violation of client confidentiality, 3.a conflicted dual therapist role as helper and test administrator, 4.a conflict of interest for therapists due to a financial interest in complying, 5.interference with the therapeutic relationship, 6.iatrogenic effects, 7.its considerable expense, 8.its pseudo-scientific pretense, and 9.its perceived lack of usefulness by those who have used it. There are many unanswered questions about the TOP.

 

Many therapists believe that insurance companies like BCBSMA already interfere with and damage therapy.  Therapists traditionally practice alone and are not known for effective collective action, especially on their own behalf.  However, the BCBS TOP assault on clients and the therapeutic relationship seems so egregious that some therapists have been inspired to act.   Many have already engaged BCBSMA in various forms of dialogue.  They have written letters (one signed by 110 practitioners), engaged in face-to- face discussions, and worked through their professional organizations. Possibilities for further action seem to include use of the press and work with politicians and involving governmental agencies like the insurance commission. 

 

I am curious as to whether it is possible for clinicians and clients to have greater power in our relationship to this insurer.   However the action does or does not develop, I would like to track this process by participating in and tracking the dialogic events, including conversations, emails, press, etc. and examine the process in light of various conceptions of power.

 

I chose Action Research as my form of research because it allows me to participate in the process of change as I document and examine it.  Hopefully, the site will change and grow as people working to improve therapy and limit efforts to damage it continue to take action.

 

I would like my research to reflect the values of Bent Flyvbjerg, Professor of Planning at Aalborg University, who talks about “making social science matter”, contribute to social change; my Advisor Harlene Anderson, who espouses “a mutual search to understand”; Ken Gergen, who asks, how can we exit from "the cycle of infirmity" and “the requirement for deficit diagnosis”; and Tom Andersen who asked, “How can the standstill system and we make a meaningful conversation together?”

 

- Frank Kashner, LICSW