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TRELOARFINANCIAL AND ETHICAL CONSIDERATIONS

Financial and Ethical Considerations for Professionals in Psychology

Hayley R. Treloar Department of Psychological Sciences

University of Missouri

The profession of psychology is one of many entities affected by the current economic recession. The question of what to do when clients cannot pay agreed-upon charges will need to be answered. Ethical issues related to setting the fee for psychotherapy, insurance coverage, abandonment, pro bono psy- chotherapy, and lack of resources are addressed in light of the 2002 American Psychological Associa- tion’s Ethical Principles of Psychologists and Code of Conduct and other relevant literature. The im- pact of the Mental Health Parity Act on the financial complexities that professionals in psychology now face is also discussed. Several recommendations are made for psychologists, calling them to be proactive in their communities, to be advocates for their clients, and to critically evaluate their finan- cial practices.

Keywords: ethics, finances, billing, fee, psychotherapy

The extent of the economic recession experienced by many of the world’s financial powers (e.g., the United States, Japan, many European nations) has been far-reaching. There is reason to as- sume that no particular entity will go unaffected. It is imperative that psychologists anticipate the difficulties that may arise for the profession. For example, psychologists may soon see an in- creased inability of clients to pay for services due to rising unemployment and more stringent in- surance coverage provided by employers. We may also see an increase in applications to graduate programs (as individuals attempt to boost their marketability with higher education or decide to apply to graduate school because of the poor job market) that is unmet by funding allocations for graduate education. Private practice psychologists may struggle internally as they set their fees for psychotherapy and other professional services in a time of financial strain for all. In these chal- lenging economic times, the intersection of ethical and financial issues for psychologists will re- quire a significant level of attention.

In an effort to fulfill their ethical responsibility and help those who cannot pay, professionals in psychology may offer sliding fee scales, offer pro bono services, barter arrangements, or allow the client to accrue debt. However, other ethical issues arise when these arrangements are made. This article addresses the widespread financial and ethical issues that psychologists face by reviewing the relevant literature and consulting the related standards in the American Psychological Associ- ation (APA) Ethics Code (APA, 2002). Specifically, ethical issues related to setting the fee for

Correspondence should be addressed to Hayley R. Treloar, 3 McAlester Hall, Department of Psychological Sciences, University of Missouri, Columbia, MO 65211. E-mail: [email protected]

psychotherapy, insurance coverage, abandonment, pro bono psychotherapy, lack of resources, and the Mental Health Parity Act are discussed.

ISSUES RELATED TO CHARGES FOR MENTAL HEALTH TREATMENT

In any service profession, setting the fee is essentially putting a price on what one’s skills are worth. Because psychology is a “helping” profession, and tends to attract individuals who have a sense of responsibility and caring for others, it sometimes seems that psychologists should be do- ing their work as volunteers or that money should not be an issue. Moreover, many psychologists have an aversion to the business side of psychotherapy (Knapp & VandeCreek, 2008). Talking about issues of fees for services is even seen by some as socially and psychologically taboo. In fact, the charge for services, collection, or reimbursement by third-party payers is seldom dis- cussed in most mental health professionals’ education and training during graduate school (Koocher & Keith-Spiegel, 2008). Tudor (1998) argued that although talking about money is of- tentimes seen as “talking dirty,” money is the principal means of exchange in our society, and un- derstanding money is central to the therapeutic process (p. 477). The fee is essential to psychother- apy because payment creates a definite boundary that separates the therapeutic relationship from other types of nonprofessional relationships, such as friendships or romantic relationships (Zur, 2007). The fee is also essential for psychologists because it is what allows psychologists to make a living and continue to provide services to others.

Market forces drive fee setting in many practices and clinics and, with an uncertain economy, fee setting may become even trickier for psychologists. Psychotherapists will need to decide what their fees should be to maintain their business, but if this means fees need to be increased, psycho- therapy may become inaccessible to some individuals (Tudor, 1998). Psychologists may wish to respond by offering reduced fees for clients who are out of work or do not have insurance. How- ever, third-party payers may take issue with this practice. They expect that standard fees are charged to all clients, whether or not they have insurance coverage. Therefore, it is unethical to charge a person with insurance one amount and a person without insurance something else. Doing so could be construed as inflating the fees charged to get at a higher rate for services covered by an insurance carrier (Fisher, 2003), and psychologists do not misrepresent their fees (APA, 2002, 6.04c).

Women have traditionally earned less than men across professions, and psychology is no ex- ception. In 2000, a nationwide Fee, Practice, and Managed Care Survey found that female psy- chologists earned 78% of what male psychologists did (as cited in Newlin, Adolph, & Kreber, 2004). The reason for this discrepancy is unclear but may be related to differences in business practices. Newlin et al. (2004) administered an anonymous survey to 75 self-employed psycholo- gists in one Colorado county. They did not find a significant gender difference in the price of the fee that was set. However, men and women did differ in whether they offered discounted services to self-pay clients, with 96% of women offering discounts compared to 44% of men. Furthermore, men and women differed in their appraisal of the influence of local competition on their fee set- ting, with women being more strongly influenced by perceived competition.

The APA (2002) Ethics Code states that “as early as is feasible in a professional or scientific re- lationship, psychologists and recipients of psychological services reach an agreement specifying

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compensation and billing arrangements” (p. 1068). Psychologists can make clear their fees and payment policies on their Web sites, in written materials they share with clients prior to the first meeting, or over the telephone when the first contact is made. Although the APA Ethics Code re- quires that psychologists talk about fees and financial arrangements as soon as possible, some psychologists may see a discussion of fees in the first session as insensitive or clinically contrain- dicated. “As early as is feasible” allows psychologists to delay discussion of fees in the first ses- sion for clients in the midst of a crisis and allows the psychologist to gather information about the client’s needs and health care coverage before finalizing a financial agreement (Fisher, 2003). Nonetheless, the fee for therapy should not come as a surprise to the client.

Fees for the initial evaluation of a client are particularly problematic to set. Psychologists differ in whether they offer brief or longer initial meetings and whether these meetings are more or less expensive than the usual session. Some psychologists may offer the initial session free, which may lead to a number of problems. For example, a client may feel betrayed after engaging in a very intimate conversation with a psychotherapist only to discover they cannot afford this particu- lar psychotherapist’s fee, or they may expect that one free session of psychotherapy will be enough to get most of their problems addressed (Knapp & VandeCreek, 2008). However, charg- ing a fee for an initial evaluation can be problematic as well. Suppose the client decided he or she did not want to start psychotherapy for some reason (e.g., finding that her HMO may stop paying for treatment after 10 sessions). In most settings, the client would still be required to pay the initial session fee. Tudor (1998) suggested that clients should be able to “window shop” for psychother- apy until they find a therapist who fits. This “shopping around” has been shown to be an important determinant of a successful psychotherapy outcome (“Mental Health,” 1995). When initial ses- sions are longer and more expensive, shopping around may not be financially feasible for clients.

University counseling centers are another setting where fees are becoming an issue. Many stu- dents and their parents will be feeling a financial crunch, and “extras” (e.g., purchasing student in- surance) may be dropped, leading to less ability to afford off-campus mental health services and more reliance on college counseling centers. Although many university mental health settings are funded by student fees, reductions in state and national higher education allocations from tax rev- enues is affecting these centers. Given the current financial situation, many counseling centers on college campuses that have not charged a fee in the past may be required to shift to some type of payment from students who utilize their services. The effect of requiring students to pay a fee for psychotherapy is unclear. Relevant to this, however, Waehler, Hardin, and Rogers (1994) col- lected data from 396 college students. The students watched a video of “Dave, a junior in college who is explaining his problem to a friend” (Waehler et al., 1994, p. 89). The authors manipulated whether students believed Dave’s college counseling center offered free, prepaid, or $70 per ses- sion services. Of interest, these students rated that counseling would be less effective in the pre- paid and $70 condition than it would be in the free condition.

Psychologists also have a responsibility to make sure their fee practices are consistent with the law (APA, 2002, p. 1068). Psychologists have a responsibility to know their local, state, and fed- eral laws (e.g., on referral fees or fee splitting) to be sure their fee practices do not violate any of these laws (Fisher, 2003). Referral fees (also sometimes know as kickbacks) involve the referral source getting a portion of the fee for making the referral, a practice common in some business professions. However, in the mental health profession, fee splitting inevitably involves a third party in the therapeutic relationship and may create a conflict of interest with regard to why the re- ferral was made (Zur, 2007).

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Knapp and VandeCreek (2006) suggested that the moral principles especially pertinent to bill- ing and collecting fees are “respect for patient autonomy” and fidelity (p. 148). To live up to these ideals, psychologists must be up front about their fees and any foreseeable extra costs associated with treatment (e.g., billing for phone calls or consultations, billing clients for missed appoint- ments when the insurance company will not pay for them, billing for written reports, etc.), and they must strictly follow through with the promises they make and adhere to their established pro- cedures (Knapp & VandeCreek, 2006). The APA Ethics Code expects psychologists to accurately represent their fees as well (APA, 2002). Therefore, psychologists should only give assessments that are necessary, should not use bait-and-switch tactics with clients’ fees, and should accurately represent their fees in advertisements (Fisher, 2003). Furthermore, psychologists are required to be familiar with their clients’ insurance limitations and let their clients know as soon as possible if they believe their client will require more extensive care or a different type of care then what is covered.

INSURANCE DETERMINES TYPE OF PAYMENT AND CARE

Insurance coverage is an important determinant of whether individuals seek mental health care and what type of care (i.e., primary or specialized) they receive (Mechanic, 2007). Managed care organizations (MCOs) typically specify how much and what type of care insurance will cover. Al- though these cost-containment practices are not intrinsically unethical, they do serve to limit care (Acuff et al., 1999). In managed care, in-network providers set a copay for psychotherapy ser- vices, and the client pays it at each visit. Clients who choose to go to an out-of-network provider may not be reimbursed by their MCO. If they do receive reimbursement, it is generally a much smaller percentage of the total cost. To receive the highest rate of reimbursement, the client must go to an in-network provider who has been preapproved by the MCO and who has agreed to ac- cept its contracted fee. In traditional indemnity insurance, the employees pay for their health bene- fits (out of their paycheck each month for the policy), but they can then decide whom they go to for treatment and they maintain more decision-making control in conjunction with the provider. Although there has been much debate about the differential impact of these insurance practices, in general, outcomes do not differ between insurance types (Bianconi, Mahler, & McFarland, 2006; Rogers, Wells, Meredith, Sturm, & Burnam, 1993; Wells, 1997). However, finding an in-network provider who is currently accepting new clients can be a challenge for clients with MCO insur- ance. Oftentimes, clients must choose to see an in-network provider who does not have as much experience with their type of problem, is not as highly esteemed by the referral source, or who is located farther from their home instead of an out-of-network provider whose fee would not be covered, or would be covered at a lower rate, by their MCO.

Recent financial changes in health care have served to promote treatment in the primary care (i.e., general medical) settings where copays are generally less expensive than in specialized (e.g., psychiatric) settings. Telford, Hutchinson, Jones, Rix, and Howe (2002) estimate that 80% of in- dividuals with depression are treated in the primary care setting. When psychological treatment is implemented by primary care physicians, it usually involves prescription medications, and often- times the drugs prescribed are either inappropriate or given at suboptimal doses (Mechanic, 2007). Furthermore, most studies find that primary care physicians fail to recognize disorders such as depression in their patients (Docherty, 1997; Mechanic, 2007). In contrast, care by mental

FINANCIAL AND ETHICAL CONSIDERATIONS 457

health practitioners leads to higher recognition of depression, higher patient satisfaction, better clinical outcomes, and more comprehensive and effective treatment (Docherty, 1997).

ETHICAL ISSUES RELATED TO ABANDONMENT

Abandonment can be defined as unanticipated or unwanted termination of treatment when the cli- ent is in need of care. Recent marketplace and insurance trends (i.e., cost-containment practices of many MCOs) have served to limit treatment and possible providers, thereby increasing the likeli- hood of abandonment (Acuff et al., 1999). Abandonment becomes an issue when a MCO’s ses- sion limits prompts psychologists to terminate treatment before clinically indicated. During this recession, job security will be a worry for clients, and many clients may be forced to change jobs and, therefore, transfer insurance companies. Psychologists will have to decide what to do when their current client changes jobs and switches to a health care coverage company for which the psychologist is not an impaneled provider (Acuff et al., 1999). In addition, the new policy might not cover services or may require a lengthy wait before coverage begins for preexisting condi- tions. Many of these problems are currently under discussion in the current national debate on health care.

The American Counseling Association and the American Mental Health Association unequiv- ocally ask counselors not to abandon their clients in their ethics codes (Vasquez, Bingham, & Barnett, 2008). Abandonment was explicitly prohibited in the 1992 APA ethics code in the section “Terminating the Professional Relationship.” Standard 4.09(a) stated “Psychologists do not aban- don patients or clients” (APA, 1992, p. 10). Vasquez et al. (2008) suggested that abandonment was dropped from the 2002 code partly because there was no clear agreement on what would con- stitute “abandonment.” The most recent version has dropped any explicit mention of abandon- ment and discusses only the way termination should be approached to avoid potential harm to the client (Younggren & Gottlieb, 2008). Standard 3.12, Interruption of Psychological Services, states

Unless otherwise covered by contract, psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist’s illness, death, unavailability, relocation, or retirement or by the client’s relocation or financial limita- tions. (APA, 2002, p. 1066)

These recommendations are meant to protect psychologists from legal or ethical causes of action and to protect the client from harm due to abandonment (Acuff et al., 1999). However, this list of factors that may interrupt treatment is not exhaustive, and nowhere does the code exactly define what “reasonable efforts” would entail (Vasquez et al., 2008). Fisher (2003) suggested that psy- chologists should discuss the termination of services with their clients, respond to their concerns, and refer them to another mental health practitioner or to another outpatient resource. However, potential providers in a community may be limited to those on the insurance company’s provider panel and community or other outpatient resources are dwindling due to financial limitations, making options for low-cost referral slim to nonexistent.

Abandonment can occur when treatment is terminated at a time when the client was psycholog- ically vulnerable, at risk, or in a time of crisis (Acuff et al., 1999; Knapp & VandeCreek, 2006).

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However, it is not unethical to terminate a nonemergency patient who, due to unforeseen financial difficulties, cannot pay (Knapp & VandeCreek, 2006), but appropriate referrals should be made so that the client is not abandoned. However, whether ending treatment when the client cannot or does not pay contradicts the APA Ethics Code’s principle of justice is a topic for debate.

Knapp and VandeCreek (2006) suggested a “pay-as-you-go” policy to avoid the issue of debt altogether. However, in the event that such a policy is not implemented and a bill does accrue, psy- chologists have the right to use collection agencies or legal measures to collect fees that are owed to them as long as they first inform the client that they are going to take action, give the client an adequate opportunity to render their payment, and disclose the minimal information necessary for that purpose in order to protect the client’s privacy (APA, 2002, 6.04e). Still, Zur (2007) argued that when psychologists use a collection agency to collect fees from clients, they are crossing the therapeutic boundary and compromising the therapeutic relationship because they are involving a third party. It is preferable for psychologists to try to reach a resolution or payment schedule ar- rangement with their clients before contacting a collection agency (Zur, 2007). However, as the APA Ethics Code states, crossing this boundary is acceptable when psychologists have fully in- formed their clients at the outset of treatment that failure to pay may result in a third party being brought in (APA, 2002).

WHEN INDIVIDUALS CANNOT PAY: PRO BONO THERAPY

Although procedures are in place for helping clients who begin psychotherapy and later cannot pay, there seems to be much less done for individuals who cannot afford to pay for treatment at the outset. These individuals are never affiliated with any particular psychotherapist. Whose respon- sibility is it to see that these individuals receive care? Typically, a state decides how to provide health care to citizens who need treatment but cannot afford to pay. However, with the rising costs of health care in general, declining tax revenues, shorter hospital stays, and an emphasis on outpa- tient treatment, many hospitals and clinics find it too costly to provide indigent care and stay in business. Moreover, due to the lower reimbursement for inpatient mental health services versus the higher revenue generating specialties (e.g., surgery), some hospitals have begun to close their inpatient psychiatric units altogether.

Although the APA Ethics Code does not explicitly give guidelines for providing pro bono ser- vices, the APA General Principle D: Justice states, “Psychologists recognize that fairness and jus- tice entitle all persons to access and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists” (APA, 2002, p. 1062). Therefore, psychologists have a responsibility to see that all individuals who are in need of care have access to and receive quality care. It is our responsibility to treat individuals (e.g., homeless, unemployed) who do not have the means to access quality care. However, providing treatment to many people who cannot pay may be impossible for psychologists in private practice, who are trying to make ends meet themselves, or clinic psychologists, who are expected to make their salary and expenses. Still, psychologists can serve as advocates by raising the issues of lack of available mental health services for certain populations by working with lawmakers, lobbying for indigent health care, and volunteering some mental health services at a community or free clinic.

FINANCIAL AND ETHICAL CONSIDERATIONS 459

The homeless are the poorest of the poor in the United States (Zuvekas & Hill, 2000). Many homeless persons have serious mental disorders or drug and alcohol disorders that prevent them from finding and keeping work. What’s more, the falling economy can only exacerbate the diffi- culties these individuals face. Zuvekas and Hill (2000) collected three waves of survey data from 471 homeless persons in Alameda Country, California, from 1991 to 1993. Mental health and sub- stance use disorders were assessed with the Diagnostic Interview Schedule. Twenty-two percent of the homeless persons in this sample had a lifetime major mental health disorder compared to 15% in the general population at this time. Seventy-two percent of the homeless persons sampled had a drug or alcohol use disorder compared to 27% of the general population. In 6 months, 52% of the population studied did not work at all, and many worked only enough to earn meager amounts of money. In addition, the current recession has increased the number of individuals who have lost their jobs and thus their homes, and who now must reside in shelters, with relatives, or elsewhere. Clearly there is a substantial and growing need for general health care services as well as mental health care.

When these individuals do receive care, they are often are treated in emergency rooms of pub- lic medical and psychiatric hospitals rather than outpatient services such as clinics and mental health centers (Padgett, Struening, & Andrews, 1990). The outpatient facilities (and more recently hospitals) are often struggling to stay afloat themselves and have no means to shelter or treat indi- viduals who cannot pay. Many homeless persons who need mental health services or substance use treatment do not seek the help they need, and when they do, they may simply be turned away. Furthermore, there does not seem to be any system in place to seek these persons out and offer them care until their problems have escalated to the point of crisis.

Pro bono, or no fee, treatment has received little attention in the literature. Some have argued that free psychotherapy produces feelings of inadequacy for clients and causes them to devalue treatment, and others suggest that the fee reflects the client’s level of commitment to treatment (Bergen, 2007). Even a small fee is thought to encourage commitment to treatment. However, some findings suggest that assumptions about the ineffectiveness of pro bono psychotherapy may not be warranted, at least in some settings (e.g., college counseling centers; Waehler et al., 1994).

Negative views of pro bono psychotherapy may stem from the long-standing negative psycho- dynamic view of free psychotherapy and cognitive dissonance theory (Bergen, 2007). According to cognitive dissonance theory, an individual will experience dissonance when two cognitions compete. For example, it may be difficult to both highly value psychotherapy and know that the psychotherapy is free. The individual will move to minimize the dissonance by devaluing psycho- therapy. However, almost all of the research in this area was published more than 20 years ago, be- fore the widespread changes in health care management that have changed the way individuals pay for psychotherapy (Bergen, 2007). Most clients today get treatment without having to pay en- tirely out-of-pocket (e.g., copays, prepaid insurance programs). The hypotheses about what it means for a client to get “free” treatment must be revisited in light of the new system and sub- jected to empirical tests before any hard and fast conclusions can be drawn.

ALTERNATIVE PAYMENT METHODS: BARTER

At this time of economic recession, psychologists should expect that more clients will be unable to pay for services. Instead of receiving pro bono psychotherapy, the client may wish to barter for

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services. Barter, or the exchange of goods and services, has been a part of human culture for thou- sands of years, and barter is still culturally normative for some groups (Zur, 2007). Bartering, like out-of-pocket fee-for-service therapy, increases client privacy by not requiring information to be sent to a third-party payer (Zur, 2007). However, it may be difficult for psychologists to avoid eth- ical risks when they barter with their clients (Woody, 1998).

Earlier versions of the APA Ethics Code (i.e., before 1992) forbid barter as unethical. In 1992, the code was changed to state that psychologists would “ordinarily refrain from accepting goods, services, or other nonmonetary remuneration for psychological services” (APA, 1992). Barter was not disallowed, but it was clearly cautioned against and thought to have the potential to be ex- ploitative or distort the professional relationship. The current version of the code removes this cautionary language and allows barter unless it is clinically contraindicated or exploitative (APA, 2002, Standard 6.05). This change arose after many psychologists, especially those in rural areas, argued that it would be culturally insensitive in some circumstances not to barter for mental health services, and in other communities, barter may be some individuals only option for enabling them to receive needed mental health care. Still, psychologists should be aware of their state laws about barter and their state’s ethics codes or guidelines. In some states, (e.g., Missouri) bartering is still forbidden as exploitive.

Psychotherapy is a service, but the barter agreement may be for either a good or a service. For example, a client may offer her plumbing work (a service) or a handmade basket (a good) in return for psychotherapy. In general, there is a greater opportunity for a dual relationship or conflict of interest when bartering is done for services. Any dual relationship may appear appropriate at first, but problems can easily arise (Woody, 1998). For instance, imagine that the psychotherapist is un- satisfied with the work the plumber has done or that the plumber does not show up when she says she will. This would likely affect the therapeutic relationship and be detrimental to treatment. Many sources agree that it is safer to barter for goods that have a predetermined value, such as of- fering a $40 handmade basket in exchange for a $40 copay (Knapp & VandeCreek, 2008).

Most often, it is the client who suggests bartering, but psychologists should be aware that al- though they may believe the bartering arrangement is for the benefit of the client, the psycholo- gist assumes the liability when problems arise (Woody, 1998). For instance, a client who will- ingly entered into a bartering arrangement with the psychotherapist may later complain to a state licensing board or pursue civil action for damages, saying that the clinician had undue in- fluence on the client’s decision to enter into the bartering agreement (Woody, 1998). The client may also claim to have diminished mental competency at the time the agreement was made (Woody, 1998).

Woody (1998) made several recommendations regarding bartering. He suggested that to avoid ethical risks (e.g., exploitation, dual relationships), unique financial arrangements, such as barter- ing, should be minimized; goods should be bartered for instead of services; the value of the goods should be evaluated by an objective source; and if the psychotherapist notices a negative effect of the bartering arrangement on the therapeutic process, it should be remedied or psychotherapy should be appropriately terminated (Woody, 1998). To avoid legal risks, the psychologist should provide a clear rationale for any financial exceptions and document it in the client’s records. All discussions regarding the bartering agreement should be detailed in writing, a written agreement should be drawn up and signed by both the client and psychotherapist, and if a misunderstanding or disagreement should develop, it should not be discussed by the client and psychotherapist but by a third-party mediator (Woody, 1998).

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LACK OF RESOURCES FOR CLIENTS AND PSYCHOTHERAPISTS

In a list of specific recommendations regarding abandonment, Acuff et al. (1999) stated, “When patients without financial resources need more treatment, psychologists should attempt to help them find alternative ways to receive the needed treatment” (p. 572). Similar suggestions are made by other authors and echoed by the 2002 APA Ethics Code. However, there seems to be a lack of awareness or acknowledgement of the limited resources for referral for low-cost treat- ment.

Amy Lynn-Larson Hawcott, a rural, family-based counselor in Boone County, Iowa, deals firsthand with the limited resources in the area where she provides services. As Hawcott describes,

Practicing in small towns and rural areas can often be a rewarding experience. However, there are of- ten many limitations and frustrations that go into the job. As a counselor, there are limited resources that clients can be referred to. One major limitation is the accessibility to groups—both therapy and support groups. Many clients can benefit from supplemental resources, but are not able to due to the unavailability of help. Also, therapists and counselors are not available for referral. There is often a limited number of mental health clinicians—especially specialized ones. This means that clients are receiving (or not receiving) help from clinicians that could not maximize their progress. The lack of inpatient/residential agencies, especially adult agencies, is also a disadvantage of working in a small town and rural area. Overall, it is very difficult for clients to get the help they need in order to attain a healthier, and often safer, lifestyle. This also means that mental health workers are often left over- worked with a clientele that could be beyond their competency level. Overworked clinicians can lead to a lower quality of work and often burnout. An adequate amount of resources would not only benefit the individual client, but would help the mental health agencies and the community as a whole. (A. Hawcott, personal communication, November 20, 2008)

Hawcott has highlighted many of the central problems clinicians face when dealing with a lack of resources, such as lack of accessibility to groups, limited number of specialized clinicians, lack of residential/inpatient agencies for adults, therapist burnout, and therapist competency.

As the economy falls, one can only expect that the difficulties related to lack of resources by patients and clinicians in rural areas will worsen. Cooper and Gottlieb (2000) suggested that re- ductions in governmental allocations for mental health during the past 25 years have led many community mental health facilities to either close or reduce many of the services they once of- fered. Staff has needed to be reduced as funding declined, leading to a reduction in amount or quality of services. Private psychiatric hospitals have met a similar fate. Thus, referral to a com- munity agency that is so often cited as an option when termination is required (e.g., client cannot pay, insurance will not pay) will often not be an option in reality. Psychologists should be aware of the availability of these services on an ongoing basis (Cooper & Gottlieb, 2000), when they are available, and make referrals as appropriate.

This problem was addressed by Watts, Richold, and Berney (2000), who examined a popula- tion of psychiatric inpatients with learning disabilities. Sixty-six individuals were ready for dis- charge, but 44 of these individuals were experiencing a delay with “lack of resources” as the key impediment to referral (Watts et al., 2000). Barriers to referral included lack of funding, lack of suitable accommodation, caregiver burnout, and insufficient clinical support (Watts et al, 2000). The APA principle of justice calls for equal quality of services for all those who seek mental

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health care. Therefore, our professional role requires that we be advocates for increased resources in our communities, which will require us to be involved with public policy.

THE MENTAL HEALTH PARITY ACT

“More than one-third of all Americans will soon receive better insurance coverage for mental health treatments because of a new law that, for the first time, requires equal coverage of mental and physical illnesses” (Pear, 2008, para. 1). After at least 12 years of advocacy, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was included in the economic bailout bill, passed by both the House and Senate, and signed by President Bush on Fri- day, October 3, 2008. The bill requires equivalence, or parity, in the coverage of mental health conditions (e.g., depression, schizophrenia, autism) and physical conditions (e.g., hypertension, leukemia, pulmonary fibrosis). For example, parity would mean that insurance companies would have to remove restrictions on the number of allowed hospital inpatient days and on outpatient treatment duration and be required to equate copays and deductibles for treatment of mental and physical illnesses. The law will improve mental health coverage for 113 million people (82 mil- lion of whom are covered under employer-sponsored plans not under state regulation) but will not apply to businesses with 50 or fewer employees (Pear, 2008).

The Mental Health Parity Act is expected to lessen some of the financial complexities psychol- ogists now face. Insurance companies should no longer be able to stop paying for services after an arbitrary or unpredictable number of sessions. Under this new law, insurance companies will be required to fully disclose their criteria for covered services and provide adequate reason for denial of any mental health services claims (Pear, 2008). As this act goes into effect, it will be imperative for professional organizations to continue their advocacy efforts and ensure that the regulations outlined in the act are upheld and that misinterpretation is avoided.

The major players in getting this legislation passed were senator Pete V. Domenici, Republican of New Mexico, whose daughter has schizophrenia; senator Paul Wellstone, Democrat from Min- nesota, who had a brother with severe mental illness; representative Patrick J. Kennedy, Democrat of Rhode Island, who has been treated for depression and suffers from alcoholism; and representa- tive Jim Ramstad, Republican of Minnesota, who has struggled with alcohol use as well (Pear, 2008). As psychologists, we should be grateful to these persons who have led the way in uphold- ing the ethical principal of justice.

RECOMMENDATIONS

Several recommendations are made for professionals in psychology faced with financial and ethi- cal issues. It is essential for professionals in psychology to do each of the following:

• Proactively work to increase resources in their communities, be aware of them, and utilize them when needed to meet clients’ treatment needs.

• Be advocates for equal access to mental health services. • Make sure their fee practices are consistent with state and federal laws. • Approach termination appropriately.

FINANCIAL AND ETHICAL CONSIDERATIONS 463

• Fully inform clients of their financial practices up front. • Make efforts to treat individuals who do not have access to quality care. • Critically evaluate the effects of payment on therapeutic process and outcomes. • Be cautious about unusual payment arrangements.

The task at hand is substantial, and it may take some time for change to occur. However, change cannot happen by itself, and psychologists need to take on a more active role. It is impor- tant for psychologists to not only act ethically themselves but also address the larger issues regard- ing access to mental health treatment and financial compensation for these services.

ACKNOWLEDGMENTS

Gratitude is expressed to Nan Presser, PhD, and Denis McCarthy, PhD, for their support of this article.

REFERENCES

Acuff, C., Bennett, B. E., Bricklin, P. M., Canter, M. B., Knapp, S. J., Moldawsky, S., et al. (1999). Considerations for eth- ical practice in managed care. Professional Psychology: Research and Practice, 30, 563–575.

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