PERSPECTIVE ON HEALTH-CARE REFORM : Will Psychotherapy Be Reduced to Pill Dispensing? : The atrocities that patients tell therapists are unheard by managed- care authorizers; the goal is profit, not healing.

The Clinton health proposal looks sure to eliminate what most people think of as mental-health care--a confidential, one-on-one relationship with a psychotherapist. Never mind the allowance for 30 visits included in the plan. Just because it’s in the package doesn’t mean utilization managers will allow it.

In order to win bidding wars and remain profitable, provider groups, some of them owned by multinational drug and insurance companies, are replacing psychotherapy with cheaper drugs-only psychiatric treatment, crisis intervention and referral to free resources like Alcoholics Anonymous.

In California, thousands of therapists, who have helped a generation’s worth of people to exorcise their demons and develop the psychological skills necessary to thrive in times of chaos and disruption, are being carved out of the health-care landscape. One utilization review clerk told me, “We just don’t believe in psychotherapy”; and in a corporate newsletter, the physician vice president of another company suggested, with undisguised hostility, that psychotherapy is not medically necessary and should be in the category of personal service, like hairdressers and fashion consultants.

It is not hard to understand the problem of the managed-care companies. Their interest is profit, not healing. To them, a patient is a service unit. The vacant stare of an incest victim is a symptom to be removed, not the outer sign of an existential tragedy that must be shared to be borne. Utilization reviewers do not hear the atrocities that patients describe to their therapists. Nor are they much interested in such agendas as developing a trusted therapist-client alliance, exploring deeper states of consciousness, acquiring relational competence and other staples of psychotherapy. They simply plug in the diagnosis and the computer spits out the number of visits and type of treatment allowed.

Psychotherapy as a mode of treatment comes from an entirely different world view. With its emphasis on trust, respect for individual difference, on inner life, on pain, love, questions of meaning and the Promethean struggle to become fully human, it is a messy, deeply personal, unpredictable enterprise. It does not fit well into the corporate culture of bottom lines and magic bullets.

But the general public knows the value of psychotherapy, and because of that, mental-health services have become a costly item on the health-care menu. Most therapists acknowledge that long-term psychotherapy--like cancer treatment, kidney dialysis or open-heart surgery--although valuable, is also expensive. Many already do pro bono work and offer sliding fee scales to the uninsured.

Maybe short-term drug therapy for everyone is a better use of shrinking resources than intensive psychotherapy for only a few. But if so, let the Clinton people and the supporters of managed competition say so. Tell Americans that they are compromising. Tell them they are rationing mental-health care. And tell them why. There is nothing shameful in living within one’s means. What is shameful is hiding the truth that the savings will come from withholding needed treatment.

And what is even more shameful, even disastrous, for individuals and for society, is the explosion of anti-psychotherapy propaganda spewing forth from the multinational drug companies, insurance groups and the provider groups they own, in an all-out attempt to undermine public confidence in psychotherapy. Corporate lobbyists are out and about trying to discredit psychotherapy and to persuade employers and the public that five visits to a randomly assigned provider who follows computer-generated treatment protocols is comparable to spending an hour every week or so with a compassionate multi-trained psychotherapist. It isn’t.

Perhaps we cannot afford to include psychotherapy on demand in the minimum national health-care package--even though one quadruple bypass would buy weekly visits with me for a lifetime. But just because purchasing groups might not want to pay for it does not mean that psychotherapy is ineffective or that their subscribers do not need it.

In these chaotic and overwhelming times, where levels of rage, anxiety and despair are careening dangerously out of control, people may need more than ever the confidential services of caring professionals. We allow at our peril market forces, drug manufacturers and bean counters to establish allowable treatment approaches for mental illness and to define what is meant by optimal mental health. That must remain the role of trained psychological professionals who understand the extremes of human experience because they encounter it every day, firsthand.