When Compromised Care Becomes “Best Practice”
How institutional pressures turn compromised care into the standard of care.
If perfunctory, insincere and frustrating interventions are represented as therapy, it will not be many years before people will think they have “tried therapy” and found it wanting. They are unlikely to think about trying it again.
—Nancy McWilliams
Psychotherapy changes when provided in institutional settings, often not for the better. Institutions have administrative and financial agendas that do not necessarily align with the best interests of individual patients. Clinicians in these settings may be overwhelmed with responsibilities, under unreasonable pressure to do more with less, and unable to spend the time that patients really need.
Administrators, accountants, and lawyers often call the shots behind the scenes in ways that impact clinical care. Decisions about what treatments are even offered may be driven by cost-cutting pressures or health insurance reimbursement schedules, which are definitely not aligned with patient needs.
When clinicians work in these systems over an extended time, cognitive dissonance kicks in. It is hard for a competent, dedicated clinician to wake up and go to work every morning thinking, we’re not doing right by our patients. We’re doing what we can, given serious constraints on time and resources, but it falls short of what patients need.
Over time, that gets rationalized away and becomes, the limited treatment we offer is good enough for most. Then that morphs into, the treatment we provide is good care. And eventually, it’s best practice. It’s the standard of care. Once people start down the path of rationalization, it’s a slippery slope.
It is hard for a competent, dedicated clinician to wake up and go to work every morning thinking, we’re not doing right by our patients.
Clinicians in institutional settings often have a fundamental conflict of interest. Psychotherapists learn in training to avoid conflicts of interest and “dual relationships” that could impact clinical decisions. But a psychotherapist employed by an institution necessarily has divided loyalties: clinical decisions are driven not only by what is in the patient’s best interest but by the administrative and financial agendas of the institution.
Clinicians are inherently in a dual relationship, functioning at once as their patient’s therapist and as representative of institutional policies and priorities. This is why, for example, a patient who would clearly benefit from weekly psychotherapy may instead be scheduled for a follow-up a month later. It is why a patient who would benefit from individual psychotherapy might be assigned to group therapy or a skills training class. Or sent home with worksheets. Or given a prescription and sent on their way.
It is bad enough that this is how healthcare systems operate, but something else also happens that makes it far worse.
Almost no one ever says to a patient, “We cannot provide the kind of care here that would be most helpful for you. This is what we can provide for you here, given the resources we have and the constraints we work under. But it is not optimal care for you.” Instead, patients are often misled to believe that what they are getting is optimal mental health care.
When patients don’t get the help they need, they don’t come away thinking, I didn’t get good treatment. They come away thinking, I am too broken to be helped. They leave more hopeless and demoralized than when they came. That is harm.
When patients don’t get the help they need, they don’t come away thinking, I didn’t get good treatment. They come away thinking, I am too broken to be helped.
Or else they come away thinking: this is what mental health care is. This is all it is. And they leave believing mental health treatment is a crock.
Compromises occur slowly, by degrees. Their effects accrue insidiously. They become invisible. Then they become the standard of care.
This essay was written without AI.
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This is an important argument, one that I'm more than happy to restack and share it with others. In fact, I made a similar point, if only briefly, this morning in another forum.
But similar "dual relationships" also occur in individual private practice (even if we don't call them that). The patient's needs may not align with the clinician's preferred treatment modality. The therapist's economic interests may sway treatment recommendations.
The real difference in corporate practice is not the existence of clashing aims—those are inevitable—but the substitution of business ethics for professional ethics.
The ethics of the helping professions is fiduciary: to put the patient or client first despite countervailing incentives. In contrast, business ethics are not inherently fiduciary; they're ultimately about earning profit any way that is legal. Ultimately, it is incumbent on clinicians and our professional organizations to uphold our own ethical standards. Institutions will not do that for us.
It really is a damn shame what has happened to this field. I can speak to the compromised care and the dual relationships I've witnessed in private equity backed mental health businesses. Ridiculous volume expectations with minimal supervision that's mostly administrative work for charting. Guidance for treatment comes in the form of PDF with a flowchart of 'best practice options' and links to online trainings for the most proven evidence based therapies.