BY COMMON CONSENT, THE UNPRECEDENTED (AND SOME SAY unholy) confluence of managed care economics and cybernetic technology is revolutionizing the mental health field. Just how is not yet clear, but one thing seems obvious: vast new systems of corporate control and electronic communication have breached the once-inviolable bond of confidentiality between therapist and client, a trust once as sacred and secure as ever existed outside the confessional.
Of course, confidentiality was never absolute, but the old "security system" the locked file cabinet in the therapist's private office was at least as dependable as the professional integrity of the practitioner. Even the burglars who tried to get Daniel Ellsberg's psychiatric chart had to actually go to the office to steal it. Yet today, even therapists of unquestioned integrity routinely consign clients' entire records, copious details about diagnosis, treatment, progress and outcome, to the vagaries of electronic mail, modem, fax machines or cellular phones in order to meet the demands of unknown administrators in the headquarters of distant managed care giants.
The story below is a composite talc of the vicissitudes experienced by everyday clients and mental health professionals enmeshed in the grid of an electronically mediated therapy system. Despite the aura of science fiction, all the events actually occurred, the practices detailed here routinely take place, the systems and companies referred to really exist and the technology described is currently available. More and more therapists, whether knowingly or not, are hooked into the proliferating information system; only those clinicians limiting their practices to self-paying clients can promise anything like the confidentiality that was once taken entirely for granted.
The widespread use of the new computer technologies promises greater efficiency and accountability in the practice of therapy, and the generation of what could be extraordinarily useful data for treatment outcomes research. Nonetheless, however convenient and potentially instructive these innovations, they leave many clinicians feeling deeply uneasy, even as they sit at their computers, keying in their claim forms and e-mailing them to a case manager in a corporate office three states away. But whether the new technology proves wonderful or terrible, or neither or both, therapists can no longer afford to ignore their misgivings, pretend they don't really know what is happening and throw up their hands at the sheer incomprehensibility of it all.
A WEEK SHY OF HER 36TH BIRTH-day, Barbara wonders why she is not happy. Her husband seems distant and reclusive, while her son, struggling through adolescence, wants little to do with her. Despite an interesting job and no financial worries, Barbara feels fragmented and unconnected. Every morning she wakes to a sense of free-floating dread and is haunted by a growing feeling of inexplicable sadness. An educated, middle-class woman of the '90s, she hesitantly considers seeing a therapist. Raised to believe that an impermeable, sacrosanct wall separates public and private life, that personal feelings should be discussed only within the intimate, confidential circle of family and closest friends, she has qualms about baring her soul to a stranger. Still, she cannot bring herself to tell her husband or anyone else about what is happening to her, and her employer's health plan includes therapy benefits.
So, after struggling with her own ambivalence for a few weeks, she finally picks up the phone and calls the primary care office of Prucare, a national HMO owned by Prudential Insurance, to get the necessary referral for therapy. It is difficult to explain herself over the phone, to say the words, "depression," "anxiety," "fear," which will get the referral, particularly as she hears the soft clicking of a keyboard in the background as the case reviewer types her words into a computer. But a …