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Glenn Yank, MD is a Psychiatrist located in Tennessee.


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Question:
I was wondering if you knew of any funding sources that pay for a person’s treatment in a hospital or residential program. I have D.I.D. and only a few days left on my lifetime limit for Medicare inpatient benefits. I have Medicaid as a secondary insurance but this does not cover very much per stay at all, and some hospitals or treatment centers don’t accept Medicaid at all. I have located a first and second choice but will likely need other funding. Some of the problems I’m having can’t be resolved overnight, and there are no suitable local services. Managed care has gutted all that was helpful here in Georgia. I now only see a psychiatrist, because the good therapist I had moved to Texas because the climate was so bad for psychotherapists here. I’m looking at going out-of-state where there are better treatment options but I want more than a quick patch-up job. Please let me know if you can find any funding sources. Anonymous

Answer:

Unfortunately, I don’t know of any specific funding sources other than Medicare, Medicaid and commercial insurance that pay for a person’s treatment in a residential or hospital setting out of state. Most state Medicaid programs do not pay for treatment out of state except in very limited circumstances in which it can be demonstrated that a person has failed outpatient treatment (i.e., they remain at serious risk of self harm or deterioration) and no in-state programs exist that could meet the person’s needs. I have seen this mechanism pay for treatment in specialized programs for eating disorder and violent children and adolescents, but I have not seen it used for the kind of treatment you are describing. However, I will concede I am not an expert in knowing funding sources, and would suggest that you discuss this with social service agencies in your area, and also consult online resources that list funding sources. The following two sites may be useful, and I am sure there are more:

Your question also raises the issue about what are the roles of hospital-based and residential treatment in the overall process of treatment for DID. I am in agreement with the stance taken by the International Society for the Study of Dissociation in their Guidelines for Treating Dissociative Identity Disorder (Multiple Personality Disorder) in Adults (1997), which is accessible on their website:

I have excerpted the section on Inpatient Treatment:

There is general agreement that inpatient treatment for DID should be used for the achievement of specific therapeutic goals and objectives. Treatment should occur in the context of a goal-oriented strategy designed to restore patients to a stable level of function so that they can resume outpatient treatment expeditiously. This remains the case, whether the hospitalization is emergent or planned, on a specialized or a general psychiatric unit. Efforts should be made to identify what factors have destabilized or threaten to destabilize the DID patient and to determine what must be done to alleviate them, if possible, and to minimize their impact. Emphasis should be placed on building strengths and skills to cope with the destabilizing factors. Optimally, these interventions should be planned and contracted for prior to or very early during an admission, but it is acknowledged that this may not be possible. Planned judicious processing of traumatic material (sometimes called abreactive work), confronting traumatic material in the supportive structure of a hospital setting, and working with aggressive and self-destructive alters and their behaviors are frequent concerns.

There is a general agreement that decompensation or failure to improve during a hospitalization may occur in several circumstances. There is consensus that DID patients often require hospital care for other intercurrent mental disorders, such as major depression or anorexia nervosa. There is consensus that a small minority of DID patients, including massively decompensated and dysfunctional individuals, and those destabilized by severe present-day trauma, may require prolonged inpatient treatment in order to be restabilized. Treatment-related factors that may impede clinical improvement include unfocused inpatient treatment or inpatient treatment with global and unrealistic goals, such as “getting out all of the memories,” an exclusive focus on past traumatic material to the exclusion of contemporary issues, or pushing for rapid integration early in treatment.

There is a divergence of opinion as to whether brief stays are less likely to be associated with regressive dependency than longer stays. Some find instances in which they suspect that longer hospital stays are conducive to regression. Others find instances in which it appears that a pressure to keep hospital stays short leads to discharge of the patient in an insufficiently stable state and at greater risk for readmission or undue suffering. Regardless of the length of the patient’s hospitalization, the therapist should maintain a stance that encourages progression and independence.

There is agreement that DID patients optimally should be treated in a manner that prepares them to do the work of therapy on an outpatient basis, including processing traumatic material when necessary. There is also agreement that for some overwhelmed patients and for a variety of patients under some circumstances, the structure and safety of a hospital setting make possible therapeutic work that would be impossible or prohibitively destabilizing in an outpatient setting.

Thus, although inpatient or residential treatment may help you by improving your coping skills, increasing your interpersonal effectiveness, and helping you to better tolerate distress, the bulk of the work you seek to do will need to be done as an outpatient. I would therefore recommend you focus on figuring out a way to get resources for the outpatient treatment you need.

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Disclaimer: The information contained here is not intended nor implied to be a substitute for professional advice relative to your specific medical or mental health condition or question. ALWAYS seek the advice of your physician or other health provider for any questions you may have regarding your medical or mental health condition. Information provided here DOES NOT constitute a doctor-patient relationship between you and the column author.

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