Square Pegs In Round Holes: Psychological Care & Medical Necessity - Kimberly Thompson

While it’s true that body and mind make up a unified whole that can’t be separated, except in death,  there is a fundamental tension between the two, especially in the area of healing people’s hurts. In this post I will be discussing the differences in physical and psychological healing arts, and how applying a standard of medical necessity to psychological care is like fitting a square peg into a round hole.

Starting with Hippocrates, Western civilization has embraced a dominant body-first paradigm of healing known as the medical model. This model rests upon direct observation of things — seeing, hearing, feeling, and smelling what’s going on. This is still true, although all sorts of sophisticated observation techniques are now available, such as blood tests, urine tests, biopsies, x-rays, CT scans, and MRIs. The medical literature (i.e., an aggregate of many observations) guides the physician to know what to look for and what they’re looking at. Standards of care are a yardstick to determine the proper action given the observation of the patient. It all remains very concrete. That’s not just me saying that. The physical exam continues to be a cornerstone of medical assessment and treatment — for example, while telehealth is a growing edge of modern medicine, my state’s medical board has decreed that physicians must do a in-person physical exam before treating anyone via telehealth.

By contrast, up until the last 125 years or so, mind-first healing was mostly left up to religious communities. When that didn’t work, the insane were locked up in asylums or in the family attic. The mind and subjective human experience were considered the realm of spirit, the turf of religion and the family. It was only in the late 1800s that Sigmund Freud, a physician, stumbled upon the talking cure for the treatment of the mind. As a secular discipline, we are centuries behind medicine in our development. Psychology is just now establishing principles of psychological treatment that can be considered evidenced-based.

There are more fundamental differences beyond the maturity of the disciplines. Medicine is concrete, psychology is abstract. The body resides firmly in the physical world, while the psyche straddles the physical and spiritual worlds. By its very nature, lived human experience is highly subjective and problems are not easily located or quantified. Although psychologists observe in order to heal, we are far more interested in patterns of thinking, feeling, and behaving — understanding the person holistically over time. There are no blood tests or x-rays for the mind, and the things that disturb it are far more elusive than germs or toxins. Most psychological problems will never directly threaten survival of the organism, yet they reduce the quality of life, derail life’s meaning, and indirectly reduce longevity by taking away the will to live.

So, while body and mind are inseparable, they are also distinct. They exist in different domains, they have their own organizational principles, and they are harmed by different experiences. It only makes sense that healers of the mind and body must also use different paradigms to do their work. When psychological care is forced into the medical model, like the proverbial square peg in a round hole, it never quite fits. Yet, often that is what we are forced to do. Psychological care is forced into the medical model when we must provide a diagnosis in order to provide care, and when we must demonstrate “medical necessity” in order for health insurers to cover our services. While there are exceptions, such as with chronic mental illness, psychological treatment is usually considered medically necessary only until symptoms are reduced enough that the client no longer qualifies for a diagnosis. Human relationships, existential questions about identity and purpose, and preventative care are seldom on the table, even though psychotherapists are well-qualified to do those things.

When they are experiencing psychological pain, many people automatically assume that they will be using their health insurance coverage. It would seem silly not to use it. What they don’t usually realize is that using health insurance limits their care to what can be shoehorned into the medical model, while their therapist is able to provide care that is much broader and richer than that. They also don’t realize that, unlike physicians, therapists seldom have enough staff support to take all insurance plans; since there is a wide variation in therapist experience, areas of expertise, and ways of doing therapy – you can’t just pick someone on your insurance plan and assume that you will get the best course of treatment for you, or even an adequate one. I limit my own practice to women who are mothers, as well as their children that are experiencing depression, anxiety, or adjustment problems. That is what I do well, and I am not spread too thin trying to stay abreast of advances in too many areas. At this writing, I do take a few insurance plans. I do this for a variety of reasons: 1) Sometimes all a client wants is short-term symptom relief, which aligns with what her insurer wants to pay for; 2) Using health insurance can be a good way for women to test out therapy and decide whether it’s helpful; and 3) Most women have never even thought about the limitations of the medical model and of using their health insurance – taking a few solid insurance plans is a good way for me to form new relationships, spread awareness, and demonstrate what the right therapist can do. At the same time, I work to cultivate trusting relationships so that clients will return to my care over time, whenever they need me, whether or not their concerns would always meet medical necessity. I work within the medical model when it’s possible, but I never forget that psychological healing is much bigger than that little round hole.


I am Dr. Kimberly Thompson, a licensed psychologist that works exclusively with women and their children, from pregnancy and postpartum through the stress of the empty nest. In addition to my professional credentials, I am a wife, mother, and grandmother. If you live within driving distance of Lubbock, Texas, you can work with me in-person. If you live elsewhere in Texas, you can work with me online. Call the office at (806) 224-0200 during regular business hours, or send a secure message anytime. Find my book, Perfect Mothers Get Depressed, at Praeclarus Press or Amazon. Subscribe to my website to receive newsletters and blog updates.