Academic journal article American Journal of Psychotherapy

Psychodynamics and Managed Care: The Art of the Impossible?

Academic journal article American Journal of Psychotherapy

Psychodynamics and Managed Care: The Art of the Impossible?

Article excerpt

Many mental health providers believe that psychodynamic psychotherapy under managed care is virtually impossible. Notwithstanding the many adversities posed by managed care, there are ways to productively apply psychodynamic principles within this health care financing system. This paper critically discusses the possibilities and costs of conducting psychodynamic psychotherapy under managed care using theory, practice applications, and a case vignette. Central to the discussion is elaboration of five central differences between traditional psychodynamic treatment versus that conducted under managed care.


Speaking of psychoanalysis and managed care concurrently is tantamount to ideological and economic implosion to many psychotherapists, who view them as completely incompatible and deserving of no common attention. Managed care is an inflammatory term. It evokes images of malignant intrusions into patient treatments, disappearing referrals, and unbearable documentation requirements. And this is for good reason. Managed care has had, in balance, an enormously deleterious impact on the mental health field. On a theoretical level, it challenges both the fundamental belief in unconscious motivation/conflict as well as the conviction that long-term psychodynamic treatment can be maximally productive and efficacious. In this sense, managed care poses a distinct threat to psychodynamic psychotherapy. Thus, it may seem counterintuitive to simultaneously recognize that managed care is not evil, but rather a financially driven management technique that can be negotiated with on an individual level while responded to and challenged on legislative and regulatory levels through education and advocacy. We have a strong identification with the powerful distrust that exists toward managed care, yet we also think it not always the most prudent attitude for psychodynamic psychotherapists practicing in today's health care environment.

Managed care has had a strikingly transformative impact on the practice of psychotherapy and on health care financing and accessibility in general. This transformation has included numerous challenges, including:

1. Reduced overall treatment length for outpatient psychotherapies, with little opportunity for long-term treatment when the care is managed;

2. much reduced overall lengths of stay for inpatient treatment, with little opportunity for psychotherapeutic intervention;

3. reduced reimbursement levels and increased nonreimbursed documentation requirements for psychotherapy;

4. an "anti-intellectualization" of psychotherapy process, wherein manualized and proscriptive treatments are being anointed as the singular gold standard to the exclusion of many other curative aspects of the clinical process that are less quantifiable and "tangible;"

5. intrusion of an active third party (i.e., managed care organization) into the therapist-patient dyad. In addition to these many disadvantages, there have been some opportunities in managed care for certain psychodynamic psychotherapists under certain conditions. We regard the following as potential opportunities:

6. Potentially steady referral base when contracted as a preferred provider on managed care panels;

7. increased incentive to generate a systematic treatment plan and regularly examine its effectiveness;

8. increased discussion with patients about the progress of and their reaction to a treatment.

We have an enduring respect for psychodynamic theory and technique, and eagerly wish that those who share our devotion to this way of understanding and helping people will meet the managed care challenge head on. When Freud, in the face of criticism, took psychoanalysis out of the university setting and established free-standing institutes, it was a questionable move. Many have argued that the isolationism this provoked has been unfortunate, and that it has enhanced the intellectual rifts and distrust between psychodynamic and other forms of psychotherapeutic practice. …

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