Academic journal article American Journal of Psychotherapy

Breaking Free of Managed Care

Academic journal article American Journal of Psychotherapy

Breaking Free of Managed Care

Article excerpt

DANA C. ACKLEY: Breaking Free of Managed Care. The Guilford Press, New York, 1997, 317 pp., $35.00, ISBN 1-57230-105-8.

Ackley clearly spells out the challenges that "Managed Care" has raised for the professional practice of psychotherapy. As a 20-year veteran employee of an HMO (a "vertically integrated monopol[y]," p. 8), who has also maintained a teaching position and a small fee-for-service private practice, I read this book with great interest and anticipation. I found it disturbing: at first because of Ackley's documentation of the economic plight of the profession, and later because of the implications of his solutions.

The book is well organized. It begins with his account of his own emotional reactions to dealing with the arbitrary and often harmful practices of Managed Care companies, and then outlines myths about the duration, cost, and value of psychotherapy. Incidentally, the very term "Managed Care" is something of a misnomer-the more precise term, coined by economist Alain Enthoven is "Managed Competition" (cf. Health Affairs, 1993 Supplement, 24-8, for a historical review), a term which more accurately describes the economic model which Ackley initially rejects, then ultimately embraces. While a careful reading of the studies that Ackley cites supports a somewhat more cautious interpretation than he makes (for example, the seminal meta-analyses of 58 controlled studies by Mumford et al, 1984, American Journal of Psychiatry, 141(10): 1145-57, found that the cost-offsets of psychotherapy came from decreases in inpatient, not outpatient use, and were found primarily for patients over age 55), this chapter is an extremely valuable resource, especially for those not yet familiar with this area of the literature. He next delivers a plausible account of how "Managed Care" was able to gain so much control over the delivery of human services, a useful section since the key to change is often found in understanding how the current situation has evolved. He ends Part I of his three-part volume with a thorough refutation of the medical model, and a vision of human-change processes that most clinicians would endorse.

Part II focuses on providing the clinician with the rudiments of skills in marketing, advertising, and devising a business plan. This section of the book is written clearly, and with some sensitivity to the emotional process of becoming a "business" person. …

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