Academic journal article American Journal of Psychotherapy

Meeting Managed Care: An Identity and Value Crisis for Therapists

Academic journal article American Journal of Psychotherapy

Meeting Managed Care: An Identity and Value Crisis for Therapists

Article excerpt

In a previous paper,(1) I argued that a host of contextual or field forces overtly and covertly influences the interactions between psychotherapist and patient. These include family and community pressures, roles and ideologies of agency colleagues, professional peer culture, guild organization and licensing sanctions, etc. In recent years, ever-new external pressures have made themselves known. A psychotherapist departing in the mid-1980s for a lengthy sabbatical might feel like Rip van Winkle returning now to a new and unsettling world. Journals and trade newsletters abound with accounts of mergers, staff cuts, and policy changes affecting the various mental health professions. Interest in these phenomena has spread to the mass media in connection with America's attempted health care reform. Questions of who will pay for health care, how much of it will remain for the consumer, and what will become of careers in the professions that traditionally provide it, have made household words of "privatization," "down-sizing," and "managed care" (some would call the latter "mangled care")] Professional workshops increasingly cash in on therapist anxiety about surviving in the mercenary 1990s. Dark rumblings are heard of bitter splits in the leadership of professional organizations--splits between pragmatists and idealists, voices of accommodation and those of resistance. Some predict the death of the mental health professions.

The present paper addresses the implicit changes that managed care (MC) asks of psychotherapists. Explicitly, MC shifts the source of payment for services. The financing of health care is now centralized and privatized, as increasingly is the delivery. Less comes out of the pocket of the defined patient/family unit or from indemnity-based insurance. Thus, health "providers" work in-house (the HMO model) or on restricted panels "fed" referrals by the insurer (the PPO model). These for-profit organizations depend on extensive and frequent utilization reviews of clinical decision-making. MC reviewers put pressure on clinicians for the briefest possible treatment regimen, often with concrete, behavior-modification objectives. The giving or withholding of prior authorization affects reimbursement (and thus de facto treatment continuance). While the justification for MC in mental health settings is often posed as quality control and cost cutting, there is growing evidence that a decline in services without the saving of money is the actual result.(2)

In the present paper, the zeitgeist of the 1950s to the early 1980s will be sharply contrasted with the one that threatens to prevail in the 1990s. In the earlier period, the major professions providing psychotherapy grew and flourished. Allowing for some retrospective idealization, the optimal standards of therapeutic conduct, in my view, arose from stated ethical codes of the disciplines, internalized knowledge and norms derived from theoretical reading, on-the-job experience, one's personal analysis or therapy, and ongoing peer or mentor teaching. The zeitgeist pervading the current period expresses its less idealistic and more mercenary attitudes, as MC systems have taken over the health insurance resources of the country and a growing proportion of the prospective patient population. As of this writing, certain areas (e.g., Massachusetts, California, Minnesota) are ahead of others in MC "market penetration" so readers practicing in the "late bloomer" states may possibly view the characterization below as unduly alarmist if not fanciful. But not, one expects, for long.

The generalized effect of MC, without overt administrative fiat, is to radically alter the behaviors and internalized paradigms of those who struggle to adapt to the realities of contemporary "providership." There are three areas of alterations to be discussed--psychotherapists' changing concepts about patients, about themselves in relation to their patients, and about their own place in the occupational or economic hierarchy of society. …

Search by... Author
Show... All Results Primary Sources Peer-reviewed

Oops!

An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.