Imagine a future in which the arbitrary distinction between mental and physical health has been obliterated; a future with a health care system so radically revamped that it addresses the needs of the whole person--medical, psychological and relational. In this system of integrated care, psychotherapists collaborate regularly with MDs, and clients are helped to feel that experiencing depression is no more a reflection on their character than is catching a flu. This new world will be convenient: People will be able to take care of nearly all their health needs under one roof--a medical superstore of services. It will be great for therapists, too, providing them with a seemingly inexhaustible stream of client referrals from the enormous pool of patients who, in earlier times (today), would have mistakenly identified their complaints as primarily physical.
Now, imagine a future in which every medical intervention in a patient's life is a matter of quasi-public record; in which therapy is tightly scripted and only a limited number of "approved" treatments are eligible for reimbursement. A future in which recalcitrant patients can be tracked and forced to undergo treatment, and in which therapists must serve as compliance cops for health management organizations and insurance companies. In this brave new world, integrated care actually means a more thoroughly medicalized health care system into which psychotherapy has been subsumed. Yes, therapists will work alongside medical doctors, but as junior partners, following treatment plans taken directly from authorized, standardized manuals.
These are not two different systems; rather, they are polarized descriptions of the same future, one that draws nearer every day. Make no mistake: A seismic change is coming to the American health care system. The age of integrated care is upon us, and psychotherapy may soon be incorporated in a way that will profoundly affect how and where it is practiced. But what will this new system really look like? How will therapists--and the therapeutic process--fit into it? What values will lie at its core? Although there is no question that a new system is coming, the nature and structure of this new system are still very much up for grabs. And this means that, for therapists, the future poses both tremendous opportunity and grave threat.
One version of the future--the one envisioned by such advocates of "reform" as the American Medical Association and the leading managed care companies--is of a seamless web of services that quickly identifies patients' true needs and efficiently delivers patients to the right professional for the correct treatment. The other vision--therapists' vision--has yet to be fully articulated, largely because most of us are still adjusting to the changes wrought by managed care and unaware of the implications of what's coming.
We have the opportunity now to present our vision, to argue for the holistic integration of medical and psychological services in a way that is true to the core principles of psychotherapy. We must resist the inevitable attempts to define therapy as, in essence, a treatment that gets dispensed by a professional to a patient and argue instead for therapy as a process of change that is entered into by client and therapist working together as allies. And it is critical to do so now, when psychotherapy is on the brink of another tectonic shift that could well discredit the majority of approaches therapists use today.
Carving In, Carving Out
To understand what lies ahead for the field of psychotherapy, we must first review some basic principles of health care economics. To state the matter in accountants' terms, mental health services have traditionally been "carved out"--handled and paid for separately from general health care costs and considered to be distinct from patients' medical needs. …