From the March/April 1994 issue

ELINOR ADAMS, A MINNEAPOLIS MARRIAGE AND FAMILY THERAPIST for more than 20 years, has earned the high regard of her colleagues, a solid professional reputation in her community and the right to expect a dependably full caseload in her private practice. Under normal circumstances or at least what used to be considered normal in private practice she would have no reason to doubt that her collegial network and pool of satisfied clients would continue to provide referrals unto perpetuity, or until she retired, whichever came first. But these are no longer normal times, and Adams says she is “anxious, afraid, uncertain” about the future. At this stage in her career, when she ought to be enjoying the professional independence and financial security that are the fruits of success, she spends all of her free time going to meetings informational meetings, brainstorming meetings, professional policy meetings, political strategy meetings, mutual commiseration and self-help meetings with other colleagues who are just as worried as she is, at least those colleagues, she comments, “who don’t still defiantly have their heads, in the sand.”

What do all these nervous people have in common, these established, mature, settled private practitioners who now fly from one meeting to another like flocks of edgy birds? These mid- and senior-level clinicians, many just as established as Elinor Adams, feel they have about as much job security right now as the engineers on the Super Collider project that Congress recently abolished. The entire health-care delivery establishment in Minnesota is, likewise, about to be “abolished” at least in its current form.

In its place, a statewide system of government-regulated managed competition, called MinnesotaCare, is scheduled to go into effect by mid-summer, fundamentally altering private practice in Minnesota, if not ending it entirely. According to unverified but widely disseminated estimates, MinnesotaCare may push 30 to 70 percent of independent therapists out of business.

As goes Minnesota, so goes, it is feared, the rest of the country. Minnesota may be at the far edge of the curve it always has been a progressive state in matters of public policy (Public Broadcasting radio personality and famous native son Garrison Keillor says that the antismoking forces have made such an impact on state law that if you want to have a cigarette in Minnesota, you have to go to North Dakota) but what’s happening there is commonly perceived as a bellwether for the rest of the nation. There is little doubt that some form of government-regulated managed competition will play a central role in national health-care reform it is the linchpin of the Clinton proposals. Already, managed care is a conduit to mental health services for a surprisingly large number of Americans. According to a market survey conducted by Open Minds Newsletter, which analyzes trends in the behavioral managed care industry, nearly half of the 178 million Americans with health insurance are enrolled in some kind of managed care company specializing in mental health.

In its broadest sense, managed care usually refers to a corporate, privately run (though often government-regulated) system of health care that coordinates and delivers an entire range of medical and, sometimes, mental health services to a “prepaid” population, while also managing the costs of providing that care. By both selling the “product” and paying the overhead of producing it, the managed care company theoretically operates under the same incentives as a wholesaler or producer, who stays in business by controlling expenses while still maintaining high enough quality to attract customers to buy what the company is selling. Typically, a managed care company stays within budget by screening medical and mental health services, restricting or denying access to those considered unnecessary or inappropriate and getting providers to agree to reimbursements below what they could get in the free market.

Statistics on how the growing managed care hegemony affects private practice patterns, fragmentary and informal as they are, suggest that the impact has already been phenomenal. In a 1992 survey of 1,905 of its readers, Psychotherapy Finances reported that 66 percent of the therapists polled had signed managed care contracts (most of which paid reduced fees) up from 51 percent for 1990. Increased numbers of therapists (10 percent more than in 1990) indicated that the effect of managed care was to reduce their income, change their therapy approach (to briefer models) and shorten the average length of therapy.

In 1989, New Jersey psychologist Stanley Moldawsky concluded from a survey of fellow practitioners in his state that the death of private practice had been very much exaggerated. He is less sanguine now. In a recent survey, he found that private referrals had dropped by 17 percent, while managed care referrals had risen by 7.5 percent not a great deal. But, says Moldawsky, “If trends continue like this for a couple of years, we could be out of business. A lot of therapists believe we are being invaded by managed care. When they get together, they talk about nothing but managed care.” Several disgruntled clinicians interviewed by Moldawsky said, “I wouldn’t tell my kid to go into this field” a poignant sign, perhaps, that an era is ending.

Almost all therapists of a certain age grew to professional adulthood during the Golden Age of private practice, when the term “rich therapist” was not an oxymoron. Many thrived in the benign hothouse climate of a medical system unique in the modern world a vast crazy quilt of private and public entities that allowed practitioners of all specialties a rare degree of autonomy the ability to contract privately with individual clients of their own choosing, to set their own fees, decide upon treatment, determine its scope and depth as well as the time and reasons for its termination.

True, independent practice has been justified for years by appealing to a vision of a sacred and intimate bond knitting healer and sufferer together, which may be increasingly anachronistic in the high-tech, bureaucratic world of modern health care. Still, there is enough truth left in the old echo to resonate deeply with many people: Who does not yearn atavistically, when in pain of body and mind, to enter into a mysterious and deeply personal healing communion with a compassionate and skillful magician? Then too, there can hardly be another area of health care in America that, almost by definition, depends upon the kind of private relationship typical of the therapy encounter. Nor has there been any discipline within the healthcare field so free of externally mandated treatment protocols, demands for evidence of success or even requirements for any stringent definitions. Kenneth Howard, a psychology professor at Northwestern University, probably reflects the elegiac thoughts of many therapists when he says, “For the 30 years I practiced therapy, what went on in my office between me and my patient was strictly between the two of us. It was wonderful.”

IT MAY HAVE BEEN WONDERFUL FOR private practitioners, but it was far from perfect for society as a whole. Health-care providers, except the bitterly reactionary (who might still oppose germ theory if given the choice) often admit that “something has to be done about America’s health-care system.” As everybody knows by now, the United States has the most expensive medical system in the world, with costs estimated by the U.S. Department of Commerce to increase by 13^5 percent a year over the next five years, and accounting for 15 percent of the gross national product. (In 1993, medical costs increased by only 6 percent, reflecting a decline in the inflation rate generally and probably due, as well, to what some call the “Hillary effect” cost control motivated by fear of health reform.)

Unfortunately, while American medicine at its best probably offers the highest quality and most technologically sophisticated care in the world, many policy analysts believe the United States is not getting very good overall medical value for its dollar. “What we have now is a nonsystem in which millions of health-care profit centers provide discrete incidents of care to the legs, knees, backs, heads of different individuals,” says George Halvorson, chief executive officer of Health Partners, one of die biggest HMOs in Minnesota. Even worse, according to Halvorson (who is also an architect of MinnesotaCare and known in local circles as “Mr. Managed Care”), ours is the only system in the world that so antiseptically isolates health-care delivery from payment. The result is an almost total lack of accountability, and no incentive whatsoever to determine the relative effectiveness of one treatment over another, the quality of care by one provider or medical center versus another. Because payment is not tied to actual performance, consumers and providers alike “are insulated from the need to be cost- and quality-conscious,” says Halvorson.

Knowing a radical operation is necessary, however, doesn’t reduce its unpleasantness or the anxiety of anticipating it, and even providers who believe in reform are also scared by it. Inevitably, the massive reorganization of the health-care system along the lines of managed competition means greater rationalization, efficiency and cost effectiveness, which, translated from the slippery abstractions of business-speak, means there will be winners and losers. For every provider who finds a warm berth in the new, pared-down corporate structures, there will be an unknown number left out in the cold. So while providers go to meetings and talk shop, just as they always have done, a set of new and ominous questions reverberates in the back of every mind like the distant boom of artillery: “Is this, finally and for real, the end of private practice?” and “What will become of me when it happens?”

Some therapists asking these questions will undoubtedly remain in private practice, though they will probably work longer hours for fewer dollars. Some will join the favored few doing what is now referred to as “boutique therapy-uninsured, long-term, fully client-paid psychotherapy for those few souls who can still afford it. But almost everybody else, if they are still in the field at all, will probably join the ranks of managed care.

MANAGED CARE IS NOT A NEW phenomenon; the so-called “first generation” of it existed during the 1950s and 1960s in the form of a few large, staff-model (meaning that all providers are salaried personnel) health maintenance organizations like Kaiser Permanente, which major corporations began offering to employees in lieu of standard indemnity insurance. A majority of insured Americans did not belong to HMOs, however, and health-care practitioners almost universally dismissed them as perverse aberrations without a chance in a population hooked on free choice and unlimited benefits.

In 1982, the curtain suddenly dropped on this placid scene when Congress, shocked by spiraling Medicare costs, enacted legislation setting up external utilization review (UR) boards that would screen treatment received by Medicare recipients to eliminate inappropriate and unnecessary procedures. This precedent was a bolt of electricity among private managed care companies, galvanizing them to set up their own massive and highly stringent review procedures as well, which became potent weapons for reducing expenses and increasing profits. Adopting these new cost-containment strategies to their own purposes, a so-called “second generation” of managed care companies sprung up and proliferated.

This rambunctious offspring of the first generation spawned an alphabetical shower of variations on a theme HMOs, PPOs (preferred provider organizations), EAPs (employee assistance programs), EPOs (exclusive provider organizations), PRSOs (peer review service organizations, a form of utilization review firms) and the like. All shared a common predilection for what therapists Charles and Beverly Browning call, in their book, How to Partner With Managed Care, the “three Ts” of managed care^ “intrusion, invasion and inquisition.” Like 20th-century Scrooges, these organizations kept a beady eye on every diagnosis, every prescribed treatment, every penny of reimbursement. Not surprisingly, thousands of providers now caught in the crosshairs of managed care surveillance commonly refer to them as “Big Brother.”

Karen Shore, a New York therapist and organizer of a consumer therapist advocacy group called the Coalition of Mental Health Professionals and Consumers, compares the managed health care industry to a “totalitarian regime, subjugating patients and therapists and depriving them of freedom and democratic process.” Therapists who refuse to disgorge quantities of highly sensitive personal information about clients to reviewers, or who ask for more sessions than the company approves are susceptible to being “blacklisted,” says Shore. “A tremendous fear permeates the system, and therapists who do more intensive psycho-dynamic or behavioral work, who argue with reviewers or file appeals of refusals, are kicked out of networks.”

This aggressive micromanagement and obsession with cost-cutting characterizes what James Shulman calls the managed care “reign of terror,” which began during the mid-’80s when medical costs soared out of sight. According to Shulman, a psychologist and CEO of INTERACT Behavioral Healthcare Services, a five-clinic mental health care and drug and alcohol treatment organization in Ohio, insurance companies, competing fiercely for business from employers anxious to reduce budget-breaking health-care expenses, ruthlessly pruned benefits and denied claims to produce programs that looked more “cost effective” (read: “cheaper”) to their corporate buyers. In the resulting melee, managing costs, not care, became the priority, while care was more or less overtly rationed, and utilization reviewers became the hired guns bullying providers into becoming de facto collaborationists.

Under this form of legalized managed care, writes Shulman in the September 1993 issue of The Ohio Psychologist, “payments [are denied] for spurious or inappropriate reasons and reviewers often refuse to negotiate on care, prices or alternative service delivery systems. Practitioners who refuse to comply with the terrorist-style tactics are ‘rubbed out’ as providers. For survival’s sake, many providers adopt compliance, becoming ‘hostages’ and thus learn to play the games, accept the prices and follow the rules.” There is one difference between a terrorist and a managed care company, Shulman points out: “You can negotiate with a terrorist.”

The terrorist analogy does not sound farfetched to providers in Minnesota right now, where hospitals, HMOs, pharmaceutical firms and insurance companies compete in an orgy of corporate warfare to secure a solid place in the coming reformed health-care system. About the blizzard of reorganizations and mergers of managed care and other health-related companies, Minnesota therapist James Maddock says, “The atmosphere here is both seductive and predatory. Organizations aggressively hunt down other organizations to buy, and there are announcements every week of hostile takeovers and an avalanche of 15-second, heart-jerking advertising sound bites [for competing health-care companies] in the media. It’s like the rollicking days on Wall Street during the early ’80s.”

The current upheaval in Minnesota-expected to travel like a virus to every state during the national transition to managed competition has not improved the quality of daily professional life, either. Walter Bera, a Minneapolis therapist who has worked both sides of the private practice/ managed care divide, compares the current situation in Minnesota to a profoundly stressed family system: with homeostatic stability gone, the entire extended healthcare “family” lurches from crisis to crisis. Managed care companies relentlessly underbid one another in estimating costs of services, pressuring their own staff members and affiliated providers to focus their best efforts on the corporate bottom line rather than on the welfare of their clients. “When you are being forced to get ‘good numbers’ on quarterly and even monthly statements, while management is slamming you for being over budget by 10 percent, and in the meantime, the managed care supervisor you reported to last week is gone this week, it’s difficult to serve the client very well,” says Bera. “And when you have insecure, paranoid and depressed therapists working with insecure, paranoid and depressed clients, it’s a nightmare.”

THE RAY OF SUNLIGHT PEEKING wanly through these dark clouds is the expectation that within the next few years, a more moderate, enlightened and negotiable “third generation” of managed care will be slowly taking the reins from its aging, terrorist parent. James Shulman of INTERACT, for example, is among those who believe that the days of managed care’s “reign of terror” may be numbered, that “the push for health-care reform . . . may be setting the stage for a new. . . paradigm of quality,” in which “the highest level of care for the best price” replaces the single-minded zealotry about cutting expenses regardless of social cost. “Health-care reform means nothing if the customer the patient is not at the top,” says Shulman. And the continuing disinterest of managed care in the real customer (rather than corporate accountants) represents an opportunity for providers to demonstrate to public and private sectors alike that they can give patients what they need at a cost they can afford and leave them reasonably happy in the bargain. According to these optimistic forecasts, once the anarchic period of upheaval is over, the truly reformist potential of managed care the delivery of fully integrated, high-quality but efficient and cost-effective medical and mental health services that satisfy both patient and provider will become a reality.

Among the most important differences between the second and third generations is the projected disappearance of external utilization review with all its egregious depredations on patient privacy, clinical prerogatives and humane care. Under the new dispensation, providers, as salaried employees of large, well-organized and relatively liberal managed care companies like INTERACT, will be given authority to monitor and review themselves, deciding as members of cooperative, interdisciplinary teams of health providers, how to manage care according to common philosophical and organizational guidelines.

But for a therapist raised under the old flag of private practice, the adjustment to the group ethic of managed care may be difficult, even under the most ideal circumstances. “In an HMO, a practitioner has to give up some autonomy in order to become part of a team, no question about it,” says Peggy Trezona, a therapist at Group Health in Minnesota, which is a subsidiary of Health Partners, widely regarded as a model for the third generation of managed health care. Not only is the practitioner’s freedom abridged to decide unilaterally when to see clients, which ones and how many to see (not to mention how much to charge them), but treatment decisions must be made in cooperation and coordination with other providers within fairly strict parameters of time, cost and theoretical orientation (long term, analytically oriented therapists need not apply).

In long-gone days (just two or three years ago), a therapist in private practice or even in a clinic concentrated almost exclusively on clinical issues, once the answering machine had been turned on and the insurance money was rolling in regularly, he or she could leave the boring details of finances and administration to a CPA and an office housekeeping service.

At Group Health, on the contrary, every provider has to think in terms of the “Three Worlds the clinical, the operational and the financial,” says CJ. Peek, consulting psychologist for medical management at Group Health. “A provider not only asks, ‘What does this patient need? An X-ray? Another therapy session?’ but ‘How are we going to get it done? Which clinic has the right equipment? Do we have the space for a 3 p.m. appointment?’ and ‘Can we do what needs to be done in a way that doesn’t overrun the patient’s allowed benefits?’ A therapist here, for example, tries to leave as many of the patient’s resources as possible ‘in the bank,’ so to speak not to use six sessions, when four would have sufficed because he or she didn’t plan the most parsimonious intervention.”

In no other form of practice except a busy community mental health center (which the day-to-day operations of an HMO uncannily resemble) can the pace be so frenetic. Group Health is a big company and a part of Health Partners, an even bigger company; there are 110 therapists responsible for over 575 thousand “lives,” as they are called in the insurance world. Not surprisingly, “the sheer volume of clients can be burdensome;” Trezona says, “the people keep coming whether or not we have as much time and staff as we’d like to see them, and because we’re an HMO, we can’t refuse to see anybody who’s a member.” Alan Goodell-Holmes, a psychologist and director of professional services for the mental health department of Group Health, refers to the constant struggle to see clients in a timely fashion and prevent a mountainous waiting list backlog from “burying us,” as the “churn factor” of life at an HMO. “The water is always being churned up here, because you have to accommodate people as they come, never knowing how many that is going to be or what they’ll need at any given time.” The pressure is intense to wring the most mental health product out of every

allotted clinical hour, which sometimes forces therapists to engage in the kind of therapeutic triage they would prefer to avoid. “It happens all the time that a person comes in complaining about an unhappy marriage,” says Goodell-Holmes. “But, as is often the case, if their company’s contract with us specifically excludes marital therapy, we do an assessment to see if there is any other DSM III (Diagnostic and Statistical Manual of the American Psychiatric Association) diagnosis. If there isn’t one, if the person is unhappy, but not diagnosable, we can either deny treatment or make up a diagnosis like ‘adjustment disorder’ and do the marital therapy under that guise. But if we do the latter, not only are we being untruthful by overdiagnosing (which may also make the client an insurance risk in the future), but we are in essence using up capitated resources provided by that contract, which might be needed more by somebody else at that company. If we give services to one person who doesn’t really medically require them, we are in effect denying them to somebody else who really does.” In these cases, says Goodell-Holmes, he advises staff members to tell the client the truth that he or she does not meet criteria for available services and then try to get them help through other affordable community resources, which might include free or reasonably priced marital counseling and enrichment programs run by local public and private institutions. Indeed, it is not unusual, says Trezona, for case managers at Group Health to work with providers outside the network when a client is felt to need special resources beyond the scope of the HMO or the client’s plan, like more individual therapy, for example.

The up side to working for an HMO, says Goodell-Holmes, is the sense of community, connection and mutual support in the workplace, as well as the ready availability of resources. The environment is extremely friendly to a dyed-in-the-wool systems thinker like Goodell-Holmes, who enjoys working in an interlocking network. “You can feel very isolated and alone in private practice, and you don’t have the other resources you need at your fingertips. Also, you’re trying to find new patients all the time. Here, you have guaranteed clients and you know you’ll get a paycheck”

As for what that paycheck will be, or what kind of money any practitioner can expect under the new system, estimates seem to follow the curve of free-floating anxiety the less secure therapists feel about their own futures (and the less experience they have with good managed care), the bleaker the financial future looks. Goodell-Holmes believes that, when health benefits and economic security are counted (the paycheck stays the same every month regardless of number of clients), remuneration for a HMO staff member is probably as good as that of any private practitioner with an average caseload of 30 hours. Needless to say, a therapist commanding $100 to $150 an hour and filling 40 hours a week probably will not do as well. “The long-term individual therapist who has enjoyed a lucrative private practice with a handful of clients whom he or she sees weekly or biweekly is most at risk,” says Walter Bera. “That kind of practice absolutely will not be done anymore.”

Perhaps “absolutely” is too strong a word, but therapists at the high end of the economic spectrum, who normally make $100,000 a year, can expect to see more clients for less money say, $60,000 or $70,000 under a system of managed care if they are still practicing. The lower figure hardly sounds like starvation wages, but, as Bill Doherty, professor in the department of Family Social Science, University of Minnesota, puts it, “Most of us, like most Americans, don’t save very much of what we earn and the cut would really hurt a loss of 2 5 grand, for example, means no college tuition for the kids.”

The other ominous fee-related issue for therapists with Ph.D.s and M.D.s is the apparent tendency of managed care companies to reimburse people exclusively for their services, without regard to their credentials, meaning that between two providers doing therapy, the lower-ranking (and presumably cheaper) master’s-level social worker is more likely to get hired than the Ph.D. “I predict that under managed care, payment for psychotherapy will be at a fixed fee, no matter who does it,” says Monica Oss, editor of Open Minds newsletter. “There will be a bifurcation between the rate paid to psychiatrists, on the one hand, who will monitor medications and do blood tests in 15-minute sessions, and another rate to psychotherapists, whatever their training. In fact, different credentials for therapists will become meaningless.”

Jim Hawkin, a Minnesota family therapist who also supervises cases for an HMO, notes that many managed care firms in his state only want people with masters’ degrees they are cheaper to hire and, presumably, more clinically pliable than Ph.D.s. If they are hiring doctorates, the salaries offered can be downright insulting, according to Hawkin. “One company was advertising for a full-time Ph.D. psychologist; they were willing to pay $34,000 a year about half what anybody I know would work for.”

PERHAPS THE MOST RADICAL change in store for a generation or two of laissez-faire therapists will be the need to justify what they do with an unprecedented precision and specificity. Managed care representatives and a surprisingly large number of therapists say that the therapeutic community has brought its current woes upon itself by its amazing failure even worse than that of the medical world to provide decent explanations, let alone measures of cost and outcome accountability, for its treatment methods. Therapists, according to this critique, are held to almost no objectively measurable, external standards for deciding what is wrong with the client, what to do about it, how long it should take to do it, when it can be considered done and how anybody knows if it is done.

The boundaries of psychological diagnosis and treatment have become so porous and malleable, it is argued, that every life problem has become a “disease,” and for every “disease,” there is an expensive, time-consuming, idiosyncratic, ad hoc remedy. Managed care case reviewers interviewed for this article said they had been asked to pass on a rich variety of allegedly psychotherapeutic interventions including “equestrian therapy” (horseback riding lessons), exorcisms, past-lives regression and, in one treatment plan for an unspecified disorder, a request in advance for 500 sessions. In another case, a therapist, who had been seeing a client four days a week for eight years at $200 a pop, wanted more.

Critics of therapy’s lackadaisical attitude toward accountability also argue that for decades, fundamental clinical decisions have been made virtually by professional fiat, derived only from the in-house rules of a professional guild and the clinical intuition of the individual practitioner. Ergo, the common complaint that the same client will receive entirely different diagnoses, modes of treatment and prognoses for improvement depending upon whether the therapist is a behaviorist, cognitive psychologist, structural-strategic family therapist, Freudian analyst, biologically oriented psychiatrist or a Jungian archetype finder. Nor are there common measures for determining appropriate “fit” between any one of these models and any particular problem the client shows up for a virtual blind date between his or her presenting complaint and the therapeutic modality of the clinician who happened to get called first.

From now on, however, therapists will have to demonstrate what good matchmakers they are, convincing corporate buyers the economic “parents” of the client that the “dates” they arrange between clients and treatment almost always lead to successful (though intentionally brief) marriages. Therapists, in other words, will have to demonstrate in advance that a particular client exhibits the specific functional impairments making him or her a good candidate for a standard treatment regimen that has already worked in numerous other similar cases.

“Clinicians will have to address themselves to a fundamentally different set of questions than they are used to,” says Mike Bowers, president of the American Association for Marriage and Family Therapy. “Our whole diagnostic system is geared to measuring illness, not health or how well somebody functions. Now, assigning categorical diagnoses will be much less important than measuring specific symptoms along a continuum of functional impairment Is she failing to hold a job? Is he too depressed to pay attention to his kids? Is the child suddenly failing at school? and then indicating a specific treatment for resolving a specific problem and addressing the identified impairment. In other words, you will have to demonstrate the level of impairment, the intensity of treatment and the expected time it will take in each case.” In short, therapists will no longer get away with saying that therapy is necessary “to improve the client’s self-esteem” or “work on characterological issues” or justify asking for more sessions because “the client seems to be feeling better.”

Numbers-crunching is fundamental to the new accountability. Every health-care reform proposal and managed care paradigm rests, ultimately, on the availability of computerized data in vast quantities. Blue Cross/Blue Shield of Minnesota, for example, is moving toward an “outcome-based delivery system,” using data on a wide variety of medical procedures drawn from a population sample of 1.2 million people. “We can tell you the practice patterns on hundreds of procedures, region by region, across the state,” says Tom Lehman, director of legislative affairs at Blue Cross/Blue Shield of Minnesota. “We can tell you how many prescriptions for Prozac statewide we are paying for, almost neighborhood by neighborhood. With millions of patient encounters in our data base, we can track provider practice patterns with ease. If every single patient walks out of one therapist’s office with a prescription for the same antidepressant or anxiety medication, that tells us something about his practice style. Just as, if every pregnant woman gets a C-section, and every nonpregnant woman gets a hysterectomy from one provider, that lets us know we don’t want him on our panels. I’m exaggerating, of course, but we can learn a great deal about how practice patterns vary from area to area, provider to provider by studying this data.” Lehman admits that mental health care is “squishier” than physical medicine, and harder to measure. Nonetheless, compiling huge data bases from utilization records and outcome studies is the direction of the future for managed mental, as well as physical, health care.

At the very least, therapists should know what their own practice looks like how many and what sorts of clients they see, the kinds of interventions they use, how long their therapy generally takes and what their successes look like. It is amazing, suggests Bill Doherty, how many therapists don’t explain (and sometimes don’t even know) what they have to offer, but expect insurers just to take them at their word that they are good at doing whatever it is they do. He and Deborah Simmons, a doctoral student in the University of Minnesota’s Family Social Science department, recently completed a study based on a random sample of Minnesota marriage and family therapists-demographic data, educational background and practice patterns and empirical data on 200 of their treatment cases. With this study in hand the first of its kind in the marriage and family field Doherty says he and Simmons were in a good position both to educate managed care executives about family therapy and also to demonstrate that it is briefer than individual therapy (average marital therapy cases involved 10 sessions and family therapy 8 sessions in four months, while individual therapy took 14 sessions).

Doherty says that this study convinced the executives of one major company that it would be cost effective to fund couples therapy. “One of the business people at this meeting said she had always thought that marital counseling just went on forever and didn’t do much good,” recalls Doherty. “I was able to tell her, and back it up with the data, that in my experience, the more people in the therapy room, the shorter the therapy.” Subsequently, the firm decided to begin funding marital therapy. The lesson Doherty draws from what he calls this “small victory” is that therapists can either “bemoan the old days and wring our hands, or we can explain what we do to the business world and learn to negotiate with them in terms they understand. We can choose to be victims, or we can actively grab this opportunity to shape the future.”

THE PROBLEM IS THAT MOST providers do not know what they want from the future because they still cannot see beyond the walls of their respective professional fiefdoms. For generations, health care in America has been defined solely in terms of the differential credentials, guild privileges and status gradations of the segregated providers in whose hands patients have found themselves. “Medicine in America has become increasingly botanized into categories and subspecialties,” says Richard Heinrich, a psychiatrist and department head for mental health at Group Health. “We’ve lost sight of the fact that we are all, whatever our individual specialties, part of the larger, more important overarching profession of health care, and that all patients are really shared by all clinicians.”

Reformers believe that if a more unified, integrated system emerges from the current debates, the traditional hierarchies and classifications in the health-care professions and the artificial boundaries between their territorial spheres may diminish, if not wither away. Ideally, then, the centripetal force of the medical system as it is now pieces of the patient dispersed to widely varying specialists and subspecialists (physicians, therapists, acupuncturists, dietitians, dentists, physical therapists and opticians, among others) would become as antiquated as ol’ Doc riding around town in his horse and buggy. At Group Health, for example, different providers psychologists, psychiatrists, nurses, social workers, medical professionals often collaborate together as members of “care unit teams” assigned to individual patients, particularly those with interlocking mental health and medical problems. The emotional and physical problems of certain patients are inextricably bound, Heinrich points out chronic pain patients, asthmatics, children with juvenile diabetes, people with eating disorders, and depressed cancer patients are among those who need the integrated services of different providers.

In the new, centrifugal system, the “shared” patient would be the center, the sun, so to speak, around which many different providers revolve. Heinrich points out that functionally speaking, the lines between mental and physical health care are already blurry. “NIH epidemiological studies indicate that half of all mental health patients are seen by primary-care physicians first,” says Heinrich. “So, as mental health providers, we need to think in terms of the diagnostic and treatment skills universal to all of us psychiatrists, psychologists, social workers, psychiatric nurses that we can use in conjunction with primary care providers. In the 21st century, I hope, we’ll be using teams of mental and medical health-care personnel, referring back and forth among each other, so we can make use of the best trained but most cost-effective person to provide assessments and treatment.” This is truly a systemic view of therapy, in which the therapist not only sees his or her clinical role as one link in an interlocking network of caregivers, but also understands that in real life no cordon santtaire isolates the technical details of something called “health care” from the economic and social structures in which it is embedded.

What seems most striking about this vision is not only that health care is being redefined, but that the medical model itself is no longer the automatic reference point for the discussion. Always before, formal legitimacy has been granted to non-M.D.s nurses, therapists, pharmacists, optometrists, chiropractors, physical therapists and so forth (called “allied, mid-level providers” in the medical world)

only to the extent that they could justify their services as “medically necessary” according to standards set by physicians. Whatever the fragmentation of the healthcare field, all providers were included in (or excluded from) this explicitly medicalized hierarchy of social power, legal merit and ethical value.

Therapists, as a group, have long been embroiled in a love-hate relationship with medicine. During the 1950s, they fell for the allure of the medical model, which promised them both the gloss of borrowed scientific and social prestige and the gold of almost unlimited insurance reimbursements, if they could just make what they did sound more medical. Like a poor but ambitious suitor wooing a glamorous heiress, the therapeutic community wanted to obscure its scientifically disreputable origins in psychoanalysis and “fit in” to the socially elevated circles of its inamorata.

Unfortunately, therapy became a resentful, ambivalent spouse, both attracted to and jealous of the prerogatives of its significant other. It is not uncommon to hear therapists in one breath (particularly those doubting the effectiveness of long-term psychodynamic therapy) castigate the use of the medical model because it “pathologizes” people, making them think of themselves as sick and damaged, and then, in the next breath, mourn the fact that therapy is not scientific, diagnostically specific and goal oriented, just like medicine. Therapists are annoyed that managed care is not nearly as stringent with physical as with mental health benefits. They point out that people with the flu or a cold are covered unquestioningly for millions of dollars in office visits and prescription drugs that are known to be useless, while every therapy request is scrutinized like an unclaimed suitcase making ticking noises while sitting in an international airport. They chronically snipe at “rich, arrogant M.D.s,” while wondering why they aren’t on the same gravy train.

In truth, many therapists want it both ways; they like the money, power and prestige that accompany the medical model, but not the requirements for scientific and fiscal accountability; they want the cash and glory that comes with marriage to an heiress, but they want their freedom, too. Some therapists even wonder if psychotherapy’s faustian embrace of the medical model during the 1960s wasn’t a fateful and ultimately self-destructive mistake.

“Psychotherapy should be separated from the medical model entirely,” says Rogers Wright, director of the Association for the Advancement of Psychology (AAP) and an expert on reimbursement issues. Wright believes that it was a serious error trying to convince the American public that there was no difference between physical medicine, in which the physician was assumed to be in active control and the patient relatively ignorant and passive (how many gall bladder patients can be expected to know the way to perform a cholecystectomy?), and therapy, which requires for its success the full agency, understanding and commitment of the patient, who should be the ultimate authority on his or her own case. “The first thing I say to a client is, ‘I am not the expert, I have no magic, no pills; all I know about is the learning process, and you are the only expert on you, you have to make the decisions about what happens to you,'” says Wright. “But the medical model is the converse of that, and subtly, over time, the white coat and stethoscope and magic mantle of the physician have migrated into the consulting room.” Not only does medicalization undermine an important goal of therapy, says Wright to inculcate habits of self-reliance and responsibility in the patient but it implicitly suggests that therapists should be able to produce the same sort of controlled outcomes that are standard for many medical procedures.

Ironically, at just the point when some therapists are wondering whether to end their long, often troubled marriage to the medical model, they are being embraced by it in a clasp that looks to many like a death grip. Like it or not, therapists are going to be sucked even further into a health-care system that, so far, has been defined and justified in largely medical terms. So far. There is talk about a new “health-care paradigm” in Minnesota says Deborah Simmons, “but MinnesotaCare is absolutely in the medical model from A to Z.”

And yet, under the new system, the medical model itself might look like nothing anybody has ever seen before in this country. Says Mac Baird, a New York family physician and family therapist, “the bad news is that the health-care system is collapsing. The good news is that the health-care system is collapsing.” Even in the midst of chaos, there is a surprising amount of hope mixed with anxiety. At Group Health, Peggy Trezona finds working in the vanguard exhilarating. “We have a wonderful chance to be in the forefront of an innovative public health effort,” she says, “to participate in educating people and changing the popular perception of health care to a more integrated vision that takes into account the whole person, body and mind.”

In the ideal version of managed care, in which “health care” is imagined comprising the whole person, therapists might have a role far more significant than they have had so far. They might become more rather than less important to the health professions as their particular contribution to healing becomes better recognized. Therapists are specifically trained to do work that physicians usually do not and cannot do, but which may be critical to physical as well as emotional health. They can help people change the way they view themselves, the way they think and feel about their lives, the way they conduct their social and family relationships, all of which can have enormous consequences for preventive and curative medicine. Consider the typical case, suggested by Deborah Simmons, of a middle-aged woman who visits her doctor with a host of vague complaints-headaches, stomach upsets, muscle pains, sleeplessness. An expensive workup by assorted specialists reveals nothing very much, her physician assumes she is “menopausal” and sends her home with a tranquilizer. But a few minutes with a therapist, or even a psychologically savvy physician, might reveal that she and her husband haven’t spoken in 25 years, her children have moved away, she has no job and the suddenly revealed emptiness of her life is literally making her sick. Whether this woman gets well or spends years chasing after futile and expensive medical remedies depends largely upon the integration of mental health services in a medical world.

MANY THERAPISTS ARE LESS worried that the medical model will prevail than that corporate imperialism will make health care over in its own conglomerated image. Skeptics of managed care, even within it, point out that the typical corporate mind, obsessively systematic, regimented, rationalized and cost-conscious, is incompatible with the delivery of humane, flexible and, in the long run, truly economical health-care services. “The corporate world tends to think about short-term profit savings they’ll promise to save an employer a certain amount of dollars in this quarter or next by limiting services but they can’t manage or legislate away people’s problems,” says Paul Herman, a Maryland private practitioner and former chairman of the Maryland Psychological Association’s committee on managed care.

James Maddock believes that the rules of the marketplace are not suited to a “product” like health care, which is not equivalent to other consumer goods. “We can decide not to buy a car this year, or a bunch of new clothes, but people cannot “choose” to do without health care, nor will they be willing to buy an inferior, albeit cheaper ‘generic’ brand,” he says. “If I run short of money, I can always buy the house brand of peanut butter, rather than the superior name brand, and survive it’s not a big deal but people won’t stand for ‘generic’ surgery.” Yet, without countervailing sources of power, the natural inclination of managed care, critics say, is to produce a standardized, mass-produced product that improves the corporate profit picture, but not necessarily the health of the consumer.

To many therapists, the constantly repeated proposition that briefer therapy is virtually always better therapy, betrays the business mind’s fundamental incomprehension of mental health issues. Clinicians no longer argue that time-limited or brief therapy is not a legitimate and useful modality; virtually all interviewed for this article agreed that many, perhaps even a majority, of clients are well-served by it. But they object to the almost universal, global dismissal of long-term therapy in discussions of reform, and the barely concealed contempt for its practitioners by numerous managed care executives.

Critics of managed care believe that, as a society, there are times when we must pay for intensive and extended psychotherapy now, or pay an incalculably higher price later for increased crime, family violence, divorce, teenage motherhood, alcohol and drug abuse, job absenteeism and a host of other problems stemming from serious and chronic emotional illness. “Clients may feel a little better after they’re allowed three or five sessions, but then their problems go underground and come back later to haunt us all,” says Paul Berman. “People can be helped to function at a limited, impaired way, dragging one foot in front of the other, but there is a larger price society pays in the ripple effect on the marriages of these people, on their children, on their ability to work.” These critics also wonder if the intense drive of managed care for hard data is suited to a field as inherently “squishy” as therapy. “It seems counterproductive to force a relationship-based cure into the justifications of hard science.” says Neil Mackstein, a Maryland therapist.

But the complaint that the unholy dyad of science and business will destroy the humanistic qualities that make therapy what it is, is considered antiquated sentimentality by proponents managed care. “People only talk about therapy losing its ‘humanism’ when their effectiveness and accountability are being questioned,” says S. Alan Savitz, a psychiatrist and senior vice president of Human Affairs International (HAI), a wholly owned subsidiary of Aetna life and Casually. “Before the advent of antibiotics, doctors could do very little to actually heal people. They just sat by patients’ beds, holding their hands and trying to make them feel a little better. Now, they can really do something for people, patients don’t just feel better because of the human touch, they are better. But I’ll bet people like their doctors personally a lot less now than they did then. Mental health care is in something of the same position as medical care in those days,” continues Savitz. “Patients may think they prefer ‘liking’ their therapist to actually getting better. Basically, they may be lonely and looking for a friend, rather than trying to change the way they live in a reasonable amount of time.”

THOUGH OFTEN COUCHED IN stupefyingly bureaucratic language, the debates about quality, accountability, cost control and efficiency really circle around a bitter truth that everybody knows, but few will openly admit: it is probably impossible to provide as much access as Americans want to unlimited, high-quality health care at a cost this society can financially afford and politically tolerate. Some form of rationing is a foregone conclusion, regardless of the soothing spin dished out with every official healthcare reform pronouncement. Of course, health care and everything else in American life has always been “rationed” to the poor, but this is the first time that masses of middle-class Americans will experience the limitations in access to medical and mental health services that the rest of the world has long since viewed as ordinary reality.

What makes this truth more unpalatable is the pervasive American habit of entitlement that almost defines our national culture. In defiance of historical fact, we believe we should be refused nothing that materially contributes to our well-being or eliminates suffering. We don’t really believe, in our optimistic and technologically masterful society, that we should ever have to suffer. “Most of the ideas about what causes [health-care] inflation do not take into account the unconscious fear of death we all have, for which we spend incredible sums of money to address,” says Rogers Wright. “We are very spoiled not just about health services, but about everything. As a culture, we have unrealistic expectations [of what medicine can do for us], and we consider personal responsibility quaintly old-fashioned.”

Some providers may find comfort in telling themselves that the inevitably protracted political conflict over competing health care reform plans can delay the Apocalypse indefinitely the apparent decline of health expenditures last year helps fuel this ephemeral dream. But whether reforms get through Congress this year, next year or five years from now and whatever they look like the world of health care will never be the same again. This rocket is already shooting into space and no amount of maneuvering or doomful prognosticating will bring it back: the control of health services by managed care in America is probably, in the words of one Minnesota therapist, “a done deal.”

Yet even a “deal” that inevitably includes some form of health-care rationing a profoundly unAmerican word does not have to be a disaster; it can be a salutary invitation to become more responsible about consuming resources, more aware of preventive health. And whether the deal becomes just another hostile takeover by corporate operators or actually sets the stage for a humane and visionary new health-care system depends as never before on another kind of professional accountability from private practitioners a sense of public service and social responsibility. If clinicians care about their clients, not to mention the quality and meaning of their own work, they must leave the safety and security of their private practice sanctuaries (not so safe and secure anymore, anyway), renounce exclusive sectarian loyalties to their professional guilds and muscle their way into the public policy-making process.

Unfortunately, diving into the debate is not as simple as lobbying for or against one or another of the health-care reform plans before Congress. In the current health-care proposals that have any chance of surviving, mental health care achieves nothing like parity with physical medicine, and outpatient therapy looks like a hasty afterthought compared to “real” medical benefits in spite of abundant cost-offset research demonstrating how much psychotherapy reduces the need for other medical expenditures. Even modest mental health interventions not only decrease the use of hospitalization and other medical health services, but also improve employee productivity and cuts job absenteeism. Mental health care is truly front-line preventive medicine.

Yet even with this data in hand, and therapy’s growing popular acceptance (due in part to the propagation of therapeutic concepts by the self-help movements), a streak of puritanical disapproval for it still lingers in the public discourse, as if something so self-indulgent and frivolous should not be considered in serious discussions about serious subjects like health care and money. Paradoxically, there is also covert recognition of its importance from unexpected quarters. “I once saw an APA survey based on interviews with Fortune 500 executives on their attitudes to therapy,” says Kenneth Howard at Northwestern University. “Every one had either been in therapy or had a relative who had, and all were in favor of it, thought it was a good thing. But none of them would say so in public.”

For more than three decades, psychotherapy has been the best-known secret of the medical world employing an army of providers, consumed by an even bigger army of users, reimbursed without question by vastly rich corporate patrons and still somehow not quite respectable. Now, the secret is on the table, receiving more open and public scrutiny from a broader cross section of society and a wider range of institutions than ever in its history. Inevitably, the discussion will center on social, political and ethical questions that neither the therapy profession nor the public has had to address before. What is therapy, and how is it (or should it be) distinguished from health care? Besides therapy’s demonstrable medical cost effectiveness, does it contribute to the public weal in ways that cannot be measured in even the most elaborate and sophisticated accountability studies? How should therapists take advantage of the current flux and upheaval to broaden standard ideas about “health” to include a deeper understanding of the interconnections between body and mind, individual emotional health and social well-being?

“This is a time of flux and upheaval, but also of great opportunity,” says Bill Doherty. “Therapists have to begin thinking big, putting more of their creative energies into issues that transcend their individual interests. It’s worth doing, not only for our own economic survival, but because as professionals, as citizens, as moral agents, we have a responsibility to help mold the future in a world much larger than our own offices.”

Mary Sykes Wylie, Ph.D., is Senior Editor of the Networker.


Mary Sykes Wylie

Mary Sykes Wylie, PhD, is a former senior editor of the Psychotherapy Networker.