Psychotherapy in the Era of Managed Care

Review of Alex Sabo and Leston Havens, eds., The Real World Guide to Psychotherapy Practice. Cambridge and London: Harvard University Press, 2000. ISBN 0674003241, 352 pages, $39.95.

The dust jacket of this book announces that “Managed care has radically reshaped health care in the United States, and private long-term psychotherapy is increasingly a thing of the past.” It continues, “The Real World Guide to Psychotherapy Practice gives voice to therapists’ frustrations with the administrative constraints under which they work. But it accepts the reality and offers guidance and inspiration to committed therapists everywhere.”

Dr. Alex Sabo’s introduction, “Psycho-therapy at the Start of a New Century,” is the only chapter that directly addresses the impingements of managed care. He clearly sees at least some of the destructive handiwork of managed care, saying “The long-term therapeutic relationship is a casualty of today’s health care.” He goes on to criticize managed care for its support of brief cognitive-behavioral treatments, saying, “These treatments will be guided by manuals. One pill or one formula for ‘cognitive restructuring’ can be delivered by ‘any willing provider’ to the ‘covered life’.” Dr. Sabo continues, “A medical director of one of the largest behavioral-health managed care companies recently remarked that any therapist who needs more than eight sessions to solve a mental health problem has a ‘seriously flawed method’ of treating patients. He teaches his case reviewers to make this assumption when they scrutinize a case.” Sabo also acknowledges that managed care promotes these policies for its own financial gain.

The reader looks forward to what might be suggested as a way of dealing with these depredations. Alas, this section on the negative attributes of managed care ends with the plea, “We hope that managed care companies learn to support the value

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of a therapeutic relationship, whether brief, intermittent, or long-term.” But it is difficult to see how managed care can ever come to support long-term therapy when Dr. Sabo has just told us that managed care has made long-term therapy a “casualty” in pursuing its goal of cutting the costs of mental health care.

Sabo then goes on to introduce the unifying theme of the book: the importance of the therapeutic relationship in any and all types of psychotherapy. The chapter following the Introduction, which is co-authored by Dr. Sabo, is titled “The Relational Aspect of Psychopharmacology.” In it, he argues for the importance of establishing and maintaining a good relationship with the patient, even when the focus of the treatment is mainly on medication management.

The rest of the book, as advertised, is about how to make the best of bad situations, including working with patients with impoverished circumstances, severe trauma history, borderline personality disorder, and psychosis; men with histories of violent behavior; and crisis situations. For the most part, these chapters provide excellent practical advice with many valuable suggestions and insights. The therapists who have written them are respectful toward their clients and recognize the value of the relationship between the therapist and the patient as a major vehicle for promoting therapeutic change. The constraints, restraints, and prohibitions of managed care are taken as givens that need to be adapted to rather than fought against.

This book typifies what I see as the unfortunate attitude that still pervades the community of mental health professionals. It illustrates the technician’s mentality that characterizes so much of the profession. Therapists don’t consider it to be part of their job to question or resist the negative intrusions imposed on them and their patients, whether they come from managed care or any other negative environmental influence. They see their job as simply trying to help people to adapt and cope with whatever situation they find themselves in.

Therapists may not be able to do much about reducing poverty, violence, or any of the myriad afflictions that impinge upon their patients from many different sources, but they certainly can have an effect with regard to the constraints imposed by managed care. Managed care can’t function, or even exist, without the active participation and cooperation of the therapists who are treating the patients. Without the clinicians, managed care companies have no services to deliver and no product to market.

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