Psychodynamic Practice in a Managed Care Environment (Book Review)

Author:  Sperling, Michael B., Amy Sack and Charles L. Field
Publisher: New York: Guilford Press, 2000
Reviewed By: George Stricker, Fall 2001, pp. 46-48

When Karl Menninger first published his classic work on technique (Menninger, 1958), he described psychoanalytic psychotherapy as a two-person contract. By the time the book had been revised (Menninger & Holzman, 1973), he had changed the description to a three-person contract, in recognition of the impact of indemnity insurance contracts (and in disregard of the earlier reality that treatment of children and adolescents, and of some adults drawing on family resources, had always been three person contracts). This change occurred more than a decade before the advent of managed care as we now know it. At the present time, Dr. Karl’s eponymous and world famous institution is in the process of being sold and moved. Neither the Menninger Foundation nor we are in Kansas anymore.

The method of payment for psychotherapy has undergone rapid change. In the 1950s, patients paid the bill for themselves (or it was paid by family members). In the 1960s, many health insurance programs included coverage for psychotherapy, on an indemnity basis, almost always only when conducted by psychiatrists. As a result, in the 1970s psychologists began to press for inclusion in health plans and achieved success by taking their concerns to the courts. This was followed by an increase in cost for mental health services and the backlash of managed care in the 1980s. In the 1990s, managed care penetrated practice to the extent that a growing number of patients were being seen through third party coverage. The shift from indemnity plans to managed care led to increased incursions on practice and decreased fees, both of which were greeted by resistance and hostility. Now, in the 21st century, statutory efforts are attempting to reduce the impact and hegemony of managed care and the only safe prediction appears to be that we will not return to the 1970s again (and attempts to do so may lead to a return to the 1950s, which some would welcome). It is unlikely that third parties will be removed from the therapeutic equation, and the primary question, for those who choose to allow third parties into the therapeutic environment (and it is difficult, economically, not to do so), is what form the management will take. The difficulties with this are obvious, in that some decisions about the length, goals, fees, and nature of treatment have been removed from professional hands. The benefit, that many more people now can avail themselves of psychotherapeutic services, is often overlooked.

Against this backdrop, recognizing the inevitability of managed care and the need for psychodynamic clinicians to understand and, if they choose, adapt to the system, Sperling, Sack, and Field have prepared a short and helpful volume to guide the clinician through the process. The authors’ viewpoint is best summarized by the following quote: “In practice, the majority of cases treated through managed care proceed rather smoothly, assuming that one learns to negotiate the constraints structured into a managed health care system and assuming that one is willing to tolerate the ethical and operational challenges. Managed care is far from an optimal system; it is still worth working with for many clinicians” (Sperling, Sack, & Field, 2000, p. 109). In the spirit of disclosure, I agree with this position, and so I welcome this contribution to the literature.

In the introduction, the authors present their wish that the reader will be able to respond to managed care with knowledge rather than with fear or contempt, a goal that strikes me as worthy, and one that might be accomplished by this volume by any who approach it with a desire to learn. They also describe differences between psychodynamic treatment in a managed care environment and in a more independent setting. The most important differences include a reduction in the ability to work with transference, a change of treatment from insight oriented to supportive, the choice of limited goals, the need to communicate with a third party, a reduction in confidentiality, a change in the language used to describe treatment, the added burden of documentation, an increased focus on resistance, and the occasional need for termination without proper preparation. Much of this has been anticipated by developments in short-term psychodynamic therapy (Messer & Warren, 1995), psychotherapy integration (Gold & Stricker, 2001; Stricker & Gold, 1996), and the emphasis on the corrective emotional experience (Alexander & French, 1946).

In providing a historical survey of the development of managed care, the authors state “If we in the mental health field had been clairvoyant and initiated regulatory and cost-cutting steps from within (an admittedly difficult thing to do), we might have held off the surge of managed care, but not necessarily” (Sperling et al., 2000, p. 21). I must point out that just such a suggestion was made (Stricker, 1983), without the benefit of clairvoyance, and that it was roundly rejected by the profession. If a peer review system had been initiated, as was suggested, it is difficult to predict what would have happened. I doubt if managed care would have been avoided, but it might have taken a different form, and one in which professional decisions would have been made by professionals instead of accountants. The importance of stating this precedent is not simply to say “I told you so.” If we repeat the error of trying to resist the tide, we will forego the opportunity to shape the system and will then be subject to regulation far more onerous than what would be produced by responsible professional oversight. Along this line, I am familiar with some attempts by psychodynamic clinicians to form Independent Practice Associations (IPA) so that treatment could be delivered in a manner consistent with sound approaches to psychodynamic practice. Unfortunately, economic realities forced those IPAs to make some decisions limiting treatment, as any management system will have to do. I don’t relish those limitations, but I would prefer that they come from peers who understand what I am trying to accomplish.

Treatment authorization may be the greatest source of acrimony in the system, as it subjects professionals to the decisions of managed care employees who rarely have the training that is seen as necessary for the decisions that are being made. Sperling et al. construct a valuable matrix in which treatment situations are placed on dual continua, one continuum ranging from functional impairment to functional adaptation and the other from intrapsychic adaptation to intrapsychic impairment. Patients who are functionally impaired will receive treatment authorization in almost all cases. Those who are functionally adaptive and intrapsychically impaired may or may not receive authorization, perhaps depending on the manner of presentation of the case. Patients who are functionally and intrapsychically adaptive are unlikely to be authorized for treatment, although they may be excellent candidates for psychoanalysis and may profit greatly from the experience. However, in honesty, we must ask whether the treatment of such patients is the responsibility of managed care plans or the personal responsibility of the individual. Whatever our social views, clearly managed care plans do not value the growth that can occur from such treatment, and this is the area of clearest conflict between the plans and the providers.

The need for treatment authorization leads to a fascinating attempt to translate psychodynamic language into behavioral and cognitive parallels so as to make the concepts more accessible to, and acceptable by, managed care reviewers. This approach has a valuable intellectual provenance (Dollard & Miller, 1950) and also may make the similarity between orientations more clear than they would be if differing languages were used. It is made clear that this is a legitimate presentation of terms in their near-equivalents and not an attempt to misrepresent the nature of the practice. For example, referring to interpretation as reattribution does not change the treatment, but it may make it more acceptable to a reviewer. This approach then is illustrated by providing parallel case reports, one in psychodynamic language and the other in managed care language. I don’t think violence is done to the cases by the rewording in either of the two examples and, if anything, the reports presented may still be longer than necessary for a managed care company.

In reviewing short term therapy principles, which are vital to much of the care offered through managed care, the authors point out, correctly, that the ego-confrontive stance of short term therapy does not refer to an aggressive approach, but to a willingness to deal actively and rapidly with conflict, defense, and affect. I wish that they also would have pointed out that an ego-supportive stance, which also is used frequently in short term work, does not refer simply to being nice to the patient, but to supporting ego functions.

I was particularly taken by the issue of the use of outcome measures in psychodynamic practice. Although this is not necessary for managed care (it might be a helpful supplement to a treatment report), it is necessary for the development and acceptance of psychodynamic practice. The reluctance of many practitioners to engage in a formal evaluation of their services has led to accusations that the treatment is not effective, and the burden has to be on those who practice to demonstrate the worth of their services. I have no doubt that this can be done, and wish it was done more widely and generally. There are problems. Self-report measures, which are easiest to employ, do not capture the depth of change that occurs in a sound psychodynamic treatment. The introduction of evaluation materials can affect the treatment itself, but I think this is less likely if it occurs from the beginning, where it will be accepted as part and parcel of treatment as usual. Along this line, the very interesting point is made that the therapist’s response often is more intense than that of the patient, and it is that response that may affect the treatment even more than the managed care incursion does. After all, we know what usually happens in the treatment, but the patient often does not, and will accept whatever structure is presented unless our countertransference creates difficulty in the treatment.

What can I say in summary? I would like to be able to treat my patients in any way that I view as clinically desirable, for whatever length of time is clinically indicated, and for whatever fee is fair and mutually agreeable, and not to have to tell anybody anything about what is transpiring. I also am aware that if my patient presented a parallel wish (to do whatever he wanted whenever he wanted to, with no external constraints, and with whatever rewards he desired), I would recognize the character pathology involved and see it as an appropriate focus of psychotherapy. Sperling et.al., outline three possible stances to managed care: 1) To approach it with assimilation and accommodation, becoming part of the process; 2) To approach it with assimilation; and 3) To reject it. Those in the first group will not need this book. Those in the third group will view the title as an oxymoron and are unlikely to read it. However, the growing number of clinicians in the second group will find it a useful and well-informed guide to contemporary practice, like it or not.

Alexander, F., & French, T. (1946). Psychoanalytic therapy. New York: Ronald Press.
Dollard, J., & Miller, N. E. (1950). Personality and psychotherapy. New York: McGraw-Hill.
Gold, J., & Stricker, G. (2001). Relational psychoanalysis as a foundation of assimilative integration.
Journal of Psychotherapy Integration, 11, 43-58.
Menninger, K. (1958). Theory of psychoanalytic technique. New York: Basic Books.
Menninger, K., & Holzman, P. S. (1973). Theory of psychoanalytic technique. New York: Basic Books.
Messer, S. B., & Warren, C. S. (1995). Models of brief psychodynamic therapy: A comparative approach (Vol. 41). New York: NY: Guilford.
Stricker, G. (1983). Peer review systems in psychotherapy. In B. D. Sales (Ed.), The professional
psychologist’s handbook (pp. 533-545). New York: Plenum.
Stricker, G., & Gold, J. R. (1996). Psychotherapy integration: An assimilative, psychodynamic approach. Clinical Psychology: Science and Practice, 3, 47-58.

George Stricker is Distinguished Research Professor of Psychology in the Derner Institute, Adelphi University. He is a Diplomate in Clinical Psychology and was elected as a Distinguished Practitioner in Psychology. His recent awards have included the National Council of Schools and Programs of Professional Psychology Award for Distinguished Contribution to Education and Professional Psychology in 1998, and the Allen V. Williams, Jr. Memorial Award from the New York State Psychological Association in 1999. Dr. Stricker is the author or editor of about 20 books, about 30 book chapters, and more than 100 journal articles. He currently serves as the Chair of the Fellows Committee of the Division.

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