The Elephant in the Consulting Room: Managed Care and the Practice of Psychotherapy

Therapists are constrained in many ways by managed care—by limits on the number of sessions, by restrictions on the problems that qualify for reimbursement, and by pressures to use inexpensive and brief forms of treatment. We ask how such constraints alter processes at the heart of therapy—how therapy begins and ends, how the therapist-client relationship develops, and how clients and therapists conceive of their work together. We addressed these issues through intensive interviews with sixteen therapists from diverse theoretical backgrounds. The interviews were analyzed using an interpretive approach derived from grounded theory (Glaser and Straus 1967).

For every therapist interviewed, some aspects of managed care were in conflict with their ethos of good care. This fundamental conflict was the root of deep discontent. Some reported that managed care restricted therapy to superficial goals and quick-fix solutions. Some reported that managed care policies disallow the types of therapy they deem most effective (e.g., psychodynamic therapies). Some could no longer continue various practices that promote and support client change, such as school consultations, family meetings, home visits, and formal clinical assessments. Such exclusions were based on financial considerations, not scientific evidence of efficacy.

Therapists also voiced a variety of ethical concerns. As they saw it, they often had to choose between honest reports about their clients and good care. To provide adequate care, they felt it necessary to conceal certain elements of their work, misrepresent diagnoses, and distort reports of clients' progress. Some therapists drew their clients into misrepresenting diagnoses and into other deceptions, a practice that may ultimately erode public confidence in the profession. Others found themselves bound by “gag” rules that prevent them from providing clients accurate information about their problems and their treatment.

Some therapists reported that client