To the Editor

After years of training and experience, clinicians often feel that they know what is best for their patients. By and large they do, but Eric Plakun, in “Jihad, McWorld and Enactment in the Post-Modern Mental Health World” (Fall 2002 issue) argues that discussing the financial limitations of managed care can actually enhance the therapeutic process through metaphor and reality testing. After completing a recent research study, “The Elephant in the Room: How Therapists View Managed Care's Effect on the Practice of Psychotherapy” (an unpublished work for my undergraduate thesis), I am drawn to a conclusion different from Plakun's. The study, in which I conducted in-depth interviews with therapists about their experiences with managed care, revealed that most therapists felt that the stance of managed care, in which cost containment is the primary consideration, is fundamentally in conflict with therapists' commitment to providing quality care for their patients. In his article, Plakun says that, like the environmental movement, there is a moral imperative behind resource limitation. The therapists interviewed in the study believed otherwise.

An equally serious concern among those interviewed was the adverse impact the managed care perspective can have on the societal sense of what therapy is about. Patients may believe that the structure and priorities set by the managed care system have a legitimacy that supercedes both their own sense of personal need and that of the therapist. Some patients use the number of sessions stipulated in their insurance benefit as a guidepost for how long therapy should take. It is difficult for individuals without training or expertise to discern which plans are genuinely better. Patients, especially those seeking psychotherapy for the first time, usually do not know what to expect or how much treatment they deserve through their insurance. Furthermore, study participants said, some patients are inclined to accept whatever therapist they a