Managed Care:
Can the Marketplace Co-Opt the
Search for Truth?

Most psychologists enter the field because we are fascinated by the mysteries of human behavior. Why did he/she do this? Why did they do that? Every school/branch of psychology has its unique answers. Psychoanalysis, behaviorism, biopsychology, cognitive psychology, evolutionary psychology all have different tenets, different ways of explaining and understanding these mysteries. The merits of these tenets have and will always be subject to debate. This debate is healthy--it is part of the scientific process that ultimately will lead to a more complete understanding of the human condition, and perhaps better ways of helping those who are in psychological distress.

In my younger, idealistic days, I thought there was no way the marketplace could co-opt this healthy debate, co-opt the goals of science itself, but I now see that I was wrong. Let's look at the effect managed care has had on my field, clinical psychology.

When managed care first appeared psychologists were invited to apply to be service providers for the managed care companies. One of the critical questions on the application forms was: what was the average number of sessions you see clients before termination. If you said more than, say ten, you were immediately rejected. The reason: managed care companies could not pay for longer therapy without it affecting their bottom line.

What was the result? First, the provider panels were filled with therapists who believed strongly in short-term therapy (and with therapists who lied on the forms to be accepted into the panels because their economic livelihood was at stake). Since managed care would not pay for any out of network therapy, and the gateway into therapy was through managed care, therapy was suddenly re-defined for the consumer as a treatment lasting three to five sessions. Often, in my heated debates with managed care companies I was told: "What you provide is deluxe therapy--we can't afford to pay for that." And I would answer back: "O.K.. Fine. I'm not asking you pay for that--I'm just asking you to put in your brochures: we offer three to five sessions for most common psychological problems. Sorry, no deluxe therapy." I pointed out that these brochures were like the sweepstakes letters received in the mail: "You have won one of three prizes: $1,000,000 in cash, a ten day all expenses paid trip to Hawaii, or a luxury yacht. Just send in your $29.95 and we will let you know which prize you have won." Of course, everyone who sends in money receives a cheap, rubber raft, with the words: "Luxury Yacht" stenciled on the side. No one at the managed care companies was ever amused.

Gag rules made matters worse. Therapists were not allowed to be critical of the managed care companies or to tell clients that they were not receiving adequate treatment. If you did you would be thrown off the panel. The party line: therapy was what happened during those three to five sessions--anything else was unnecessary.

Did this effect what people were taught in graduate school? You bet. Boston University, for decades a bastion of long-term psychoanalytic psychology, did a complete reshuffle. Was this because short-term therapy had been proven to be more effective than long-term? No. They had to change because their graduates were not going to be able to make a living doing long-term therapy.

The field of clinical psychology has changed entirely, not because of new scientific discoveries but as a result of economics and marketplace reality. Managed care companies will always promote ignorance for the sake of their bottom line unless they are compelled not to. Because these companies have blackmailed a generation of therapists with their threats, they hold tremendous power. It is urgent that the consumer recognize this. When we think we have been told the "truth" about therapy, or about the adequacy of medical treatment in general, we must always consider the source.

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