It is also important to any new authoritarian power to control the education of the young, so that new generations learn only what the regime wants them to learn, and no one has any memory of any other way to think. The managed care industry applies the same principles--not through banishment, incarceration and murder, of course, but through forcing the opposition out of work, intimidating a majority into submission, and taking over the education of the new generation of mental health clinicians.

Jerry Rubin, one of the Chicago Seven tried for inciting a riot outside the Democratic National Convention in 1968 in a protest against the war in Vietnam, once said: "The power to define the situation is the ultimate power." Indeed.

Managed care is defining psychological treatment and the role of psychologists, and I am saddened to report that psychology's graduate schools, with only a few exceptions, are adapting to the industry's definitions of treatment and the demands of the "marketplace," rather than fighting for an end to the industry's economic murder of academic freedom and clinical wisdom. This adaptation by psychology includes neglecting intensive, inner-focused psychotherapy, teaching business principles and managed care financial arrangements in order to work in managed care, and learning to develop group practices that will take case rates or capitated contracts. These adaptations are meant to help psychologists "survive." Unfortunately, this is a short-sighted solution that, in the long run, will help managed care bring Clinical Psychology to its death as a major and significant clinical profession. If repeated in all our professions, we will soon have a generation of therapists who have no memory of how to do any intensive inpatient or outpatient treatments.

As a member of the Training Committee at Long Island's V.A. Medical Center, I interview applicants for our internship positions in a group interview format. In these groups, applicants used to talk about patients they have worked with, people, what psychotherapy is about, what is helpful to patients. One of my colleagues commented that it doesn't seem that recent applicants have any idea that they are coming to the V.A. to work with people. My own perception is that they are sounding more and more like robots or accountants (no offense meant to any accountants out there--accountants should sound like accountants, but psychologists shouldn't). The applicants are talking about "techniques," research, neuropsychology and about "being marketable." Once in a while one will say. "I want to work psychodynamically because it's so important," yet he or she also clearly recognizes that this may be impossible. And the others giggle. I'm not sure why. As a group, the applicants also seem less insightful about themselves than applicants were just a few short years ago. Further, it is increasingly common that our interns have gotten through four years of graduate school without ever having spent more than 12 or 15 sessions with any given patient, and they haven't the faintest idea what to do beyond that number of sessions.

I also want to inform you of two disturbing reports our V.A. Internship Training Committee recently received, as did many other Internship sites and graduate schools around the country. The major report is titled: "Final Report of the APA (American Psychological Association) Working Group on the Implications of Changes in the Health Care Delivery System for the Education, Training and Continuing Professional Education of Psychologists." The authors are Jean Spruill Jessica Kohout, and Sheila Gehlmann. The companion report is smaller and has almost the same title, substituting the word "Impact" for "Implications," and the authors are Kohout and Gehimann. These reports can be obtained from the APA by calling (202) 336-5980. All quotes and citations below will be from the major report by Spruill et al.

Before informing you of the contents of the report, I want to clarify that the paper clearly states that the report is, "not meant to reflect a policy statement of the American Psychological Association with respect to organized systems of care and training of graduate students" (p. 1). Further, the report was not commissioned by APA, but by the Center for Mental Health Services, a federal agency, and it was apparently handled by APA's Education Directorate and Research Office, and not by the Practice Directorate (pp. 2 & 3 of the "Impact" report).

To obtain information on graduate training needs and then feedback on preliminary recommendations, the Working Group surveyed the leadership of the Practice Divisions, State Psychological Associations, The Council of Graduate Departments of Psychology, The Association of Psychology Postdoctoral and Internship Centers, the Association of Medical School Psychologists, and the Association of V.A. Chief Psychologists, as well as recent graduates and others.  The purpose of the contract was to "draft recommendations for changes in the education and training of psychologists at the doctoral, internship, postdoctoral, and continuing education/professional development stages for the delivery of services in the emerging health care systems" (p. 1). The Working Group stated that the purpose of the report was to address training needs for psychologists who likely will have to work within an organized care setting when they begin their career (p. 2).

What has been happening in graduate psychology programs is a submissive yielding to managed care and the call of "the market-place," a focus on "empirically-validated techniques," and an abandonment of traditional, clinically-informed theories and therapies, especially psychodynamic or humanistic theories and treatments. Graduate schools feel they must "prepare students for the market-place" with techniques that are backed by a rigid, objective "science" that does not do justice to the human mind, rather than prepare them for the real and complex people with real and complex problems who will seek their help. Even the strongest and most proud psychoanalytically-oriented programs have changed their focus to satisfy, demands of managed care.

An artificial economic power has coerced these changes against the clinical experience of practitioners. And this is resulting in a new generation of psychologists who have little insight into themselves or into their patients, and who will be more likely to work as objective scientists in their clinical work rather than as scientifically-informed whole human beings. And they will be less likely to doubt the rightness of the marketplace, as they will professionally grow up with no memory of any other way to work. As those of us who remember intensive therapy retire and die off or are pushed out of practice and out of graduate faculties, there will be no one left who thinks a fight is warranted. By "banishing" its opposition, i.e., driving them out of work and out of the field, managed care ensures its success, just as imprisoning or killing off all potential protesters helps authoritarian regimes hold on to their power and control.

Before I highlight a few quotes from the main report, I want to say that I think this is a very excellent report, accurate in that it does predict what psychologists will need to learn, assuming that managed care will continue to dominate the "marketplace" and that there will be little private practice and only a small self-pay market. Where I believe the report is inaccurate is in its optimistic belief that many psychologists will be employed in the ways they predict. My own guess is that Clinical Psychology, if managed care continues, will wither and die, for few will be able, on such low reimbursement rates, to pay back the student loans of $50,000-90,000 that doctoral training often requires, and the "industry" will only require a handful of doctorally-trained psychologists to do the tasks the Working Group outlines. Further, a large portion of excellent people who would want to become clinicians will not be attracted to what Psychology is becoming.

At this point, I will quote from the Final Report without comment. I believe the quotes will speak for themselves:

1.  "The focus of our training will need to be changed because it is unlikely that professional psychologists in the future will be solely, or even primarily, direct service providers..." (p. 7).

2.  "… psychologists of the future are more likely to spend more of their time in training and supervising other mental health professionals in the provision of clinical services. They will design and evaluate programs, design quality management activities, develop screening instruments, treatment interventions, treatment planning modules, and outcomes assessment for various populations…" (p. 8).

3.  "In making changes, the programs will need to become sensitive to market demands for professional psychologists and be flexible in adapting their training to society's workforce needs" (p 9).

4.  "Psychologists will do fewer direct services in the future. Instead they will develop treatment protocols, which they will teach others to carry out; will supervise the services of psychological extenders and other mental health professionals..." (p. 39).

5.  "The changing health delivery model increasingly thrusts the psychologist into a leadership role in which he/she manages or directs a team of professionals.  Capitated and contract methods of behavioral service delivery allow the doctor to utilize bachelors and masters-level assistants in a cost effective manner that has previously been prohibited by federal and private payers.  These dramatic changes present significantly expanded opportunities for psychologists to compete in an efficiency driven market in which they will develop enhanced psychological methods and delivery systems to utilize finite resources to reach large numbers of patients" (p. 39).

6.  Summarized from pages 39-44: Supervised experience supervising others increasingly will become a necessary part of clinical training.... Internship experiences should expand and enhance the MCO and managed care training that was acquired during graduate school.... Practica should include experiences as a case manager or team leader making decisions to apply a particular modality based on the admitting diagnosis and clinical need.  For training programs that elect to create an MCO environment when training in an MCO cannot be obtained, programs should.... Select cases that lend themselves to short-term interventions, limit treatment to a pre-specified number of sessions; have students justify additional sessions; have students serve as reviewers for granting additional sessions; have students supervise other students; develop provider profiles of their caseloads....

7.  "Professional psychologists are trained to do individual evaluation and differential diagnosis to determine what kind of intervention or treatment is most appropriate from the full range of psychological treatments available.  Once that determination is made, a number of other providers have intervention training and can provide the services required, and can provide the services required, either independently or under the supervision of others" (p. 45).

8.  "MCOs are concerned about therapists' attitudes because their negative attitudes are easily conveyed to patients.  An attitude of shared commitment to shared goals ensures far better functioning and promotes self-initiated quality efforts on the part of sub-contractors. If the client perceives an unfavorable attitude on the part of the provider/therapist towards the MCO, this will get back to the employer and raise problems for the MCO and subsequently for the therapist/provider.   A collegial attitude helps in working with case managers--you can disagree and still get along" (p. 59).

9.  "As much as we may wish otherwise, psychology has become a business, and psychotherapy is one of our products.  To be competitive in the evolving healthcare market, we must have products other than psychotherapy.  We need to understand and accept that psychology has become a business and learn how to market psychology, its products, and ourselves to MCOs and the public" (p. 60).

10.  In various parts of the report, graduate programs are urged to forge new relationships between their programs and managed care organizations in their communities, including having MCO executives come into the classroom to teach graduate students.

I know that given this description of psychology and graduate training, I would never have gone into psychology, for what is described holds no interest for me and ignores everything I value as a person who wants to try to heal people in emotional pain.

What I want to know is: Where is the "Final Report of the APA Working Group on the Overthrow of Managed Care Industry's Control over the Health Care Delivery System"? Where is the "Final Report of the APA Working Group on the Violation by Managed Care Companies of Professional Ethics and Humanistic Values"? Where is the "Final Report of the APA Working Group on the Development of Pro-Quality, Pro-Consumer Alternatives to Managed Care"? And please do substitute for "APA" the letters for any of the other mental health professions. Where is the collaboration of all our disciplines for a "Final Report from the Professional and Consumer Communities on the Development of Pro-quality, Pro-consumer Alternatives to Managed Care"?

As Jerry Rubin warned, the power to define the situation is, indeed, the ultimate power.  Graduate programs in psychology seem to be allowing managed care to define psychology, and psychology's graduate programs are following managed care's lead, rather than relying on their storehouse of scientific and clinical experience and protesting that "the marketplace" is out of control.

Interestingly, in an article in the American Psychiatric Association's Psychiatric News (1/16/97, pp. 3, 32), current President, Herbert Sacks, M.D., wrote an article about the current debate over practice guidelines for patients with panic disorder.   Apparently, early drafts of the guidelines focused on "evidence-based" treatments.  Apparently, enough psychiatrists criticized these guidelines. Dr. Sacks reported that the sixth draft had included "extensive and detailed responses ... from senior professors and outstanding clinicians who have contributed widely to the literature and to the teaching of psychodynamic psychotherapy to medical students and psychiatric residents.... The guideline section on psychiatric management was recast, providing richer descriptions of psychotherapy's role.  Cognitive-behavioral therapy, developed by psychiatrists, is now more appropriately balanced by the discussion of psychodynamic psychotherapy" (p. 3).  Sacks stated that, from the outset of the project, the APA's position "has been that evidence utilized will be of two forms: clinical research and clinical consensus based upon decades of experience" (p. 3).  It is this area of "clinical consensus based upon decades of experience" that is not at all valued by managed care.  It is "clinical consensus based upon decades of experience" that we must fight for in both inpatient and outpatient treatments of all kinds.

Take warning from the "Final Report" described above. Managed Care will change Psychology to suit its own selfish purposes, and our graduate programs have already largely caved in to their demands. Psychiatrists and social workers tell me that the same kinds of things are happening in their graduate training programs. Further, to complete the control over training and education, managed care companies are increasingly developing practica and internship sites for professionals in training.   I used to half-joke that we will soon see the industry buying or building their own graduate programs.  The Managed Care University School of Professional Psychology will be here soon unless each of you becomes far more involved in the fight to preserve quality treatment and the professions.  Before we "market" psychology, we should focus solely on defeating and replacing managed care with pro-consumer, pro-quality alternative systems of insurance, for it doesn't matter how superb our marketing campaign is, the majority of consumers will still not have the freedom or the money to choose us.

All our professions need to take back the power to define their work.   I see a potential direction from Social Work.  The Winter, 1997 edition of the Clinical Social Work Federation's Progress Report (pp. 1, 20) includes an article by Denny McGihon, Ph.D., National Representative for Government Affairs in the CSWF (and a Coalition member) that describes the efforts of the American Association of State Social Work Boards to define the scope of practice of BSW's and MSW's, and to distinguish them from Clinical Social Workers.  Dr. McGihon's article states that the clinical social workers have created a "Model State Social Work Practice Act."   This Act defines the scope of practice in psychotherapy as limited to clinical social workers but not to licensed BSWs or licensed MSWs who are not trained as clinical social workers.  Further, what I greatly admire is the Model Practice Act's definition of psychotherapy: "Psychotherapy means the use of treatment methods utilizing a specialized, formal interaction between a Clinical Social Worker and an individual, couple, family, or group in which a therapeutic relationship is established, maintained and sustained to understand unconscious processes, intrapersonal, interpersonal and psychosocial dynamics, and the diagnosis and treatment of mental, emotional, and behavioral disorders, conditions, and addictions" (p. 1, quoting from p. 14 of the Model Practice Act).  This definition of psychotherapy appropriately goes well beyond managed care's limited "behavioral health care" model, for it includes things emotional, unconscious, interpersonal, and intrapersonal, as well as behavioral.

We can no longer allow business interests to define psychotherapy or any other form of mental health treatment.  All our professions must join together to define our work and our training programs so that future generations of professionals will be able to fully meet the needs of real human beings in pain who will seek mental health services.   We must do this while there are still practicing clinicians left who remember how to do intensive treatments. 

Dr. Shore is President of the National Coalition of Mental Health Professionals and Consumers, an organization that works to bring public attention to problems and abuses in the current health-care system and to find workable alternatives to managed care. This article was originally published in the newsletter of the National Coalition. It is reprinted with permission. The address of the National Coalition is: P.O. Box 438, Commack, New York, USA, 11725. Telephone: (888) 729-6662. Email: NCMHPC@aol.com Website: www.nomanagedcare.org

The Legal, Ethical, and Professional Issues Committee agrees wholeheartedly with Karen Shore’s articulate account of what is wrong with the current “health-care delivery system" and how our graduate programs and professional organizations are failing. Where we differ is with regard to her conclusions about the best way of solving the problems she describes. Dr. Shore and the National Coalition support the establishment of alternative systems of insurance to cover psychoanalysis and all other forms of psychotherapy--which they see as health care services.  In contrast, the Academy supports the redefinition of psychoanalysis as an art rather than a health care profession, and many of our members reject third-party payment as an intrusion into the necessary privacy of the analytic encounter. This harrowing, "heads-up" report invites us all to become more active in the search for solutions.

Legal,  Ethical,  and  Professional  Issues  in  Psychoanalysis  and  Psychotherapy