As recently as 1960, before the onset of managed mental health care, the roles of psychiatrists, psychologists, and clinical social workers tended to be distinct. Psychiatrists had the overall responsibility of patient care, conducted psychotherapy, prescribed medication, and supervised hospital care. Clinical psychologists conducted testing and provided group therapy and other therapeutic modalities in institutions and hospitals. Clinical social workers performed comprehensive psychosocial assessments, counseled regarding family issues, and created discharge plans for patients in social services agencies.
At that time, the mental health field was far from overcrowded. With psychiatrists’ shift in emphasis, clinical social workers and clinical psychologists assumed more responsibility in mental health treatment, and psychotherapy, in particular. The proliferation of managed care companies during the 1980s furthered the increased involvement of clinical social workers and clinical psychologists. Because of improved training and the less-expensive nature of their services, clinical social workers and clinical psychologists were more involved in providing psychotherapy to patients suffering from mental illness. (Committee on Therapy, Group for the Advancement of Psychiatry, 1992). Conflict in Roles
According to Gibelman & Schervish managed health care companies have continued this trend of expanding the roles and responsibilities of nonmedical providers–primarily clinical social workers and clinical psychologists–while narrowing the scope of psychiatric practice. Managed health care companies see clinical social workers in particular as an economical, substitutable source of labor for both clinical psychologists and psychiatrists in the treatment of patients suffering from mental illness. Presently, clinical social workers provide a wide array of services to clients with mental illness in a variety of settings and at all functional levels of practice. Clinical social workers practice in institutions, hospitals, school systems, clinics, correctional facilities, and private practices. They function in positions of direct service, supervision, management, policy development, research, community organization, and education and training. Clinical social workers frequently perform assessments and arrange and develop services. In these roles they serve as gatekeepers and treatment providers.
For some time, clinical social workers have performed the largest portion of psychotherapeutic work done in the United States. Clinical social workers provide as much as 65 percent of all psychotherapy and mental health services (1997). Payers have begun to ask, “What type of therapist is the most cost-effective?” and “What is the advantage of paying one profession higher fees than another for rendering the same service?” when an objective review of empirical studies shows that there is no absolute proof that one profession can perform psychotherapy better than another. Such research leads managed care companies to conclude that many of the cheaper sources of labor in the mental health field, such as clinical social workers, are as effective in administering treatment to patients suffering from mental illness as other more-expensive practitioners (Gibelman & Schervish, 1997) Individual verse Group Practice
With managed care’s influence, outpatient treatment, and private practice, in particular, has become a viable and increasingly important role for clinical social workers. Although mental health clinics and other institutions provide the greatest opportunity for clinical social workers, a growing number are now carrying out services in a primary setting of solo or group private practice (Gibelman & Schervish, 1996). In 1995, 19.7 percent of NASW members cited private solo and group as their primary practice, and 45.5 percent as their secondary practice setting (Gibelman & Schervish, 1997). Findings indicate that the proportion of clinical social workers entering and practicing as private practitioners continues to grow (Gibelman & Schervish, 1996).
The future treatment of patients in solo private practice may be in jeopardy, as managed care companies force clinical social workers and other mental health care providers to join group practices. In group practices, clinical social workers, in combination with other mental health practitioners, provide individual and group therapy, family interventions, and a variety of other services, all through one office (Shera, 1996). These groups provide “one-stop shopping,” as well as greater access to less-expensive professionals, such as master’s-level clinical social workers. Managed care companies find that group practices are more efficient and cost-effective in the management of a population of patients (Johnson, 1995). As managed care companies continue to reduce reimbursement dollars, changes in multidisciplinary team structures are inevitable, with even more reliance on master’s-level service providers.
Practitioner distinctions already have begun to diminish in favor of more team-oriented models, with the boundaries between the uniqueness of the individual disciplines beginning to blur (Eubanks, Goldberg, & Fox, 1996). Psychiatrists often head the team, coordinating services in conjunction with psychotherapists and other mental health care providers on the treatment team. However, it is not unusual for a clinical psychologist or even a clinical social worker to lead the team, with the psychiatrist relegated to the role of psychopharmacology consultant rather than an active team member (Brooks & Riley, 1996). Treatment
In addition to changing the role of mental health practitioners and the structure of treatment teams, managed care has forced the clinical social work profession and the mental health field in general, to examine how its members provide care. Managed care companies are exploring new ways they can provide the most effective services to more people under increasing resource constraints (Shera, 1996). The transition from fee-for-service to managed mental health care services has created an entirely new culture for mental health care providers and consumers (Geller, 1996). Practitioners must accommodate their treatment to the preferences of managed care. Otherwise, they risk a decrease in referrals, which could ultimately lead to loss of status and income. Managed health care companies have exerted influence on the ways that mental health practitioners conceptualize their practice, forcing treaters to modify therapeutic interventions and practice protocols significantly (Shera, 1996).
Brief therapy now appears to be the preferred mode of intervention (Gibelman & Schervish, 1996). Long-term psychotherapy has been virtually eliminated for all but private-pay patients. Managed care companies find that studies of short- and long-term therapy suggest that brief approaches are as good as or better than long-term treatment, except in special cases (Lazarus, 1996). The majority of interventions distinguishing themselves in comparative outcome studies are based on behavioral or cognitive-behavioral theories. These treatments tend to be goal- and present-oriented, behaviorally specific, symptom-directive, advice giving, educational, collaborative, and aimed toward the resolution or amelioration of symptoms in relatively brief periods (Johnson, 1995). The shift in preference to brief modes of therapy by managed care organizations has changed expectations for therapists. Theoretical orientation of practitioners has become of great interest as managed care companies look for practitioners who use brief treatment methods (Giles, 1993).
The practitioners most significantly affected by managed care’s shift in preferred mode of treatment have been those who provide the extensive and intensive treatments of psychoanalysis and psychodynamic psychotherapy, predominantly clinical psychologists. Their emphasis on Freudian psychotherapies, which generally have a very long duration of outpatient care and discouraging results in the outcome literature, have been, criticized heavily (Giles, 1993). Emerging models of psychotherapy endorsed by managed care organizations assume that the psychotherapeutic process occurs in pieces over time. In these models, psychotherapy functions as an active working relationship between the patient and the therapist, whereby the goal is defined as change rather than cure. Managed care companies’ focus on resolving patients’ acute symptoms, rather than ridding them of their mental health conditions, has led to the gradual disappearance of the use of the psychodynamic model as the dominant framework in the treatment of individuals suffering from mental illness (Edwards, 1997).
Recently, group treatments have received attention as a cost-effective means of treatment (Iglehart, 1994). A group format allows a number of patients struggling with similar life issues to come together and benefit by interacting with one another and a therapist, the group leader (Shapiro, 1995). Managed care companies support group designs, relying on numerous studies that demonstrate the efficacy of short-term therapeutic groups using behavioral and cognitive-behavioral approaches. Managed care organizations find group treatment inexpensive relative to other treatment methods, because one practitioner can treat many clients at once, significantly reducing billable hours of treatment incurred. The potential of group treatment to alleviate the psychological problems of large numbers of people at relatively low cost makes group therapy an attractive option for managed care companies (). Despite the utility gains, however, managed care companies do not rely on group treatments as widely as might be expected, primarily because of patients’ resistance to group treatment.
Some patients find the idea of group treatment difficult to accept because they have a hard time understanding how they will benefit. Many patients prefer individual treatment sessions, where they have the therapist’s undivided attention. These patients may be embarrassed about their problems and reject the notion of others besides their therapist providing input. The logistics of setting up short-term groups, along with current therapist practice patterns, present additional impediments to managed care’s use of group therapy (Crespi, 1997). Nevertheless, the immediate cost-effectiveness of groups, coupled with documented positive outcomes, has made the modality particularly appealing in mental health delivery systems and provides a compelling argument for their use (Crespi,1997). Projection
Managed health care organizations have influenced the delivery of services in the mental health field considerably and will undoubtedly continue to do so (Eubanks et al., 1996). Whether the developments instituted by managed care companies are greeted with pleasure, indifference, or hostility, general agreement exists that the treatment of patients suffering from mental illness will be irrevocably changed as managed care continues to alter drastically the delivery, definition, and outcome of treatment that patients receive. In the future, indicators (Iglehart, 1994) suggest that nonpsychiatric practitioners will emerge as the dominant providers of treatment. According to Giles (1993), managed care companies will expect nonmedical practitioners, such as clinical social workers to provide the bulk of outpatient care in the mental health care field. Clinical social workers are cost-effective, fully qualified providers of mental health care services in the eyes of managed care companies.
Distinctions between master’s-level and doctoral-level providers will become more evident as master’s-level practitioners assume primary responsibility for direct mental health services, and doctoral-level providers assume more administrative, supervisory, and research-oriented roles (Crespi, 1997). The rapid increase in managed care’s influence, accompanied by the reduction of referrals to more-expensive specialists, suggests that demand for clinical psychologists will continue to diminish (Johnson, 1997). As managed health care organizations restrict consumer choice of providers, many mental health professionals, such as clinical psychologists, may have difficulty joining reimbursement plans (Gibelman & Schervish, 1997).
Despite the shift away from doctoral-level providers and the narrowing role of the medical practitioner in the treatment regime of managed care companies, psychiatrists will likely have an essential and continuing role in the mental health care system. According to Giles (1993), managed mental health care still needs medical practitioners for their knowledge of psychopharmacology and experience in prescribing medications. Scientific literature has demonstrated that psychotropic medications are an effective and essential treatment component for most psychiatric illnesses, and psychiatrists, being physicians, are currently the only ones who can prescribe these drugs with the knowledge to do so effectively. Another likely development with the influence of managed health care is the rarity of the solo practitioner (Crespi, 1997). Individual practitioners and small group practices will likely remain, but will probably represent a much smaller proportion of psychotherapists (Committee on Therapy, 1992).
With commentators predicting a demise in solo private practice, practitioners will either have to affiliate with managed mental health care groups or forego clients with insurance in favor of those able to afford private payment (Gibelman & Schervish, 1996). The psychotherapist who decides to operate outside of the managed care system faces not only a degree of professional isolation, but also limitations in referrals and remuneration (Committee on Therapy). The managed care initiatives sweeping the nation have profoundly affected the ways that clinical social workers and other mental health practitioners deliver services to people suffering from mental illness (Shera, 1996). As these changes continue, clinicians working in a managed care environment will more often practice time-limited psychotherapeutic interventions and, in all but the rarest cases, the practice of unregimented intensive psychotherapy and psychoanalysis will take place outside of the confines of the managed care arena.
For the majority of mental health care consumers, therapeutic work will focus on precipitating stressors and acute exacerbation that may be treated within the reimbursable framework (Committee on Therapy, 1992; Crespi, 1997). Finally, with managed care’s increasing influence, use of outcome measurement and management will continue. Quantifiable data will play a larger role in treatment decisions. Funding sources of mental health care services will increasingly seek quantitative methods to measure the quality and efficiency of different interventions to guide their purchasing decisions (Johnson, 1997). As managed care companies look for hard data to determine the most effective professionals and treatments, mental health care providers will have to quantitatively demonstrate effectiveness of interventions and treatment through evidence of patient improvement (Gibelman & Schervish, 1996). Thus, the ability to implement and participate in outcomes measurement processes is vital for any practitioner who wishes to operate in the managed care environment. Conclusion
Despite widespread criticism and various efforts at reform, managed care companies continue to expand. Clinical social workers currently involved in the mental health field, as well as incoming social work students interested in mental health, must take heed of the rapid developments in the field. Although the changes resulting from the influence of managed care present many challenges, they also create many opportunities for mental health care providers, and for clinical social workers in particular. To take advantage of these opportunities, clinical social workers, and the institutions educating them, must be prepared (Geller, 1996). Many clinicians currently practicing, as well as current and incoming graduate students, lack information on the breadth of these developments (Crespi, 1997).
Clinical social workers must actively seek out continuing education courses, conferences, and journal articles discussing developments in the field related to managed mental health care to be better informed. In addition, schools of social work must update their curricula for incoming students to reflect the realities of changes in managed care. Graduate schools must educate future social workers regarding developments, providing students with the information and skills necessary to survive in this evolving culture (Shera, 1996). Many social work programs are discovering that traditional curricula are no longer adequate to prepare students for practice in the era of managed care. Managed care’s emphasis on the provision of mental health services at contained costs requires specialized practice skills, particularly rapid assessment, brief treatment, and the ability to document treatment outcomes. Social work educators must incorporate these elements into their programs.
As managed care continues to expand and evolve, social work educators need to continue to evaluate its effect on the training of current and potential clinical social workers. Educators in the field, along with graduate school instructors and administrators, must make the necessary changes to provide clinical social workers with the ability to adapt to the changing environment. Collaboration with managed care is necessary for professional survival (Eubanks et al., 1996). Clinical social workers have an enormous role in the treatment of people suffering from mental illness and have a real opportunity to play a major role in managed mental health care (Shera, 1996). Clinical social workers must rise to the challenge.