The Heart of the Matter: An Essay about the Effects of Managed Care on Family Therapy with Children*

Abstract

This essay is based on a pilot study that examined the effects of managed care on the treatment of children and families, with special attention to community mental health. We embarked on the pilot study to test the accuracy and generalizability of our impression that family therapy and other systemic practices have been marginalized in ordinary clinics and agencies, and to understand the reasons why. We interviewed managed care providers, researchers, family therapy trainers, and clinicians in the Northeast. Our findings led to seven themes that support our impression that, even though there is a consensus about the need for coordinated family-based services, there is a disconnection between state policies, contractual requirements and what is actually occurring at the implementation level. This study suggests that our knowledge of human systems may be in danger of being disqualified and lost, with damaging consequences for the care of children. Yet, as systemic thinkers and practitioners, it is our belief that ethical and effective treatment need not be at odds with care that is cost-efficient. The direction of our future research will be to study whether the involvement of all stakeholders at all levels of planning and training leads to systemic family-based practices that consistently save costs and provide high-quality care.

Taking it to the Streets: Family Therapy and Family‐Centered Services

“…I will undertake both a personal and professional accounting of the interface of family therapy and frontline public sector practice. More than 10 years ago, Pulleyblank Coffey, Olson, and Sessions () documented the impact of managed care and other developments in public sector services on family therapy in community mental health centers. Based on interviews with managed care providers, researchers, family therapy trainers, and clinicians, they traced out intertwined trends of the medicalization of mental health, the rise of time consuming paperwork requirements, and funder reimbursement changes that encouraged agencies to move from salaried positions to “fee‐for‐service” positions in which clinicians are paid on an hourly basis for clients that they see.…”

“…So instead of me having a staff, I have a collection of entrepreneurs.” This trend contributed to greater isolation of clinicians, reduction in training in agencies, and encouragement of an atheoretical, primarily pragmatic approach to practice. Pulleyblank Coffee, Olson, and Sessions () concluded that family therapy's knowledge of human systems was in danger of being disqualified and lost with damaging consequences for the care of children. Since then, these trends have continued and have been exacerbated.…”

Expanding Systems Thinking: Incorporating Tools from Medical Sociology into MFT Education and Research

“…These dilemmas highlight the tension between the therapist's agency and the power of the managed care system. Additionally, research has shown that structures requiring systemic therapists to use the language of managed care (i.e., medically oriented) results in loss of knowledge of systemic theories, reduced complexity in therapeutic family treatment, and increased focus on decontextualized biological explanations and practice (Pullyblank Coffey, Olson, & Sessions, ).…”