Ideas and Managed Care - by Liam Marsh

Controlling the Origin of Psychological Ideas

Managed care is taking control of mental health and is making demands upon psychology's world of ideas. Psychological ideas are being gagged and tied by the emerging romance between professionally minded psychologists and their courtiers, the profit oriented managed care industry. In an effort to control costs, managed care is controlling the way therapy is practiced, emphasizing inexpensive and simple approaches to the psyche. As psychologists struggle to establish professional status in a competitive field, they are willingly agreeing to align their ideas and therapeutic techniques with the employment criteria of managed care. As a result, the job of the psychologist has become doing the public relations work of maintaining managed care's personas of scientific objectivity and therapeutic effectiveness, and in exchange they receive a slice of upper class pie.

Former APA president Nicholas Cummings, in a professional journal, supports well the financial interests of managed care as he calls on psychologists to change their therapeutic beliefs so that cost-effective techniques will be embraced by the psychotherapeutic community. In his article, "A Primer for Survival", he instructs psychologists to retrain and regroup themselves so that they may prosper as professionals in this new era of mental health. Arguing short-term therapies to be as effective as long-term ones, Cummings calls on psychotherapists to make essential paradigm shifts implementing these cost-effective methods. He believes that mental health can offer a variety of services which, if integrated well, can provide episodic soothing for people and families in need. Cummings correctly calls his article "A Primer for Survival", informing psychologists that if they wish to prosper as professionals in the field than they need to adapt themselves to employment demands of managed care.

Managed Care, Quackery, and Science

Managed Care has moved in and is making decisions as to what is science and what is quackery in the field of mental health. The "science" of effectiveness has become an afterthought, a rhetorical technique to justify the profession of healing being governed by managed care's want for profit. A parallel to this occurs in the medical profession. Ten years ago the art of chiropractic was continually criticized by the medical profession as being unscientific and ineffectual. Now, however, under the umbrella of managed care chiropractors have a new life as their services are seen as inexpensive alternatives to costly surgical solutions to chronic back problems. An even more extreme example of this is with acupuncture which until very recently was considered a voodoo practice from old-world China. Kaiser Permamente, however, in reaction to the competitive cost cutting atmosphere of the medical industry, has recently begun employing such practitioners and aggressively exploring "alternative" medical approaches.

The point here is that it is irrelevant whether acupuncture and chiropractic are effective. What is relevant is how these treatments effect the finances of the governing economic bodies. When doctors were in control of the medical profession, they stood to lose money if the populous viewed these practices as anything but quackery. Yet, now, as the economic dominus has shifted to insurance companies, the once ruling doctor is a costly expense, making a demand for less expensive and less professional options. Techniques of psychotherapy have traditionally been chosen by psychoanalysts and similar practitioners who had a vested interest in job securing long term therapies. Today, however, managed care is taking control of mental health and their investment is in inexpensive, short term therapies.

The Myth of Outcomes Research

Cummings correctly identifies the "skill" of outcomes research as being a very important component of the psychologist's "survival". Outcomes research is a scientific methodology which is taught to the graduate level academician and serves to give the illusion of objectively ascertaining the effectiveness of psychological interventions. The psychologist who can demonstrate, wearing the cloak of science, that the quick and inexpensive therapy is the effective therapy will be highly sought in the managed care industry. For it is this person who will ultimately argue the lie of managed care that we can be primarily concerned with money and still provide the best possible care for the needy or sick. The psychologist becomes the illusionist and mythically weaves the pseudoscience's outcomes research to sooth everyone's guilt and anxiety about their primary value of monetary gain. In their psychologist, managed care companies have the P.R. representative to defend their cost cutting managing. The psychologist is compensated by getting the coveted position of mental health professional and is still able to give lip service to the myth of healing. Class protects class and the world continues.

The problem with managed care is that the therapies are not chosen based on beliefs about healing effectiveness but rather based on cost effectiveness. Cummings writes, "A growing body of outcomes research demonstrates that efficient therapy can also be effective (Bennett, 1994)." The language here shows efficient (short-term) therapy to be a potential equal to non-efficient (long term) therapy. As used here, outcomes research does not seek to discover what is the most effective way of doing therapy but rather attempts to justify efficient therapy, arguing it to be effective. The value of outcomes research becomes clear, to rationalize managed care. When the scientist has an investment in the outcome of the research, we can not pretend that the scientist is operating within the myth of objectivity. The researcher has her professional livelihood at stake when her research results need to be agreeable with managed care. In the modern era of managed care the psychologist who can "prove" that efficient therapy is effective will have a job and the psychologist that demonstrates otherwise will not. In an atmosphere that combines profit minded managed care with a culture in which professional success has the utmost value, it is laughable to consider any research that would result as having meaning.

The Real Kook is Cummings

Even though Cummings is trying to live in the cold business consciousness of the managed care, he makes the typical Psychologist's emotional error of believing his ideas to be deeper than they really are. For Cummings it is not enough for the psychologist to kiss ass to get (a)head; as all business people do. He feels there needs to be a change in personality as well. He writes:

Over the past decade I have retrained literally hundreds of psychiatrists, psychologists, social workers, and counselors in a 130 hour module over a 2 week period and observed that for retraining to be successful there must be significant changes in the practitioner attitudes and belief systems.
He considers these new attitudes to be "enabling attitudes" and further emphasizes the deeper nature of his retraining when he quotes Balint's "monumental work", "...the acquisition of psychotherapeutic skill does not consist only of learning something new, it inevitably also entails ... a change in the doctor's personality."

Besides advertising his own courses, Cummings is suggesting that for the psychologist to survive professionally he must not only change his therapeutic approaches but also make a shift in his personality to meet managed care's need for greater profit. What is simply a need to change therapy methods, if you want to make money, somehow becomes a need for personality transformation. The enabling attitudes are the attitudes that enable you to ignore all fantasies of science, helping or healing so that you can embrace the image of professional prestige. Hopefully, for most of us, this would require a change in personality.

Marx Calls for Revolution

Marx writes that the ruling class, the class that controls resources and capital, also controls ideas. His belief is that even though people may think ideas to be the result of science, intuition, common sense, or revelation, ideas can actually be traced to historical and cultural currents which serve to reinforce and continue class structures. This old and simple analyses of the world of ideas is very visible today in the politics of managed care and their psychologist. The psychologist's job is to produce and maintain ideas which are congruent with the mental health political apparatus. The shadow here is that there is nothing scientific nor original in the origin of the professional's ideas. The ideas themselves are mere puppets pulled by the capital controlling class, serving their self protecting needs. For Marx, however, there is nothing new about managed care's control of ideas. Academia has well served this need since its inception. Money to the professional, professionalism to the educated, education to those with money. The only change is that managed care is now in direct charge of psychological ideas. The academic middleman is no longer the primary controller of ideas. Academia still has a role as an upper class filtration device, keeping the controlling class's population down, but the world of ideas is no longer theirs. Marx would have us believe that academia and science have never been in control. Capital interests have always led the way. With managed care, the psychologist is confronted with the reality of who is in charge of the ideas of their profession. Ultimately the psychologist must choose between the control of their own ideas and professionalism.

The Dryness of the Managed Care Fantasy

As an elder in the field of psychology, Nicholas Cummings does a fine job of educating the psychologist, aspiring for success, of the revolutionary changes that are occurring in the field of mental health. He, however, is dry of any other fantasy of the psychologist's role beside that of the technical P. R. man for managed care. Where is the calling to science with its mythic methodology for discerning truth in the world? Where is the alchemical doctor's fantasy of transforming that which is ill into that which is well? Vacant is the psychotherapist's dream of helping his fellow woman. Omitted is the valuation of healing. Cummings suggest's that the psychologist fall asleep in her pursuit of professional status and let herself be carried away in the arms of insurance companies and their plans for profit.

Quoting himself, Cummings suggests that the psychologist of managed care can take the role of "the family doctor in this age of alienation." Yet, he never addresses the problems of this age nor reflects on managed care's relationship to them. Our culture harbors our social malaise from which situations of individual discontent arise. It is the role of the psychologist to trouble shoot these social ills as they effect the psyche. Acquiring arsenals of time effective treatment techniques and strategies, as Cummings advocates, may be part of a therapeutic solution, but if psychologists make their professional advancement the source for their therapeutic models, giving up theoretical beliefs to the whims of managed care's stock market value, then our culture of individual-minded capitalistic values will be perpetuated. As our culture continues to recreate itself in social structures such as managed care, the ill situation of American mental sickness will also continue and psychotherapy will become a cost-effective band-aid on lacerations which require stitches.

by Liam Marsh

Return to "Ideas and Managed Care"
Return to Ares Press homepage
Responses/Reactions encouraged!

Referenced articles:

Balint, M. (1957). The doctor, his patients and the illness. New York: International Universities Press.
Bennett, M. J. (1994) Can competing psychotherapists be managed? Managed Care Quarterly, 2, 29-35.
Cummings, Nicholas. (1995) Impact of Managed Care on Employment and Training: A Primer for Survival. Professional Psychology. Research and Practice Vol 26, 1, 10-15