Managed care and the evolving role of the clinical social worker in mental health.

Cohen, Jeffrey A.

During the past 15 years, managed care has become a central philosophy and organizing theme for the delivery of mental health care services (Gibelman & Schervish, 1996; Hartman, 1994). With managed carets increased control, the mental health care delivery system has undergone massive changes. These changes are reshaping professional practice and radically altering the provision of mental health services in the United States (Crespi, 1997; Cummings, 1995, cited in Chambliss, Pinto, & McGuigan, 1997). Managed care has already altered standard system delivery models in mental health, replacing the traditional model of individual practitioners providing fee-for-service medical care with a variety of groups contracting to provide services to organized groups of citizens (Committee on Therapy, Group for the Advancement of Psychiatry, 1992).

Shapiro (1995) defined managed care as "any kind of health care services which are paid for, all or in part, by a third party, including any government entity, and for which the locus of any part of clinical decision-making is other than between the practitioner and the client or patient" (p. 441). According to Iglehart (1994), managed care systems integrate the financing and delivery of appropriate medical care by

* contracting with selected practitioners and hospitals that furnish a comprehensive set of health care services to enrolled members, usually for a predetermined monthly premium

* using quality controls that contracting providers agree to accept

* creating financial incentives for patients to use preferred providers and facilities

* assuming some of the financial risk for practitioners, altering their role from serving as agent for patients' welfare to balancing patients' needs against the need for cost control.

More than 200 managed care companies serve approximately one-half of the U.S. population. It is anticipated that within the next two or three years this figure will approach the entire population (Bozutto, 1992, cited in Alperin & Phillips, 1997).

With its involvement in the mental health field, managed care strives to provide efficient quality care at a lower cost than that offered in the fee-for-service professional community (NASW, 2000). Support of managed care companies is largely a reaction to escalating costs in the health care field. Americans in 1995 were spending 12 percent to 14 percent of their income on health care, with costs increasing about 11 percent to 12 percent each year. Health care costs in the United States have been rising at alarming rates, because of the aging population, changing disease patterns, increasing costs of health care technology, and focus on treatment of disease rather than prevention. Mental health care costs are no exception (Crane, 1995; Crespi, 1997). To address the rising expenses of treatment, profit-driven managed care companies have assumed increasing control. They scrutinize the nature and scope of mental health treatment, looking for ways to cut costs (Edward, 1997). Managed care companies have attempted to achieve cost savings by instituting financial, administrative, organizational, and monitoring constructs that minimize resource allocation and maximize efficiency and quality of care (Croze, 1995, cited in Geller, 1996).

Managed care companies have looked to control costs by shifting from a manipulation of patients' benefits to cost control through the proper management of care. In furtherance of these goals, managed care has implemented gatekeeping devices to determine when patients have a real need for treatment. As a result of these changes, managed health care companies have limited authorization of expenditures to only those services that the gatekeepers deem necessary and appropriate, to be delivered in the least-restrictive and least-intrusive treatment setting, and only by designated qualified practitioners. Despite these changes, advocates of managed mental health care believe that patients can still receive proper care, at the proper time, in the proper setting, by the proper type of provider, and with considerable cost savings compared with unmanaged care (Schamess, 1996).

Managed care has limited the use of the most costly services--inpatient psychiatric care--in preference for less-expensive outpatient treatment (Geller, 1996). When inpatient care is necessary, periods of hospitalization are shortened, and these stays are authorized only for individuals deemed a danger to themselves or others (Giles, 1993; Schamess, 1996). Managed care providers encourage services that rely on a combination of brief and intensive outpatient therapy and long-term, low-cost maintenance and support, using brief rehospitalizations sparingly when patients relapse (Bedell, Hunter, & Corrigan, 1997; Schamess).

Another strategy to reduce expenditures has been the use of external review procedures, such as utilization management or review, to regulate patients' access to care. Utilization management is a set of techniques used by or on behalf of the provider of health benefits to manage mental health care costs by influencing patient care decision making through a case-by-case assessment of care before its provision (Institute of Medicine, 1989, cited in Alperin & Phillips, 1997). Under this approach, managed care providers must authorize treatment before it is rendered if reimbursement for services is to occur. Once treatment is authorized, individuals in the managed care organization determine which professionals the patient may see, what type of treatment he or she may receive, how frequently the patient may be seen, and for how long. This process removes control over many treatment decisions from the practitioner and places it in the hands of managed care decision makers, giving officials from managed health care companies the authority to make many decisions that mental health practitioners and consumers used to make (Edward, 1997).

These changes occurring at the system level of mental health care delivery have transformed substantially the roles of mental health practitioners. Managed health care companies have begun to use the clinical social worker in a much more active role for the treatment of individuals suffering from mental illness. Managed care organizations are beginning to see clinical social workers as preferred providers of nonmedical treatment, in large part because they are less-expensive sources of services compared with clinical psychologists and psychiatrists (Schamess, 1996). All of the changes taking place with the increased involvement of managed health care will have vast implications for the role of practitioners in the mental health care field, and, in particular, the clinical social worker.

Key Issues

Brief History

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 (Fink, 1996).

By the mid- 1970s the number of clinical social workers providing mental health treatment in the United States had grown, almost equaling the number of psychiatrists. Both professions had almost twice the number of clinical psychologists. In the subsequent 15 years, clinical social workers and clinical psychologists tripled their numbers, while the number of psychiatrists grew by less than 40 percent (Goleman, 1985; Manderscheid & Barnett, 1987, cited in Committee on Therapy, Group for the Advancement of Psychiatry, 1992). With the increased number of nonpsychiatric practitioners, along with the introduction of psychotropic medication, the role of the psychiatrist shifted. As psychopharmacology, biology, genetics, and hard science influenced psychiatry, psychiatrists began to withdraw from psychotherapy. Psychiatric practice instead shifted its primary focus to patients in need of psychopharmacological agents, with psychiatrists prescribing and monitoring medication use and administering medical procedures su ch as electroconvulsive therapy (ECT) (Committee on Therapy; Hartman, 1994).

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; Geller, 1996; Hartman, 1994).

Role Conflict and Competition

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 (Lazarus, 1996). 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 (Gibelman & Schervish, 1996; Shera, 1996). For some time, clinical social workers have performed the largest portion of psychotherapeutic work done in the United States (Hartman, 1994). Clinical social workers provide as much as 65 percent of all psychotherapy and mental health services (Gibelman & Schervish, 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 (Austad, 1996).

Until 1985 consumers had a variety of options among mental health clinicians. Patients could choose among practitioners; however, many insurance companies would only reimburse psychologists and psychiatrists for services provided, effectively limiting patients' choice. With the advent of managed health care, further limitation of patients' choice of providers occurred (Herron, 1997; Munson, 1996). Today, choice is often limited, except for the very wealthy, who have more options in their choice of providers because they can afford the most-expensive insurance benefits packages or pay for treatment out-of-pocket (Munson, 1996). Most mental health consumers no longer have the option to go to the provider of their choice and still receive health care insurance coverage. Instead, they are limited to a panel of providers chosen by their insurance company (Gibelman & Schervish, 1996; Munson, 1996). Because of this shift in control of whom mental health care consumers may see for treatment, many practitioners are se eing decreases in client referrals, while other practitioners' practices are thriving.

With managed care's influence, psychiatrists are being replaced by nonmedical practitioners in many domains of mental health treatment in which they once predominated. Psychiatrists are being forced into new practice arrangements and roles, such as consultants for multidisciplinary groups. Psychiatrists are also increasingly being limited to dealing with patients with the most severe mental disorders, which tend to involve the use of medication and need for prescription privilege (Goleman, 1985; Lazarus, 1996). Past responsibilities of long-term therapy and treatment aimed at overcoming problems that diminish patients' quality of life have given way to treatment of such cases as serious psychotic disorders, with threat to life and risk of decompensation deemed the main reasons for their involvement (Committee on Therapy, 1992).

The new trend of using clinical social workers in place of clinical psychologists and psychiatrists by managed care companies has touched off territorial disputes among practitioners in the mental health field (Lazarus, 1996). As the mental health professions compete for the same health care dollars, each profession guards its turf, protecting itself by defining responsibilities it is uniquely qualified to perform, and, at the same time, vying for the right to expand services (Austad, 1996). For example, as the number of clinical social workers has grown in the area of psychotherapeutic treatment, clinical psychologists have lobbied for prescription and full hospital privileges, which historically have been reserved for psychiatrists. Clinical psychologists reason that they could serve as a less-expensive replacement for psychiatrists, or even provide both psychotherapeutic and psychopharmacological treatment to patients (Austad; Fink, 1996). As managed care companies pass psychologists over for less-expensiv e clinical social workers, the lack of differentiation among mental health professionals by managed care companies undoubtedly frustrates clinical psychologists.

Solo versus 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 biggest stimulus in the use of clinical social workers in private practice came with the states' licensing of clinical social workers. Increased licensure of clinical social workers gave clinical social workers credibility as providers of mental health treatment, allowing the movement of numbers of clinical social workers into private practice. As clinical social workers have gained legal recognition and entitlement to third-party reimbursement, the income-generating potential of independent practice has grown (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; Munson, 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 (Fink, 1996).

Mode of 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 feefor-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 (Hoyt, 1991, cited in Austad, 1996).

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). Longterm psychotherapy has been virtually eliminated for all but private-pay patients. Managed care companies find that studies of short- and longterm 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). In response, clinical social workers are trying to align themselves with insurers' goals and preferred modes of treatment, now taking a more-focused, goal-directed, and short-term approach (Austad, 1996). In 1992 NASW found that 37 percent of its surveyed membership had already changed their treatment approach because of managed care's preferences (Rose & Keigher, 1996).

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 (Alperin & Phillips, 1997). 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 framew ork in the treatment of individuals suffering from mental illness (Fink, 1996).

Recently, group treatments have received attention as a cost-effective means of treatment (Folkers & Steefal, 1991, cited in Rosenberg & Wright, 1997). 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 (Austad, 1996). 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 (Rosenberg & Wright).

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 (Rosenberg & Wright, 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 (MacKenzie, 1995).

Outcome Measurement and Management

In addition to changes in practitioner roles and mode of treatment, another major trend emerging under managed mental health care is an emphasis on performance and outcome measures. Outcomes management serves several important functions in the mental health field, including evaluating and refining treatments, identifying the most-effective treatments, providing clear descriptions of therapeutic procedures, and enhancing the credibility of psychotherapy. The current marketplace of mental health care increasingly demands greater accountability of its practitioners (Pekarih, 1993, cited in Pratt, Berman, & Hurt, 1998).

Increasing numbers of third-party payers, including federal and state governments, will not fund mental health services without detailed performance outcome data using standardized measures. Therefore, the need to measure patient improvement in treatment and demonstrate efficacy of treatment interventions is greater than ever (Kelly, 1997). Outcome measurement and management is aimed at obtaining evidence of such results. Such evaluative measures provide payers with a quantitative basis to differentiate among providers and types of treatment. Supplying the most cost-effective treatment possible is the primary goal of managed care companies, and by providing empirically validated treatment methods, managed care companies hope to get the most from their expenditures (Jackson, 1996).

Outcome measurement and management not only benefit third-party payers, but also the patients themselves. Outcome measurement and management provide a written record that allows patients to evaluate their own care with a tangible and quantitative product. At the same time, managed care companies, practitioners, and mental health professionals in general, can learn which types of treatment tend to be the most effective for different patient populations. In addition, outcome data can provide credibility for the effectiveness of mental health treatment, thus eliminating any perceptions of arbitrariness (Kelly, 1997).

It is becoming increasingly necessary for mental health professionals to incorporate outcome measurement and ongoing assessment of treatment as part of the normal process of doing business (Pratt et al., 1998). Practitioners who fail to record outcome measurements and demonstrate treatment effectiveness are at a great disadvantage in negotiating with payers compared with those who can. Managed care organizations prefer providers who can demonstrate that their services are cost-effective and will more likely support a practitioner and a treatment intervention that proves results with data. Clinical social workers are at an advantage because they, along with representing a less-expensive source of labor, have been involved in practice effectiveness research for some time (Jackson, 1996).

Case Management

Changes occurring in the mental health field with managed care have increased the importance of the clinical case manager. Typically, the clinical case manager--usually a licensed clinical psychologist or clinical social worker--is the person responsible for the management of patients' treatment. The clinical case manager oversees the patient's benefits, coordinates the efforts of the various entities involved in patients' care, and provides a single point of professional contact for a patient. The clinical case manager stands at the point of interface between the provider--facility and the managed care company. He or she works with the mental health care practitioners to ensure optimum use of the patient's available health care benefits in accordance with the parameters set forth by the individual's insurance policy. Case management and community treatment play an important role in managing mental health care services (Bedell et al., 1997; Birne-Stone, Cypres, & Winderbaum, 1997).

Because clinical social workers have almost exclusively concentrated in this area for some time, many managed care companies hire clinical social workers to fulfill the role of case manager (Jackson, 1996). Clinical psychologists have not embraced case management as part of their routine clinical practice like clinical social workers, making clinical social workers the primary resource for providing case management responsibilities, an important role and a great opportunity in the managed care era (Bedell et al., 1997).

Projections

Managed health care organizations have influenced the delivery of services in the mental health field considerably and will undoubtedly continue to do so (Jackson, 1996; 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 (Bozutto, 1992, cited in Alperin & Phillips, 1997). In the future, indicators (Iglehart, 1994) suggest that

* nonpsychiatric practitioners will emerge as the dominant providers of treatment

* use of the traditional fee-for-service health care structure will decrease

* integrated service delivery systems will become the predominant treatment model

* brief modes of therapy will become the preferred method of treatment

* use of outcome measurement and management will continue to grow.

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 (NASW, 2000).

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 (Cummings, 1995, cited in Crespi, 1997; Belar, 1995, cited in 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 (Frank & Johnstone, 1996). 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; Stroup & Dorwart, 1996).

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 (Fink, 1996). 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 (Goleman, 1985; Phillips, 1997).

The distance between the domains of psychotherapists and psychopharmacologists will continue to widen, however, as psychiatrists undoubtedly will continue to be the most-expensive mental health professionals. Psychotherapy has already become a predominantly nonmedical activity, and there is every indication that this trend will continue until the medically trained therapist becomes rare (Committee on Therapy, 1992). Some practitioners (for example, psychiatric nurses) who are not psychiatrists can circumvent the barrier to their prescribing drugs through an alliance with a psychiatrist. This practice is likely to increase in frequency, further narrowing the role of the psychiatrist and widening the gap between the medical and nonmedical mental health practitioner (Goleman, 1985). In the future, psychiatrists will more likely focus on treatment planning, supervision, and evaluation, coordinating treatment and providing consultation services. Psychiatrists may still directly treat individuals with the most seve re mental illnesses who often do not respond to psychotherapy, such as patients suffering from schizophrenia. Their primary responsibility with these and other patients will be providing medication and administering procedures that require medical training, such as ECT (Giles, 1993).

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 (Jackson, 1996). 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 (Hoyt, 1995, cited in Chambliss et al., 1997). 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 (Brooks & Riley, 1996; Schamess, 1996). Social work schools not only should provide training of specialized clinical interventions, but also should focus on the broader range of skills needed for this new era of mental health care services. Some field instructors have reported spending more time teaching the administrative skills required for managed care practice. One school of social work even added a class that deals strictly with managed care issues (Brooks & Riley).

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.

Original manuscript received February 20, 1998

Final revision received June 4, 1999

Accepted August 18, 1999

References

Alperin, R. M., & Phillips, D. G. (Eds.). (1997). The impact of managed care on the practice of psychotherapy: Innovation, implementation, and controversy. New York: Brunner/Mazel.

Austad, C. S. (1996). Can psychotherapy be conducted effectively in managed care settings? In A. Lazarus (Ed.), Controversies in managed mental health care (pp. 229-254). Washington, DC: American Psychiatric Press.

Bedell, J. R., Hunter, R. H., & Corrigan, P. W. (1997). Current approaches to assessment and treatment of persons with serious mental illness. Professional Psychology: Research and Practice, 28, 217-228.

Birne-Stone, S., Cypres, A., & Winderbaum, S. (1997). Case management and review strategies. In R. M. Alperin & D. G. Phillips (Eds.), The impact of managed care on the practice of psychotherapy: Innovation, implementation, and controversy (pp. 41-56). New York: Brunner/Mazel.

Brooks, D., & Riley, P. (1996). The impact of managed health care policy on student field training. Smith College Studies in Social Work, 66, 307-316.

Chambliss, C., Pinto, D., & McGuigan, J. (1997). Reactions to managed care among psychologists and social workers. Psychological Reports, 80(1), 147-154.

Committee on Therapy, Group for the Advancement of Psychiatry. (1992). Psychotherapy in the future. Washington, DC: American Psychiatric Press.

Crane, D. R. (1995). Health care reform in the United States: Implications for training and practice in marriage and family therapy. Journal of Marital and Family Therapy, 21, 115-125.

Crespi, T. D. (1997). Managed mental health care and institutional downsizing: Status, directions, and considerations for the family therapist. Family Therapy, 24(1), 1-8.

Edward, J. E. (1997). The impact of managed care on the psychoanalytic psychotherapeutic process. In R. M. Alperin & D. G. Phillips (Eds.), The impact of managed care on the practice of psychotherapy: Innovation, implementation, and controversy (pp. 199- 216). New York: Brunner/Mazel.

Eubanks, J. D., Goldberg, A. L., & Fox, R. (1996).

Workforce issues in professional psychology. In R. L. Glueckauf, R. G. Frank, G. R. Bond, & J. H. McGrew, Psychological practice in a changing health care system: Issues and new directions. New York: Springer.

Fink, P. J. (1996). Are psychiatrists replaceable? In A. Lazarus (Ed.), Controversies in managed mental health care (pp. 3-16) Washington, DC: American Psychiatric Press.

Frank, R. G., & Johnstone, B. (1996). Changes in the health workforce. In R. L. Glueckauf, R. C. Frank, C. R. Bond, & J. H. McGrew, Psychological practice in a changing health care system: Issues and new directions. New York: Springer.

Geller, J. L. (1996). Mental health services of the future: Managed care, unmanaged care, mismanaged care. Smith College Studies in Social Work, 66, 223-239.

Gibelman, M., & Schervish, P. H. (1996). The private practice of social work: Current trends and projected scenarios in a managed care environment. Clinical Social Work Journal, 24, 323-338.

Gibelman, M., &Schervish, P. H. (1997). Who we are: A second look. Washington, DC: NASW Press.

Giles, T. R. (1993). Managed mental health care: A guide for practitioners, employers, and hospital administrators. Boston: Allyn & Bacon.

Goleman, D. (1985, April 30). Social workers vault into a leading role in psychotherapy. New York Times, pp. Cl, C9.

Hartman, A. (1994). The winds of change. Smith College Studies in Social Work, 64, 211-220.

Herron, W. G. (1997). Restructuring managed mental health care. In R. M. Alperin & D. G. Phillips (Eds.), The impact of managed care on the practice of psychotherapy: Innovation, implementation, and controversy (pp. 217-233). New York: Brunner/Mazel.

Iglehart, J. K. (1994). The American health care system: Managed care. In P. R. Lee & C. L. Estes (Eds.), The nation's health (4th ed., pp. 231-237). Boston: Jones and Bartlett.

Jackson, V. H. (Ed.). (1996). Managed care resource guide for social workers in private practice. Washington, DC: NASW Press.

Johnson, L. D. (1995). Psychotherapy in the age of accountability. New York: W. W. Norton.

Kelly, T. A. (1997). A wake-up call: The experience of a mental health commissioner in times of change. Professional Psychology: Research and Practice, 27, 349-363.

Lazarus, A. (1996). Afterword: Is managed care psychiatry's internecine war? In A. Lazarus (Ed.), Controversies in managed mental health care (pp. 403-410). Washington, DC: American Psychiatric Press.

MacKenzie, K. R. (1995). Effective use of group therapy in managed care. Washington, DC: American Psychiatric Press.

Munson, G.E. (1995). Loss of control in the delivery of mental health services. Clinical Supervisor, 13(1), 1-6.

Munson, C. E. (1996). Autonomy and managed care in clinical social work practice. Smith College Studies in Social Work, 66, 241-260.

National Association of Social Workers. (2000). Managed care. In Social work speaks: National Association of Social Workers policy statements, 2000-2003 (4th ed., pp. 215-221). Washington, DC: NASW Press.

Phillips, D. G. (1997). Legal and ethical issues in the era of managed care. In R. M. Alperin & D. G. Phillips (Eds.), The impact of managed care on the practice of psychotherapy: Innovation, implementation, and controversy (pp. 171-184). New York: Brunner/Mazel.

Pratt, S., Berman, W. H., & Hurt, S. W. (1998). Ethics and outcomes in managed behavioral health care: "Trust me, I'm a psychologist." In R. F. Small & L. R. Barnhill (Eds.), Practicing in the new mental health marketplace (pp. 121-138). Washington, DC: American Psychological Association.

Rose, S. J., & Keigher, S. M. (1996). Managing mental health: Whose responsibility? [National Health Line]. Health & Social Work, 21, 76-80.

Rosenberg, S. A., & Wright, P. (1997). Brief group psychotherapy and managed mental health care. In R. M. Alperin & D. G. Phillips (Eds.), The impact of managed care on the practice of psychotherapy: Innovation, implementation, and controversy (pp. 105-120). New York: Brunner/Mazel.

Schamess, G. (1996). Introduction: Who profits and who benefits from managed mental health care? Smith College Studies in Social Work, 66, 209-220.

Shapiro, J. (1995). The downside of managed mental health care. Clinical Social Work Journal, 23, 441-451.

Shera, W. (1996). Managed care and people with severe mental illness: Challenges and opportunities for social work. Health & Social Work, 21, 196-201.

Stroup, T. S., & Dorwart, R. A. (1996). Can managed competition reform mental health care? In A. Lazarus (Ed.), Controversies in managed mental health care (pp. 337-350). Washington, DC: American Psychiatric Press.

Jeffrey A. Cohen, MSW, ACSW, was a client services manager, Washtenaw County Community Mental Health Adult Services, 3981 Varsity Drive, Ann Arbor, MI 48108. The author expresses his appreciation to Associate Professor Larry M Gant, University of Michigan School of Social Work, for his guidance and encouragement; to Associate Professor Candyce S. Berger, University of Michigan School of Social Work, for her insights and suggestions; and to his brother Paul D. Cohen, for his editing expertise.