Curriculum changes to meet challenges: Preparing MFT students for managed care settings
Patterson, Jo Ellen
Fledgling therapists who graduate from family therapy training programs will have to navigate the world of managed care. In this article, faculty of University of San Diego share changes in its accredited training program that prepare students for practice in an increasingly multidisciplinary world where health maintenance organizations and other versions of managed care predominate. The paper touches on contextual issues, provides a detailed outline of coursework presenting basic knowledge and skills involved in clinical practice in a managed care environment, and comments on clinical placements and the challenge of helping the next generation of clinicians “fit” into the future of health care delivery while maintaining their unique identity as family therapists.
Over the past several years, the United States has experienced a revolution in how health care is provided and financed. In January, 1996, more than 70% of Americans with health insurance (including Medicare and Medicaid) were enrolled in some form of managed care plan, compared with fewer than 50% in 1992. Moreover, fewer than 40% of employers even offer traditional indemnity health insurance plans to their employees (Myerson, 1996) (Table 1). This dramatic growth in the popularity of managed care as a treatment provision strategy has occurred with little government guidance or regulation (Patterson & Scherger, 1995). More importantly, the exceptional growth of this industry has occurred with little direction from the health care providers and the organizations that represent them.
As marriage and family therapy faculty, we wondered how these changes would affect the new generation of therapists who graduate from our program every year. Most importantly, we began searching for ways to prepare them to face a dynamic health care marketplace while, at the same time, protecting their identities as specialists under the mental health rubric. The first step was a simple acknowledgement that our profession is no less vulnerable to the sweeping and sometimes unpredictable changes in health care provision than any other group in mental health. Moreover, while it is probably true that managed care will not consume the practice of every provider in health care, professional organizations and training programs should take the lead in responding to the managed care movement in order to have some influence over the future of service delivery. For example, the American Psychological Association and the American Psychiatric Association are currently developing treatment guidelines for mood and other common disorders that can be adopted by the utilization review committees of managed care companies.
The American Association for Marriage and Family Therapy (AAMFT) is also moving toward initiatives to shape the provision of mental health services within the managed care environment. One of the AAMFT’s goals in responding to health care reform is to produce substantive research that ultimately may influence payers. Recent research (Pinsof & Wynne, 1995) on the efficacy and cost-effectiveness of family therapy supports further development of the profession and sends an important message to purchasers of mental health care. Other responses by the AAMFT include provision of the Practice Strategies Newsletter to inform clinicians of trends and opportunities in modern clinical practice. It is hoped that these strategies will begin to address the role of MFT in an integrated, managed care environment.
While professional organizations play problem-solving and advocacy roles in dealing with the changes brought on by the health care revolution, students may not be attuned to the changing world in which they will practice. Many highlight private practice as their postgraduate goal-clearly demonstrating a need for educators, regardless of their personal reactions, to consider how best to prepare the next generation of marriage and family therapists for work in the managed care environment.
While the focus of our program remains training students in family therapy theory, assessment, treatment, and technique, we also encourage beginning therapists to become independent as clinicians, urging them to experiment with different treatment plans and evaluate these against various outcome criteria. These should be the essential goals of any training program, where faculty and students can focus on quality of care without being distracted by the bottom line of service delivery. But MFT programs must also prepare students to face the realities of a managed care environment (Tuttle, 1996). This includes some exposure to settings in which managed care is used.
The purpose of this paper is to provide a detailed description of a new course, “Professional Issues in Family Therapy,” which is part of an expanded curriculum in the University of San Diego’s marriage and family therapy program. The course material is presented here as a resource and guide for MFT educators to instruct students on the “hows” and “whys” of health care reform and managed care. Following the course guide, we briefly describe three additional new classes that enhance training for multidisciplinary and managed care settings: “Family and Health,” “Pharmacology,” and “Psychoeducational Group Therapies.” We conclude with some comments regarding student clinical placements and the unique position of family therapy in the world of managed care.
THE COURSE IN PROFESSIONAL ISSUES
“Professional Issues in Family Therapy” is aimed at increasing students’ awareness of health care reform and related changes that profoundly affect the profession of family therapy. The course, equivalent to a one-semester unit, focuses on the “business” of professional practice by providing practical information on managed care models and general trends in health care delivery, models of clinical practice, utilization management, marketing, and implications for family therapists.
The following section highlights the Professional Issues course content-five threehour sessions-and can provide the basis for other programs to develop similar courses or identify topics that are particularly relevant to the locale. Sessions combine lectures and interactive discussions in which students can identify and inquire about particular concerns regarding their future careers. Students have an opportunity to practice documenting a diagnosis and creating a treatment plan according to managed care company guidelines and requirements. Subsequently, instead of a final exam, students are required to write a strategic and operational plan to achieve career goals after graduation. A list of readings on managed care and health care reform, some of which are used in the Professional Issues course, follows as Appendix 1 at the end of this article.
Session 1. The Marketplace: Health Care and Mental Health Care
To orient students toward the “economic environment of psychotherapy,” this session introduces the notion that cost reduction is the main driver behind health care reform, and that subsequent changes in health care delivery carry important clinical, ethical, and professional implications. Preparing family therapy students to deal with these issues is seen as practically and ethically justified. The following description of historical problems and considerations in health care delivery provides a foundation for the remainder of the course. Access to care. Issues here concern both users and providers. Factors affecting access to care include the following: (1 ) Some 37 million Americans do not have health insurance and their numbers are predicted to grow. Ironically, this drives up health care costs since uninsured people may not seek treatment early and often present with serious, acute problems in emergency rooms where care is more expensive. (2) Mental health care providers may not see patients who would benefit from therapy. Clients in need of treatment may not seek mental health care due to stigma, confusion about mental health care providers, or simple lack of knowledge on how to access care. Frequently patients consult a physician instead of a therapist to address psychological distress. Physicians may prescribe psychotropic medications and not refer patients to psychotherapists. (3) The vast majority of insurance plans place arbitrary limits on the number of sessions that will be reimbursed. Likewise, providers must demonstrate “medical necessity” as part of a pre-authorization procedure in order to justify treatment. These attempts to combine medical and psychotherapeutic models are the focus of ongoing debate in public and private sectors.
Cost of care. Health care spending in the United States rose 4,000% between 1960 and 1990. In 1993 alone, combined private and public spending reached $1.7 trillion. Despite efforts to reduce spending, health care costs continue to rise at double to triple the rate of inflation. A number of factors may be responsible: lack of regulation around malpractice insurance and settlements; extensive use of expensive emergency room visits by uninsured patients; unnecessary use of new technologies (e.g., unjustified use of expensive tests); lack of regulation for new diagnostic tools and techniques; and, in the mental health field, overuse of extended inpatient treatment.
Government and private business have been hit hardest by rising costs since they carry most of the financial burden for health care. A majority of Americans are insured through their employers, who are paying increasing proportions of health care coverage for workers. Since business is driven by economics, the private sector is a major source of pressure to contain health care costs. Likewise, government has borne unprecedented increases in health care costs, and spending frequently outpaces other areas in state and federal budgets-thus, the initiative to regulate portions of the health care industry. Meanwhile, under growing pressure to control costs, insurance companies are in effect saying to providers, “Enough is enough.” Outpatient group treatment and brief therapy may have more appeal, at least financially, than inpatient treatment or long courses of individual psychotherapy. Further, the use of medical models and “gate-keeping” physicians means that health care organizations may see prescription of psychotropic medications as a standard first step in treating psychopathology. Thus, the battle for cost-effectiveness has reached into the psychotherapist’s office.
Implications. Family therapists and other mental health care providers may encounter dilemmas within a managed care environment-for example, in some organizations, decisions regarding treatment authorization and mode of care may be made by professionals with backgrounds outside mental health. This loss of autonomy, plus economic disincentives, may comprise serious concerns for established practitioners. On the other hand, beginning family therapists may not miss what they never had, and may actually benefit from health care reform. As insurance companies search for cost-effective options, they may be more inclined to utilize master’s-level therapists, who are more affordable than psychiatrists or psychologists and are seen as providing similar services. In some states, providing certain psychotherapy services might pose an ethical dilemma if family therapists’ scope of practice is defined and limited by law. Another challenge for beginning therapists is the task of making one’s way onto a provider panel, especially in areas where managed care companies contract with anchor groups to handle mental health care provision. Further, marriage and family therapists are not recognized (for reimbursement purposes) as widely as psychiatrists and psychologists, nor do they have a national standard as clinical social workers do. The implication here is that marriage and family therapists need to be better organized and lobby strongly for greater recognition. This is especially true given the dramatic growth in the number of mental health care providers who compete in an ever-tightening marketplace.
Quality of care. Before the “new” era of managed care, practitioners had the relative luxury of focusing on quality care for their patients. In the managed care environment, new concerns about cost-effectiveness must be balanced with quality. Current issues for practitioners include: limits on length and type of treatment; requirements to follow treatment guidelines and document these steps; the difficulty of fitting therapy into a medical model; the inadequacy of many treatment guidelines; lack of autonomy to make treatment decisions; and accountability to professionals who may work from different frameworks or who may not understand how therapy works. Further, ethical dilemmas are bound to appear when managed care companies ask master’s-level professionals to provide treatment that is outside their scope of practice.
Session 2. Solutions: Current and Future Trends in Mental Health Care Delivery This session is designed to familiarize students with typical managed care models, all of which represent a shift toward more organized systems of health care delivery. The trend toward integration, of which managed care is one part, aims at a “supermarket” ideal, in which mental health care is one department. The structure, roles, and interrelationships of various models are discussed. Figure 1 illustrates managed care in its various forms.
Managed care comprises the major response to skyrocketing health care costs. This alternative system aims at containing costs by regulating the price, utilization, and site of health care services. Managed care companies reimburse providers through a variety of models that range from fee-for-service to capitation. Fee-for-service means a therapist provides a service, perhaps an hour of therapy, and is paid for that service. Under capitated systems, a therapist or group of therapists is paid a set amount “per life” to provide all mental health services for a specific identified population, regardless of the frequency or intensity of services provided within a specific time frame. In other words, services become costs rather than revenues, and economic responsibility is shifted onto the provideroverutilization by patients becomes a liability because providers can not be compensated for services provided beyond the capitated amount. Conversely, underutilization (e.g., positive outcome and termination after three sessions when guidelines provide for six) means that providers essentially make a profit.
Health maintenance organizations (HMOs). The most common managed care model, the HMO, is defined as a legal entity that finances and furnishes health care for a fixed, prepaid charge. HMOs are also distinguished from standard insurance companies in that they shift financial risk onto the provider (i.e., this risk used to be carried by insurance companies, which paid providers for any services given beyond those calculated by the company and figured into its premiums, thus a provider who overused certain procedures was reimbursed, while the insurance company lost financially). Since HMOs are both insurers and providers, they can maintain tighter control over utilization and costs. All services through HMOs require pre-authorization in some form. Common HMO models include:
In the staff model HMO, providers work as employees for the HMO, which operates its own hospitals and clinics. A medical model predominates, specific guidelines must be followed, and proven cost-effective treatment plans are favored (e.g., group therapy, medication management, psychoeducational groups). For consumers, the staff model provides the least expensive version of health care coverage, but patients do not choose their provider or immediately access specialists, and there may be some question as to quality of care when individual treatment is needed. For example, in some cases providers may be obligated to use specific treatment approaches when a more individualized treatment is indicated.
Rather than hire their own providers, the HMO in the group model setting contracts group practices to provide mental health services. Providers still must work with set rates of reimbursement and follow the HMO’s particular administrative processes.
Sometimes the HMO contracts with an independent practice organization, a corporation organized by private practitioners. Reimbursement can be on a fee-for-service schedule or on a capitated basis.
Preferred provider organizations (PPOs). Insurance companies contract with providers (forming a panel) who agree to charge lower fee-for-service rates, thereby obtaining more referrals and frequently being reimbursed more quickly. For providers, there are fewer regulations and less documentation than required in an HMO. PPOs are not as costeffective as their HMO counterparts.
Provider hospital organization (PHOs). This comprises a contractual relationship between hospitals and providers, which merge into one organization that provides comprehensive services. The PHO then bids for contracts either to employers or insurance companies.
Management service organization (MSOs). A corporate entity (sometimes jointly owned by providers), the MSO handles marketing, billing, and other administrative tasks. Anchor groups. These are organized groups of providers, such as “groups without walls,” to which a larger PPO or HMO may send its clients. Such providers share a tax identification number, and are utilized by insurance companies because they eliminate the hassles of dealing with individual providers.
Session 3. Current and Future Models of Clinical Practice
This section defines and examines various settings in which marriage and family therapists may work. Since managed care companies were discussed in detail in Session 2, this lecture focuses on other sources of clinical practice. For example, during this lecture, students are informed of the unique characteristics of working as a clinician within the following mental health settings.
Employee assistance programs (EAPs). EAPs are highlighted as a growing provider of a wide range of services. While some businesses use internal EAPs, most have contracts with large, national EAPs, which in turn may contract out for mental health services (e.g., an EAP may refer clients to specific providers and offer capitated reimbursement). Whether external or internal to the particular business/company, EAPs may provide assessment and referral services, and can act as “gate keepers” through which employees gain access to health care, legal, and financial services. EAPs are playing an increasingly larger role in managing health care costs and providing short-term interventions. Because the EAPs comprise an integrated, costeffective system, more companies may opt for the EAP to handle its mental health care needs rather than purchase separate insurance policies for mental health.
Private practice. Although the era of third-party, fee-for-service private practice may be drawing to a close, private practitioners may still adapt to a predominately managed care setting. Various forms of private practice include:
Solo practice. Clinicians in this setting may obtain contracts with managed care companies but in doing so, they may have to march to the beat of the managed care drummer. This implies that clinicians provide administrative services and quality assurance (e.g., provide outcome measurement), have access to other levels of care (e.g. staff privileges at hospitals), have active professional relationships with psychologists, psychiatrists, and primary care physicians, and are required to obtain pretreatment authorizations and contracts for treatment episodes rather than operating on a session-by-session basis.
Informal alliances. Private practitioners maintain separate identities and autonomy but ally on administrative tasks (e.g., billing) and share overhead costs. Such groups may enhance a private clinician’s ability to draw clients, particularly if the alliance is multidisciplinary.
Formal alliances. While practitioners within formal alliances may have less autonomy and might cope with higher overhead costs, the formal alliance is attractive to third-party payers in that this group looks after management and the managed care company simply audits its work.
“Groups without walls” and “multidisciplinary groups” also consist of private practitioners who join forces in order to compete in the marketplace. Although such groups may cope with higher overhead costs as well (e.g., the need to contract with an MSO for administration tasks), they are attractive to managed care companies, particularly if they offer multiple specialties. Anchor contracts are potential client sources for such groups.
Session 4. Clinical, Ethical, and Professional Implications
This session addresses specific changes and requirements regarding assessment, diagnosis, and treatment planning that are congruent with a managed care environment, as well as discussing the dilemma these changes pose for MFTs, and the skills needed to respond appropriately.
Overview. In the past, marriage and family therapists have based treatment goals primarily on changing family interactions. In a managed care setting, however, treatment planning must focus on outcome and consider cost-effectiveness, benefit limitations, and medical necessity. Working from a linear, medically driven model poses certain dilemmas for a family therapist who is faced with presenting relational problems as a “medical necessity” for treatment.
Authorization requirements. Marriage and family therapists must learn to convey appropriate information to managed care companies, and must be aware of specific criteria. Documenting a diagnosis, level of impaired functioning, level of care needed, and prognosis are important components in assessment. For example, proving “medical necessity” includes addressing diagnostic and functional criteria. While DSM-IV (American Psychiatric Association, 1994) Axis I diagnoses indicate acuteness, the diagnosis of more chronic Axis II conditions may not be sufficient to qualify as “medical necessity.” Clinicians can focus on the acute manifestation of an Axis II disorder, which likely brought the client into therapy. In addition to providing a DSM-IV diagnosis, clinicians may need to provide information about the client’s potential lethality to self or other, current medical status, and abilities to perform the daily activities of living (self-care). Therapists will also address interpersonal relationships and a client’s ability to maintain vocational and other activitiesproblems in these areas might be classified as functional impairments. In obtaining treatment authorization, then, problems are best defined in behavioral terms. For therapists this can mean an initial focus on the “identified patient” rather than on the system. Similarly, goals must be written in behavioral terms-they should reflect the symptom (e.g., symptom reduction). Treatment modality must be identified and rationalized (e.g., document issues of safety and security in justifying inpatient treatment).
Skills. Working in a managed care environment will require therapists to be informed about and attentive to the following issues:
Balancing patient needs with cost-effectiveness
Educating patients “up front” about treatment planning goals, including a focus on desired outcome, and how to achieve this in a brief period of time
Identifying and documenting the focus of treatment early, and using behavioral terms
Familiarity with crisis intervention skills
Familiarity with case management (including knowledge of resources and ability to consult with related professions)
Careful attention to informed consent (beyond understanding confidentiality and release of information, clients need to be clear about benefit limitations)
Using the number of authorized sessions creatively (e.g., finding alternatives to the standard weekly session)
Taking an interdisciplinary approach (consulting with psychologists and physicians)
Familiarity with utilization review methodologies (e.g., managed care companies may request: a clinician’s own guidelines for determining treatment modality; ability to track files and keep them up-to-date; progress notes that are legible and complete; files that include other forms such as informed consent)
Familiarity with quality assurance (e.g., clinicians should be able to demonstrate they are following current standards of practice).
Session 5. Businesses Strategies and Critique of Managed Care
The final session provides students with specific strategies to set and accomplish career goals, including market analyses and marketing skills. A critique of managed care alerts students to potential problem areas of this delivery system, for both providers and patients.
Marketing Overview. When preparing to market their practice/skills, therapists are encouraged to initially focus on identifying major referral sources. For example, marketing aimed directly at particular clients or disorders (e.g., advertising a specialty in family treatment of substance abuse) may be insufficient if clients’ health care plans require them to go through a primary care physician to obtain a referral. Managed care companies then become a central referral source. Gaining access to this source may involve direct application to managed care companies, but networking through various other contacts may improve one’s opportunities (e.g., contacting human resource departments or employee assistance programs, learning from managed care gate keepers, such as primary physicians, how mental health services are provided for specific patient populations, using resources provided by professional associations.) As in many professions, increasing one’s visibility is a component of marketing. Beginning therapists might consider developing presentations or providing a service to professional and community organizations or schools at all levels. Even before graduation, students can read psychotherapy, political, and financial literature to catch trends and thus prepare for them. For example, potential growth areas include assessment and treatment of substance abuse/dependency, domestic violence and child abuse, and an array of adolescent problems (gangs, drug use, violence, teen pregnancy). Developing and marketing innovative ways to serve these populations and problems may increase a therapist’s salability.
Career planning. A course requirement is development of a strategic and operational plan to achieve short-term (e.g., five-year) career goals. The model for this plan is taken from the American Psychological Association Practice Directorate’s (1994) Business Strategies for a Caring Profession: A Practitioner’s Guidebook, which outlines the following steps:
1. Write a mission statement: How do you envision your practice developing (types of care, client base, financial goals, etc.)?
2. Conduct an external environment analysis: Evaluate how health care is delivered in your area (look for trends, resources you might need to utilize).
3. Check your practice’s strengths and weaknesses: This step helps you determine what steps you need to take to become more competitive in the marketplace.
4. Formulate objectives for your practice: Designate points in the future by which you will reach various goals (e.g., increasing referrals, building alliances with other professionals).
5. Develop alternatives for accomplishing each objective and choose the best option: Generate ideas and activities to reach goals, then evaluate and prioritize them.
6. Implement the tasks that lead to accomplishing your objectives: As these tasks are accomplished, analyze them to ensure they are directed toward fulfilling your objectives.
Managed Care Critique
While managed care is presented as a reality to which new marriage and family therapists can adapt, a number of troubling issues are discussed. The relative youth of the managed care movement entails certain growing pains that need to be acknowledged and addressed. Some of these include:
Gate keeping. Case managers and primary care physicians need to authorize referrals to and treatment by therapists and other health care specialists. This may postpone treatment, present bureaucratic obstacles that ultimately cause clients to give up, result in referrals being made to providers about whom the “gate keeper” knows little or nothing, and prevent clients from making informed choices about whom they will see. In addition, treatment authorizations may hinge on the provider’s ability to show “medical necessity.” Unfortunately, definitions of medical necessity-frequently ambiguous and based on a medical model that can not account for the realities and subtleties of mental health-may prevent many individuals from getting the treatment they need.
Inappropriate reviews and reviewers. For private practitioners who contract with managed care companies, reviews of treatment can be expected. Often, however, reviewers may not be in the best position to make decisions about the future of a client’s treatment (e.g., to authorize or not authorize further work), about the current outcome, and so on. Occasionally, financial concerns rather than patient needs determine whether care is extended. Chronic care. While many clients will benefit from popular, brief approaches (and managed care companies will utilize such cost-effective methods), clients with chronic mental health problems may have difficulty receiving the treatment they need given time-limited guidelines. It is therapists’ responsibility to discuss treatment options with such clients, be aware of exceptions to standard guidelines, and know how to utilize those exceptions.
Quality of providers. Since managed care companies are most concerned with cost, there may be a tendency of some to utilize providers whose quality of care or experience in dealing with various target cases is limited. For example, a provider who averages four sessions per client is attractive to managed care companies, but whether all clients benefit with such limited treatment is open to question. Further, managed care companies may make decisions regarding referrals and treatment based on economics, in some cases disregarding therapies recommended by current literature. This indicates a need for therapists from diverse schools to educate both the public and managed care on what mental health is and how therapy works, and thus lobby for treatment considerations that may not fit imposed medical models.
Imposed limits. Managed care companies are in a position to make decisions regarding how providers become part of a panel, who ultimately joins a panel, what scope of care providers may offer, and which group of clients they will see. These are some of the restrictions under which clinicians must work if their practice objectives include contracting with managed care companies.
Confidentiality. The practice of utilization review, including checks for compliance to treatment guidelines, means that providers must supply information on their cases to reviewers. Several individuals may potentially examine case summaries, and thus undermine therapist-client confidentiality. Clients therefore should be clearly informed about limits to confidentiality beyond the usual abuse reporting and duty to warn issues.
Disruptions in treatment. Because of gate keeping, many clients may face considerable delays in obtaining necessary treatment. And when treatment is authorized and set up, some may still face limitations on the number of sessions allowed. Further, clients may find themselves shifting providers mid-stream and enduring a lack of continuity in treatment when their managed care company alters its contracts with providers.
Reliance on medication. In an environment where cost-effectiveness is so crucial, some managed care companies may be inclined to refer all or most patients to a psychiatrist for medication when therapy is clearly indicated. What follows may be an over-reliance on drugs. The ease with which medications such as antidepressants or stimulants are prescribed (and the use of both as diagnostic tools in certain cases) might ultimately prevent clients from seeking other needed types of treatment-a particular danger when medication fails to work.
Uncertain Savings. While managed care may give the impression of reducing health care spending in the short term, its long-term efficacy at saving mental health care costs is less clear. Managed care may add two or more additional administrative layers between insured clients and providers, thus adding to costs. In addition, chronic problems and acute disorders that do not qualify for time-limited therapy or benefit from strict adherence to managed care treatment guidelines may end up costing clients, insurance companies, and the public in the future.
Course Evaluations
Anonymous course evaluations of “Professional Issues in Family Therapy” have prompted the following responses from students:
“This class is essential. . . Well-prepared graduates of this program know what to expect thanks to this class!”
“This course helped to clarify which direction I’d like to take after graduation….
Actually, it reduced some anxiety because I had no direction.”
“Helpful in deciding what our future will be as MFTs.”
“Gave me an awareness of the current environment.”
“It’s good to be aware of what we’ll be facing as professionals in the field.”
OTHER COURSE OFFERINGS
In addition to the Professional Issues course, the University of San Diego also offers three other classes to further equip MFT students for practice in multi-disciplinary and managed care settings where biopsychosocial approaches predominate.
Family and Health
In response to integrated health care delivery, this course prepares students to work with and understand medical models. Taught by a family physician, the five-session class examines the interaction between family systems and health. Sessions cover: the biopsychosocial model and definitions of health, disease, and illness; family functioning and behaviors that promote health and wellness; the effects of acute illness, role of family supports and stressors, and development of illness behavior; the bidirectional influences of chronic illness and family functioning; death and dying, and the role of the family therapist in treating families with terminally ill members; and the use of medical family therapy and other collaborative approaches. The course summarizes existing research on families’ responses to health problems and on treatment protocols. Information is drawn from the fields of health psychology, behavioral pediatrics, nursing, family medicine, psychiatry, and family therapy.
Pharmacology
Proven efficacy and relative cost-effectiveness of psychotropic drugs means that family therapists will see increasing numbers of clients who are taking medication. This course supplies a basic knowledge of the biological component of mental illness and prescription drugs used in treatment (Patterson & Magulac, 1995). The five-session class is taught by a psychiatrist, and it addresses two inter-related areas: psychopharmacology and the context of psychopharmacolgy. The curriculum in the former area explains biological aspects of pharmacology as well as major diagnostic categories, their biological substrates, symptoms, indications for medication referral, and prescription effects and side effects. The latter section explains the biospsychosocial model and the necessity of split treatment approaches, how to obtain and what to expect from a psychiatric consultation, how to establish a relationship with a potential psychiatric consultant, how to write referrals for such consultations, patient-centered considerations in using psychotropic medications, and scope of practice issues when using split treatment models.
Psychoeducational Group Therapies
A shift toward goal-directed, time-limited, cost-effective therapies has made psychoeducational groups and group therapy appealing to managed care organizations. This class prepares students to develop and conduct group therapies, with an emphasis on multifamily psychoeducational groups within a managed care environment. The class includes an introduction to group therapy, covering the model’s various stages (e.g., initial, transition, working, and final stages); examines therapeutic factors (universality, education, interpersonal learning and imitative behavior, among others); and utilizes a helpful guide by Spitz (1996) in adapting group approaches to managed care environments (e.g., the referral process, precertification review, concurrent review, discharge planning, and retrospective review). Specific attention is given to the use of multifamily groups with medically ill members; education and enrichment models targeting stage of life problems; and structure, planning, and development of psychoeducational groups (multifamily groups for those affected by schizophrenia and affective disorders are examined in detail). Students are required to design and present a model for a psychoeducational group.
CLINICAL PLACEMENTS
As noted earlier, the shift toward managed care means beginning family therapists may find themselves in multidisciplinary settings where clinicians of various persuasions work within the bounds of increasing controls. Preparing students for this challenge extends beyond the classroom and into clinical placements where, although clinical experience is the goal, familiarity with managed care-type practices is crucial. For example, our program contracts with numerous health care settings that provide students with this diverse and upto-date experience. Our affiliation with a family medicine residency in a large health maintenance organization (Patterson, Bischoff, Scherger, & Grauf-Grounds, 1996) has provided students the opportunity to work in family medicine community clinics alongside physician residents, and participate in large-scale research projects at the same time. MFT programs should consider the possibility of making contact with local HMOs and exploring clinical placements in such settings.
Students who are placed outside HMOs are also likely to encounter managed care practices. At the University of San Diego, practicum students at outpatient psychiatry clinics for adults and children and at an inpatient child and adolescent psychiatric unit (both affiliated with a medical school) work side-by-side with family physicians and medical specialists, psychiatrists, psychologists, social workers, and nurses. In such environments, familiarity with medical views of health, psychotropic medications, and split treatments is essential. Similarily, practicum students are required to understand medical necessity, carefully document diagnoses, outline treatment plans in detail, and closely monitor and record progress. The plans and progress notes of family therapy students, like other clinicians at these settings, are regularly scrutinized by utilization reviewers.
As faculty explore practicum sites for their MFT students, they can expand their scope of inquiry to include managed care issues and practices. And by integrating information relevant to health care reform into their curriculum, they will enhance students’ successful transitions into workplaces where increased controls and multidisciplinary involvement are facts of life.
CONCLUSION
Marriage and family therapy has emerged from its relative adolescence to find that it is not immune to the effects of a health care revolution. And while we make efforts to better prepare students for the reality of managed care-sometimes by joining forces with members of other mental health domains-it is critical that we also retain a focus on ways the profession is set apart from the rest.
In terms of surviving in a managed care environment, marriage and family therapists may be uniquely equipped to meet the challenge. They treat a wide range of serious psychological problems in adults and children, thus sharing a common scope of practice with other mental health professions; they utilize individual, couple, and family treatment modalities; and their treatments are relatively brief (Doherty & Simmons, 1996). Curriculum changes presented in this paper and other suggestions for making family therapy “an equal partner in health care” (Shields, Wynn, McDaniel, & Gawinski, 1994, p. 133) can increase marriage and family therapists’ potential for acceptance and collaboration within the interdisciplinary environment of managed care. Such measures, rather than “obfuscate the field’s technical base” (Hardy, 1994, p. 140), help to ensure family therapy’s entrance into the dominant discourse, at which point the field can assert its distinctiveness and demonstrate its value. In addition, the relational focus.and systemic orientation of family therapy make its practitioners uniquely suited to managed care. Their ability to understand clients as interacting with many, varied systems is especially critical at a time when contextual issues demand attention and even define target populations that managed care plans would serve. Further, marriage and family therapists recognize themselves as playing a role within systems, whether it is a therapeutic system involving family and clinician or an interdependent network of health care professionals.
As we struggle to adapt, the students whom we train can learn important skills and understanding that befit managed care, without losing their identities as family therapists or compromising the field’s distinction. In fact, educators can support and be aware of research efforts within the profession that demonstrate the efficacy and cost-effectiveness of marriage and family therapy (Pinsof & Wynne, 1995). This kind of empirical support will help to ensure family therapy’s role in a managed care environment where students will someday work. Training programs can likewise address in their curricula some of the implications of health care reform, without detracting from their essential mandate. In this way, we help enhance the success of our graduates as well as the credibility of the profession.
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American Psychological Association Practice Directorate. (1994). Business strategies for a caring profession: A practitioner’s guidebook.
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Patterson, J., Bischoff, R., Scherger, J., & Grauf-Grounds, C. (1996). University family therapy training and a family medicine residency in a managed care setting. Family Systems and Health, 14, 5-16.
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Jo Ellen Patterson, PhD, is Director and Associate Professor of the Marriage and Family Therapy Program, University of San Diego, 5998 Alcala Park, San Diego, CA 92110.
Leita McIntosh-Koontz, MA, is a graduate of the University of San Diego MFT Program.
Moises Baron, PhD, is Adjunct Faculty in the Marriage and Family Therapy Program and Director of the counseling center at the University of San Diego.
Richard Bischoff, PhD, is an Assistant Professor in the Marriage and Family Therapy Program and Director of the Counseling Center at the University of San Diego.
Copyright American Association for Marriage and Family Therapy Oct 1997
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