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Michele's Dissertation Web Hosting by Netfirms | Free Domain Names by Netfirms CHAPTER I INTRODUCTION Background of the Study The landscape of the American health care system is changing. Strom-Gottfried (1988)

reported that in 1986, the health care industry as a whole accounted for 9% of the United States'

gross national product. This represented an increase of more than 44% during the preceding 15-year period from 1971 to 1986. Current estimates of the contribution of health care dollars to the

gross national product exceeds 15%. The vast majority of these dollars are wholly or partially

subsidized by third parties, the most common of which are managed care organizations (Strom-Gottfried, 1998). All military personnel have been converted to managed care systems; Medicaid

is now managed in all but seven states (Galambos, 1999), and many Medicare beneficiaries have

already converted to managed care options (Zieman, 1998). Today, approximately 250 million

Americans receive healthcare benefits distributed through the vehicle of managed care (Madonna,

2000). Parity for mental health benefits is currently an issue of considerable debate among

legislators (Feldman, Bachman, & Bayer, 2002). Thirty-five states have already enacted legislation

which supports bolstering insurance benefits for behavioral health to equal those already provided

for physical health. Health Maintenance Organizations (HMOs) in America were subsidized and accredited by

the federal government in response to escalating concerns over skyrocketing healthcare costs

during the Nixon administration in the 1970s (DeLeon, VandenBos, & Bulantao, 1994).

Employers who offered insurance benefits and who had more than 25 employees were required to

offer an HMO option. Although the elderly, the disabled, and the poor were receiving assistance

through the then recently implemented Medicaid and Medicare programs, the majority of the

nation's citizens lacked similar options. The original intent of the federally sponsored Health Maintenance Organization or variants

now collectively referred to as managed care organizations (MCOs), was to provide physicians

with a disincentive to ordering superfluous tests and procedures, and keeping patients hospitalized

for inordinate amounts of time, in an attempt to maximize reimbursement from indemnity-based

insurance companies (Shore, 1998). In effect, a small group of physicians became concerned that

their colleagues lacked any incentive to restore the health of their patients, in that they were

financially rewarded for behavior which is not conducive to the restoration of health. The

development of the HMO was an attempt to eliminate indiscriminate spending and promote the

pursuit of patient health and healing (Madonna, 2000). The implementation methods used to achieve this purpose included both the requirement

of obtaining confirmation from the HMO overseers that a given procedure would be reimbursed,

as well as caps (i.e., dollar limits) placed on the level of reimbursement provided (Wickizer &

Lessler, 1998). A further incentive to the judicious use of medical care and resources was

accomplished on the patient side of the equation through the requirement of co-pays, co-insurance, and deductibles, each a variant of the portion of payment for services for which the

patient is personally responsible. This double-barreled approach to financial risk management,

therefore, was intended to curtail excessive spending and create an accountability system which

would ultimately benefit the consumers of medical care. Some studies have demonstrated

additional cost savings through the implementation of preventive behavioral health interventions

(Dorfman & Smith, 2002). These approaches to cost containment remain in effect today, as the

fee-for-service model of health care reimbursement fades into history (Gibelman & Whiting, 1999;

Morgan & Morgan, 2001). In addition to the cost containment measures of preventive interventions and pre

authorization requirements, HMO's developed other 'watch dog' procedures, such as

credentialling, concurrent review, and retrospective review (Tuttle & Woods, 1998).

Credentialling is the term used to describe an HMO process of validating proper education and

licensure of providers on a given panel or group of approved practitioners for which the managed

care organization will provide reimbursement. Credentialling procedures are designed to protect

the insured from inappropriate or dangerous medical procedures provided by a non properly

credentialed healthcare provider. Concurrent review provides an opportunity for the HMO to

continually assure that additional procedures, medication, hospitalization, or continued treatment

remains necessary and appropriate. Consumers receive another level of protection through the

application of retrospective reviews, whereby the HMO carefully reviews documentation of

medical procedures which have already been authorized and implemented. The HMO or managed

care organization reserves the right to refuse to pay for any procedure they subsequently conclude

was either inappropriate or unnecessary, regardless of whether or not the provider obtained the

required preauthorization. The medical procedures for which these levels of cost management and patient protection

exist also include services provided by psychologists. In the case of outpatient therapy, pre-authorization, concurrent review, retrospective review and credentialling is typically accomplished

through the psychologist's interaction with "case reviewers" (Ken Salzman, Ph.D., personal

communication, May, 2001). Psychologists review diagnoses, prognoses, symptom changes, and

treatment plans with case reviewers who, in turn, determine whether or not continued sessions are

warranted. This process can assist psychologists in terms of accountability and access to an

impartial view of therapeutic effectiveness (Doherty & Heinrich, 1996). Through the frequent

review of patient progress, the psychologist is encouraged to carefully identify presenting

problems, appropriately document patient progress toward meeting treatment goals (for which a

direct link to a presenting problem is provided), and maintain a vigilant and exclusive focus on

alleviating those problems. The credentialling process helps to assure consumers of mental health

services that the chosen provider is legitimately trained, licensed, and in good standing, thereby

potentially limiting the liability of the MCO (Newman & Bricklin, 1994; Higuchi, 1994). The management of psychological and substance abuse/chemical dependency benefits are

frequently contracted out to managed behavioral health care organizations or MBHOs. A number

of these organizations exist, including Magellan Behavioral Health, ValueOptions, United

Behavioral Health, and Managed Health Network. The majority of the 250 million Americans

with health insurance (approximately 68%) access both inpatient and outpatient mental health

benefits through MBHO's (A Fresh Look at Carve-Outs, 2001). Kiesler (2000) estimates that

88% of managed healthcare corporations provide behavioral health benefits through an

independently operating entity. Murphy, Debarnardo, and Shoemaker (1998) reported that half of the clients of

psychologists surveyed in 1996 were managed care clients. This is a notable increase from the

estimates of the 10% to 15% figure provided for 1991. Because clients with MBHO-managed

benefits comprise such a significant portion of the caseload of the typical psychologist in private

practice, assessment of the impact of managed care on the practice of outpatient psychotherapy is

a critical issue. Managed care, in its most current form, is described by Strom-Gottfried (1998) as "a

range of strategies for ensuring that services are carefully structured and scrutinized to assure

both fiscal responsibility and acceptable quality of care". Managed mental health care has evolved

since its inception in the 1970's. Both three (Miller, 1994d) and five (Tuttle & Woods, 1997)

tiered models have been offered to describe this process. Miller points out the fairly gradual

movement from lower to higher levels of intrusion and restriction, ranging from the establishment

of provider networks, to the addition of more aggressive utilization review and treatment

proscriptions, to provider-managed financial risk sharing (e.g., capitated contracts). The advent and growth of managed care has deeply affected not only the consumers of

mental health treatment, but also the providers of those services. Examples of areas most

profoundly affecting mental health professionals include: treatment duration limitations (Bilynsky & Vernaglia, 1998; Dziegielewski, , 1997; Miller, 1996a), expectations for increased use of more

cost effective group interventions (Taylor et. al, 2001), inappropriate triangulation of the

therapeutic relationship (Cooper & Gotlieb, 2000; Daniels, 2001; Masters, 1998; Sanders, 1998),

increased rates of relapse (Bezold, MacDowell, & Kunkel, 1996; Segal, Akutsu, & Watson, 1998;

Wickizer & Lessler, 1998), a number of legal and ethical challenges (Danzinger & Welfel, 2001;

Davidson & Davidson, 1996; Doherty & Heinrich, 1996; Hanson & Sheridan, 1997; Miller,

1996c; Shore, 1998;), perception of decreasing levels of autonomous clinical decision-making

(Buckloh & Roberts, 2001; Greggo, 2001; Herron, Eisenstadt, Javier, & Primavera, 1994;

Murphy et al., 1998; Pipal, 1995; Shore, 1998; Stern, 1993) and decreased career satisfaction

(Bradley, Lan, & Gould, 1996; Kalman, & Goldstein, 1998; Phelps, Eisman, & Kohout, 1998;

Russell, de la Mora, Trudeau, Scott, Norman, & Schmitz, 2000; Plante, Boccaccini, & Andersen,

1998; Vyhmeister, 2001). In cooperation with the Practice Directorate of the American Psychological Association

(APA), Phelps, Eisman, and Kohout (1998) surveyed nearly 16,000 practicing members of the

Association with respect to the some of the above-referenced concerns regarding the influence of

managed care on the practice of psychotherapy and psychotherapists. The vast majority (80%)

reported that managed care had a negative impact on their practice. Eighty percent of respondents

reported that they were practicing, to some degree, independently. Changes in clinical practice as

well as ethical dilemmas generated by managed care were cited by respondents as notable

concerns. Although problems related to excessive pre-certification requirements and reduced

income were endorsed by 49% of the total sample, this varied by primary work setting. Sixty-two

percent of psychologists primarily involved in independent practice endorsed this concern,

whereas only 28% of psychologists in an academic setting responded similarly. Murphy et al. (1998) surveyed 442 psychologist of APA Division 42 (Division of

Independent Practice) and found that 70% believed managed care had negatively affected their

work. These authors highlighted some of the adaptations psychologists are making in order to

successfully navigate in the landscape of the managed care arena. These changes included moving

from solo to larger practices, obtaining hospital privileges, increasing the proportion of Medicare

business, and hiring additional clerical staff. Acuff, Bennett, Bricklin, Canter, Knapp, and

Moldawsky (1999) suggest that although ethical problems related to client abandonment have

existed in the past, the penetration of managed care into the market has increased the frequency

and intensity of this ethical dilemma for psychologists. Ethical and professional concerns noted by

respondents to this survey included loss of control over clinical decision-making as well as limits

and caps on the number of authorized sessions for their clients. On a Likert-like scale ranging

from 1 to 9 (with 9 being "a great deal"), 80% of respondents ranked the following item as a 7 or

higher: "To what extent have you found the limits imposed on number of sessions interfering with

services you deliver?" The modal response to this item was a 9 . Problems specifically related to session limits and caps on total expenditures per insured

customer have been well-documented (Bilynsky & Vernaglia, 1998; Herron, Javior, Eisenstadt,

Javier, Primavera, & Shultz, 1994; Miller, 1996b; Sederer & Bennett, 1996; Stern, 1993). Miller

(1996) outlined the potential outcome of continued limits on reimbursement for mental health

services. He asserted that treatment denials will increase, current clients will be underserved, and

clients with moderate to severe psychological problems will be denied access to treatment

services. A typical yearly session limit for an clients with an HMO is 20 (Stern, 1993; Miller,

1996d). Dziegielewski (1997) concluded that "brief" psychotherapy can mean as few as 6 to 8

sessions, but up to 20 is still an acceptable duration. Managed care, therefore, can largely be seen

as necessitating the utilization of brief term therapeutic models. Curiously, some therapists seem

to be somewhat biased against the use of this theoretical model (Warner, 1996). Despite this

apparent bias, practitioners are increasingly obligated to work within these brief-term parameters,

regardless of their preferred theoretical orientation or treatment approach.. Given the frequency, intensity, and scope of the problems practitioners are experiencing as

a result of expanding reliance on reimbursement for services via MBHOs, one may suspect that

dissatisfied practitioners will respond to client needs by using other options for service delivery.

For example, Rosenberg (2000) suggests that practitioners consider utilizing their training in

systems theory and consultation to tailor their services to suit the changing demands of the current

marketplace. Reed, Levant, Stout, Murphy & Phelps (2001) summarize current marketplace

trends, as well as the wide variety of opportunities that have simultaneously evolved for

psychologists to transform current practices in ways that more efficiently balance quality and cost

containment. The recently emerging trend of augmenting or replacing traditional avenues of service

delivery with 'virtual', non-managed care subsidized options offers support for the contention that

an exclusive focus on conventional practice may not be as viable as in years past (Cairo &

Dotlich, 1999; Hargrove, 1995; Hendricks, 1996). New, virtual avenues of service delivery

include internet-based real-time therapy "chat", "cyber-counseling", programmed distanced

writing (Jordan, 2001), and personal coaching conducted exclusively by telephone, fax, and e-mail. Budman (2000) describes this burgeoning trend toward both internet and non-internet based

computer-mediated communications, and projects that this trend toward increased utilization is

likely to continue. Other authors have postulated a direct relationship between managed care

involvement and actual or intended exodus of practitioners from traditional "brick and mortar"

private practices to more contemporary "virtual" modes of service delivery. In addition, MacKain, Tedeschi, Durham, and Goldman (2002) suggest that recent

master's level practitioners have begun a migration toward work in the public sector due , in part,

to marketplace trends and managed care demands. Bankhead (2002) examined the success of

public child mental health care cost containment measures. Contrary to the intended results, these

recently implemented managed care policies were found to have increased comprehensive costs of

treatment in this population. Empirical studies have demonstrated significant correlations between level of exposure to

managed care (measured in a variety of ways) and the following variables: increased frequency

(Buckloh & Roberts, 2001) and distress related to managed care-mediated ethical problems

(Stevens, 1998), decreased income (Greggo, 2001; Phelps, Eisman, & Kohout, 1998), increased

movement from solo to larger, multi-disciplinary practices (MacKenzie, 2001; Murphy et al.,

1998), and decreased levels of job satisfaction (Stevens, 1998; Wilkinson, 1998). The association of lower levels of job satisfaction with increased absenteeism, decreased

productivity (Dupree & Day, 1995), significant stress-related health problems (Wilkinson, 1990),

burnout and turnover (Johnson, 2001; Riffe, 1999) is well-documented by many years of empirical

research across various disciplines. Mental health practitioners are not immune to these sequellae

(Evans, & Hohenshil, 1997; Johnson, 2001; Riffe, 1999). Vyhmeister (2001) identified specific

managed care related perceptions that have negatively impacted psychologists' job satisfaction.

These consequences of decreased job satisfaction have the capacity to deeply and profoundly

impact not only the practitioners themselves, but also the clients whom they serve. Statement of the Problem While the job satisfaction literature contains many studies examining a wide variety of

fields, there is a curious dearth of empirical studies on the levels of and factors associated with job

satisfaction of mental health professionals. Given the fact that the existing body of job satisfaction

literature was generated largely by mental health professionals, this gap in the research is

particularly noteworthy. Anecdotal evidence supporting the contention that the advent of

managed care has been accompanied by a corresponding decrease in job satisfaction among

mental health professionals is mounting at a rapid pace. However, a more targeted examination is

needed of the relationships among psychologists' job satisfaction and their level of involvement

with managed care, experienced levels of locus of control specifically as it pertains to the

perception of independent clinical decision-making, discrepancies between what one should do

and what one did do in a managed care-mediated ethical dilemma, the use of brief term

therapeutic treatment models (particularly when this is not the preferred theoretical orientation of

the psychologist). Purpose of the Study Because the influence of managed care on mental health services is projected to continue

(Gibelman & Whiting, 1999; Miller, 1996d; Rosenberg, 2000; Strom-Gottfried, 1998),

psychologists must thoroughly investigate its impact on both the consumers and providers of

mental health services. Exploration and intensive examination of the specific aspects of managed

care that practitioners find problematic affords the profession an opportunity to begin the strategic

development and implementation of well-informed, compensatory plans of action. The present

study is designed to shed light on some of the factors related to managed mental health care which

are specifically relevant for psychologists. The purpose of this study, therefore, is to provide

information necessary for effectively addressing the expanding impact of managed care, with the

goal of enhancing the job satisfaction of current and future mental health professionals. Research Questions 1. Are psychologists' levels of involvement with managed care correlated with job satisfaction? 2. Are psychologists' locus of control correlated with job satisfaction? 3. Is the frequency of psychologists' ethical dilemmas related to managed care correlated with

job satisfaction? 4. Are psychologists' locus of control affected by the interaction of the frequency of ethical

dilemmas related to managed care and the accompanying distress? 5. Are psychologists' loci of control correlated with their level of involvement in managed care? 6. Are psychologists' levels of involvement with managed care correlated with their use of brief

term treatments? 7. Are psychologists' use of brief term treatments correlated with job satisfaction? Definition of Terms Managed care

. "A range of strategies for ensuring that services are carefully structured

and scrutinized to assure both fiscal responsibility and acceptable quality of care" (Strom-Gottfried, 1998, p.393 ). Managed behavioral healthcare organization (MBHO)

. An organization or entity with a

primary function of fiscally managing the distribution and certification of reimbursable

mental health and substance abuse/chemical dependency benefits. Capitation

. "A prepaid plan based on a set number of covered lives under a defined

benefits package. Payments are made to the provider in monthly advances, rather than as

fees for services provided" (Tuttle & Woods, 1997, p.125 ). Fee-for-service

. The fee-for-service third party reimbursement system allows practitioners to be paid for the provision of virtually any treatment they deem appropriate (Durham,

2001). Medical necessity

. For a given service to be deemed medically necessary, the following

qualifications must be met: "For the treatment of sickness or injury, consistent with

generally accepted medical practice, efficient, in the sense that a less expensive treatment

works as well as a more expensive treatment, and not for the patient's or provider's

convenience" (Ford, 1998, p. 183). Utilization review (UR)

. UR is the process by which managed care organizations evaluate

requests for treatment on a case-by-case basis, and determine whether the requested

treatment will be certified as clinically appropriate and medically necessary (Wickizer &

Lessler, 1998, p. 844). Delimitations Participants will be psychologists. Results may not be applicable to other groups of mental

health professionals (e.g., psychiatrists, psychiatric social workers, licensed counselors). 2. Participants will be licensed psychologist members of the American Psychological

Association (APA). Results of the study may not be applicable to psychologists who are

not APA members. 3. Participants will be licensed psychologist members of the Divisions 6 (Behavioral

Neuroscience and Comparative Psychology), 7 (Developmental Psychology), 12 (Society

of Clinical Psychology), 13 (Consulting Psychology), 17 (Counseling Psychology), 18

(Psychologists in Public Service), 22 (Rehabilitation Psychology), 25 (Division of

Behavior Analysis), 29 (Psychotherapy), 30 (Society for Psychological Hypnosis), 32

(Humanistic Psychology), 35 (Society for the Psychology of Women), 36 (Psychology of

Religion), 37 (Child, Youth, and Family Services), 38 (Health Psychology), 39

(Psychoanalysis), 40 (Clinical Neuropsychology), 42 (Psychologists in Independent

Practice), 43 (Family Psychology), 44 (Society for the Psychological Study of Lesbian,

Gay, and Bisexual Issues), 45 (Society for the Psychological Study of Ethnic Minority

Issues), 47 (Exercise and Sport Psychology), 49 (Group Psychology and Group

Psychotherapy), 50 (Addictions), 51 (Society for the Psychological Study of Men and

Masculinity), 53 (Clinical Child Psychology), 54 (Society of Pediatric Psychology), and 55

(American Society for the Advancement of Pharmacotherapy). The results may not be

representative of former licensed psychologist APA members who those who members of

Divisions other than those referenced above. 4. Participants will be licensed psychologist APA members of the above-mentioned Divisions

who have provided e-mail contact information. Results may not be applicable to licensed

psychologist APA members of these Divisions who did not provide this information. CHAPTER II LITERATURE REVIEW This chapter is a review of literature related to managed care and its possible effects on the

practice of psychology. First, a general overview and brief historical background of health

insurance will be provided, followed by a description of contemporary practice. Next, the

implications of increased utilization of brief term treatment models will be examined. Common

ethical dilemmas encountered by mental health professionals who participate in managed care will

be reviewed, including confidentiality, honesty, integrity, multiple relationships, and boundaries of

competence. The final sections will include a review of contemporary management styles and

locus of control issues as they relate specifically to the job satisfaction of psychologists. Overview Brief History of Managed Care. The concept of health insurance rapidly evolved during

the World War II era (Pipal, 1995). It was during this time that employer wage freezes were

widely applied due to governmental requirements. Instead of wage increases or bonuses for

employees, businesses began offering benefits

, a non-monetary method of remuneration for

services rendered. Health insurance was one of these. The core idea was that contributions by the

many (in terms of premiums often paid by employers) would finance the catastrophic losses of the

few. Managed care had its critical debut during the early 1970s (Sederer & Bennett, 1996). During this time, HMOs (Health Maintenance Organizations) were flourishing, and the Nixon

administration began encouraging cost containment on a larger scale. The next decade led to

astronomical increases in the number of psychiatric and substance abuse facilities (Galanter,

Keller, Dermatis, & Egelko, 2000), with accompanying inflation in treatment costs. Following

that extreme rise in mainly inpatient psychiatric care costs, various cost containment mechanisms

were quickly yoked to reimbursement. Today, of the 250 million Americans with health insurance, managed behavioral health

care organizations (MBHOs) administer the mental health benefits of approximately 68% (A

Fresh Look at Carve-Outs, 2001). All military personnel, all but seven state Medicaid programs,

and an estimated 25% of Medicare recipients by 2002 are expected to receive mental health

benefits via the vehicle of a managed care organizations. Of the estimated 52 million Americans

who experience a mental health problem during a given year, more than 31 million are covered by

an MBHO for reimbursement of mental health-related visits (Madonna, 2000). Collectively, the

MBHO industry reported an impressive growth rate of 42% from 1996 to 1999. A 'carve-out' is a separation of certain subset(s) of insurance coverage from the

remaining medical/surgical benefits. Further, establishment of sub carve-outs specific to substance

abuse benefits and managed separately from other behavioral health benefits are becoming more

common. Madonna (2000) explains how insurance plans establish mental health carve-outs: "The

plan sets aside a block of funds and contracts with a vendor [MBHO] to manage all the mental

health services for the plan. Contractors are usually paid a flat fee per member per month to

manage the benefit". Some recently implemented, integrated service delivery models, such as the

Johns Hopkins School of Medicine's management of a 22,000 member TRICARE (family health

insurance for uniformed military personnel) contract, have been particularly successful (Fagan,

Schmidt & Cook, 2002). The five largest MBHOs (non-integrated, carve-out modeled entities) in the United States

cover more than 114 million lives (Oss & Naughten-Travers, 2000). Magellan Behavioral Health,

by far the largest, covers 69 million customers through its Green Spring, Human Affairs

International (HAI/Aetna), Vista Behavioral Health, and Merit divisions. Among them, the top

three MBHO's (i.e., Magellan Behavioral Health, ValueOptions, United Behavioral Health)

control more than 53% of the market (Oss & Naughten-Travers, 2000). Mental Health Network

(MHN) and MCC Behavioral Care (a Cigna subsidiary) represent the last two of what many have

described as "the big five". Together, MHN and MCC cover approximately 15 million people. Mental Health Madison is an organization that has been collecting data with respect to

various aspects of each of "the big five" which are particularly meaningful to mental health

professionals. For several years, mental health professionals have submitted reports to www.MentalHealth-Madison.com in the form of 'grades' on the following MBHO-related issues:

credentialling, paperwork, intrusiveness, patient needs, reimbursement (speed of), and rates of

reimbursement for diagnostic interviews, and individual sessions. In terms of credentialling, for the Southern Region, for Ph.D. level psychologists,

Magellan received an F, ValueOptions a C, United Behavioral Health (UBH) an F (only Master's

level clinicians were included in this particular average for UBH), Managed Health Network

(MHN) a D, and MCC received a D (only Master's level clinicians were included in this particular

average for MCC). Grades by psychologists for the 'paperwork' variable were D, B, D, F, and C,

respectively. Intrusiveness grades were similarly bleak: D, B, D, D, and D, respectively.

Responsiveness to patient needs were graded as follows for each of "the big five": F, C, F, F, C.

Aggregate speed of reimbursement grades were D, B, F, C, and C. Reimbursement rates for

diagnostic interviews ranged from $75 to $120, while rates for individual sessions ranged from

$70 to $85. Translated to the caseload composition of the typical psychologist in clinical practice, this

means that the services of approximately half of clients seen for psychotherapy are reimbursed

through some variety of the MBHOs described above et al., 1998). Three years after Murphy's

examination, more than 90% of mental health counselors indicated that managed care had affected

their practice (Danzinger & Welfel, 2001). The scope of influence of managed care on the

profession of psychology is clearly quite broad, and is predicted to continue to grow in the future. Psychologists' Perceptions of Managed Care. Interviews with psychologists revealed a variety of potential advantages in working in a

managed care based practice. Some of the advantages identified by the ten subjects in Neill's

(2001) study included financial benefits, working with a variety of challenging clients, and the

opportunity to utilize brief therapy successfully, for a broad array of presenting problems. Recent surveys by two groups of researchers (Murphy et al., DeBernardo & Shoemaker,

1998; Phelps, Eisman, & Kohout, 1998) have yielded important information regarding

practitioners' attitudes and behaviors about the current state of affairs with respect to managed

care. Of the 15,918 licensed psychologists surveyed by Phelps et al. (1998), four of five indicated

that managed care had a negative impact on their practice. Professional concerns of those

surveyed included: excessive utilization review (UR) requirements, income reductions, and ethical

dilemmas. Plante, Boccanccini, and Anderson (1998) found that 94% of the 400 Clinical Diplomates

of the American Board of Professional Psychology (ABPP) they surveyed reported a negative

impact of managed care itself as well as a negative impact of the cost containment procedures

used. In their survey of APA's Division 42 (Independent Practice) membership, Murphy et al.

(1998) stated that 91% of respondents reported that managed care has affected their practice.

Analogous to Phelps, Eisman and Kohout (1998), these researchers found that 70% of their

sample perceived a generally negative impact of managed care. Among the problems cited by the

authors were: reimbursement for marital/family counseling, significant investment of non-reimbursable time with utilization review (UR) and paperwork activities, ethical dilemmas leading

to inappropriate treatment of clients, income reductions, and difficulties with reimbursement for

psychological testing. Problematic reimbursement for psychological testing was also documented by Piotrowski,

Belter, & Keller (1998) and Werthman (1995). Over 40% of a sample of child and adolescent

psychologists reported significant constraints on psychologist testing due to managed care policies

(Cashel, 2002). Maruish (2002) provides recommendations for increasing the likelihood of

obtaining reimbursement for the use of a variety of psychological instruments. Although changes in the marketplace have impacted practitioners' scope of reimbursable

assessment tools, in a recent survey of training directors of APA approved doctoral programs,

29% indicate their clinical psychology programs have been significantly impacted by managed

care (Belter & Piotrowski, 2001). In particular, traditional testing course work emphasizes

competence in assessment strategies which are largely no longer viable in non-academic settings.

In contrast to the 2001 study summarized above, a related study by Daniels, Alva and Olivares

(2002) revealed that nearly 60% of counseling psychology, clinical psychology, and social work

training director respondents now provide some type of managed care related training. Some

psychologists have expressed concern that failure of graduate training to address changes in the

contemporary marketplace may contribute to a future lack of professional viability (Neill, 2001). In an interesting, more recent adjunct to the Division 42 study, Jung, Pomerantz,

Tuholski, and Sullivan (2001) examined the potential impact of therapist attitudes towards

managed care, as identified by Murphy et. al (1998), on managed care clients. The results suggest

that the negative attitudes identified by Murphy et. al have a significant, negative impact on

clients. Furthermore, Jung et. al (2001) suggest, that given the salience of therapist attitudes

towards managed care on prospective clients, therapists would be well-advised to consider their

managed care related attitudes when designing informed consent discussions and documentation. In an extension of the Murphy et. al (1988) study, Orr (2000) administered a revised

version of the original survey as well as the Maslach Burnout Inventory to a group of 128

additional psychologists. Orr's results not only support the core findings of the Murphy et. al

(1988) study, but also indicate that depletion of psychologists' emotional stamina is an additional,

possible risk of a caseload comprised even of a relatively small number of managed care clients.

Increased levels of depersonalization, as well as decreased levels of sense of personal

accomplishment were also positively associated with higher managed care caseloads. Recent research suggests that not only are psychologists vulnerable to the impact of

managed care, rehabilitation counselors (Chan, Rosenthal, Pruett & Ferrin, 2002), psychiatrists

and other physicians have also been effected. In their extensive survey of more than 12,000

physicians, Stoddard, Hargraves, Reed and Vratil (2001) determined that autonomy was one of

the two most efficient determinants of career satisfaction, and that proportion of managed care

revenue was directly and positively related to reported levels of clinical freedom. In a study of

Manhattan area psychiatrists, Kalman and Goldstein (1998) reported that significant differences in

rates of job satisfaction existed between managed care participants and non-participants, with the

managed care participants' levels of professional satisfaction being lower than those of their non-participating counterparts. Data from another recent study suggest that communication with

managed care contacts accounts for the largest percentage of reported variance in physicians'

levels of job satisfaction (Lammers & Ashley, 2002). Increased levels of professional

dissatisfaction in psychiatry has also been reported by Sturm (2000). Interestingly, Sturm's data

indicates that managed care related issues may not be the source of the higher levels of

dissatisfaction for psychiatrists (as opposed to other medical doctors) after age and practice

setting are taken into account. A group of 392 child and adolescent psychiatrists recently beginning their careers

identified managed care as one of the least desirable aspects of their work, and concurrently

identified autonomy as one of the most desirable aspects (Stubbe & Thomas, 2002). Contrary to

prior studies, this group of early-career psychiatrists, as a whole, generally indicated satisfaction

with their current occupation. It is possible, therefore, that age and/or years in practice may be an

important co-variate when assessing levels of career satisfaction among other practitioners in the

field. In addition to psychologists, psychiatrists, and other independent practitioners in the

community, some counseling center-based therapists have also been effected by managed care-like

cost containment measures. In fact, Whitaker (1994) suggests that colleges and universities have

always engaged in treatment allocation and limitations for health services, including counseling

centers in some cases. She also suggests that college student psychotherapy is inherently brief

given the nature of the situation. She reports that this type of therapy is typically very, very brief.

In fact, the modal number of sessions is 1, and the second highest is 2. Thus, the inherently very

brief nature of therapy for most college counseling center consumers can easily offset the unusual

case where longer term therapy is warranted Some counseling centers, however, have found themselves "under the gun" so to speak,

and overwhelmed with requests for services. Dworkin and Lyddon (1991) found themselves in

just such a predicament. Their solution was to implement a managed care-like system within their

counseling center, whereby students were seen initially for intake interviews, and their cases were

assessed to be in one of four categories: short-term (5 or fewer sessions per semester),

intermediate (up to 10 sessions per semester), extended (conducted over the course of several

semesters and only used rarely and for training purposes), and group work. Beyond the preceding

parameters, students were referred off campus for treatment. In a related study in a Canadian university, Warner (1996) investigated client/student

satisfaction with services received. He found no statistically significant difference in reported

levels of student satisfaction under brief term (3 or fewer sessions) and longer duration

therapeutic encounters. Interestingly, Warner found that therapists were less satisfied with the

briefer term encounters. Warner attributes this to counselor bias against brief term therapy

restraints in some college counseling center settings. As the population treated by outpatient psychologists, both in counseling centers and in

the community, increases in acuity and diagnostic severity, the management of potentially

dangerous patients is becoming more important (Wysoker, 1999). Telephone triage presents some

particularly formidable risks, and is frequently used as a screening tool when potential patients

phone their managed care company for referrals and/or authorization (Erdman, 2001). In his

description of another potentially hazardous treatment setting, Robert Simon (1998) outlines

duties of psychiatrists in inpatient settings with violence-prone patients. Several of his points

parallel the responsibilities of psychologists in this critical area. One of his most crucial points

regarding managed care and violence-prone patients is that practitioners must not abandon

patients on the basis of reimbursability and that appeals to review boards are required whenever

denial of coverage would result in dangerously premature termination. Wysoker (1999) reports

that appropriate monitoring of suicidal patients currently receiving inpatient treatment is in serious

jeopardy due to inadequate staffing and managed care related restrictions. For example, criteria

for continued inpatient treatment, in many cases, necessitates patient verbalization of a specific

suicide plan. Brief Term Therapy and Medical Necessity Dziegielewski (1997) provides a synopsis of contemporary forms of brief psychotherapy

used in delivering what managed care organizations describe as medically necessary psychological

services. She reports that "brief" can mean as few as 6 to 8 sessions, but up to 20 is still of an

acceptably short duration. The first form of brief treatment mentioned is Interpersonal Psychotherapy or IPT, which

concentrates on guiding the clients' focus to the "here and now" while highlighting interpersonal

events directly related to client's mood states. The second form of brief treatment she summarizes

is Cognitive-Behavioral, which focuses on replacing maladaptive thought patterns with more

effective ones in order to eliminate problematic emotional experiences and accompanying

behaviors. Dziegielewski also discussed Solution-Focused Therapy (SFT), in which the client and

therapist engage in "change talk" rather than "problem talk", and the focus is more on client

strengths and innate tendency to move toward more healthy solutions. Dean (1998) described another form of brief term treatment, Narrative therapy, which is a

post-modern approach that emphasizes therapy as a reflexive conversation in which both client

and therapist develop new stories about the client's problem and about solutions to that problem.

Notably absent are the more traditional theoretical orientations, such as psychodynamic

approaches (Demos, 2001;Eckardt, 2002; Sperling & Sack, 2002). The array of treatment

avenues available to therapists and clients can be considerably curtailed when managed care

companies limit access to these methods.. The current managed care philosophy and approach to the treatment of psychological

disorders is one of brief stints of psychotherapy throughout the lifetime of the insured rather than

the more traditional approach of one, more lengthy "permanent" or "curative" experience

(Gibelman & Whiting, 1999; Segal, Akutsu, & Watson, 1998). Certain subsets of psychological

disorders are particularly adversely affected by this philosophy (e.g., eating disorders, personality

disorders, etc.). Galanter et al. (2000) as well as Franko and Erb (1998) report that a number of

DSM-IV diagnosable conditions are generally not responsive within the typical time frames set by

managed behavioral health care organizations. Standard treatment for alcoholism and other

substance abuse disorders, for example, are rarely provided via a 30 day inpatient program today.

Harris-Lemak and Alexander (2001) have documented a negative correlation between stringency

of managed care oversight and number of group and individual treatment sessions in outpatient

substance abuse facilities. Although the National Institute of Health (NIH) has estimated that the

costs of these disorders will exceed 276 billion dollars, federal funding for treatment of substance

use disorders (both inpatient and outpatient modalities) has sharply decreased (Galanter et al.,

2000). Several suggestions for combating this problem have been offered by various concerned

parties which include specific examples of methods of more effectively negotiating with managed

care reviewers. Other researchers have expressed deep concern regarding the potential disservice

or damage to clients who are in need of services, but fail to meet the technical criteria of medical

necessity as defined by their managed behavioral health care organization (Acuff et al., 1999;

Cooper & Gotlieb, 2000; Daniels, 2001; Galambos, 1999). Sulman, Savage and Way (2001) offer

a model for re-tooling psychotherapy practice to meet the new demands for shorter treatment

durations. They also highlight the emerging competition among disciplines (e.g., psychologists,

pschiatrists,, and social workers) for counseling and psychotherapy patients. Finally, the authors

recommend that practitioners (particularly those in acute care settings) focus on developing

solution-focused brief intervention skills. Although some therapists have been expressing deep concern regarding the constraints of

working within a brief term psychotherapy format, Garfield et al. (1994) point out that the overall

median number of sessions, over a number of studies ranging from 1948-1989, in a wide variety

of treatment settings, was 12 sessions. Premature termination, non mutually agreeable

discontinuation following acceptance into therapy, accounts for a considerable percentage of the

typical psychologist's caseload. Curiously, whereas 32% of patients who could receive up to 12

sessions terminated prematurely, more than 60% of patients who could receive 3-4 months of

therapy made the same choice (Sledge, Moras, Hartley, & Levine, 1990, cited in Garfield et al.,

1994). Despite this pattern of premature termination regardless of available treatment duration,

psychologists may perceive interaction with managed care reviewers to be somewhat strained, in

that they may be required to exert considerable time and effort in obtaining these sessions. Sabin

and Daniels (1994) attribute much of the impetus for the frequently adversarial relationship

between psychologists and managed care case reviewers to a fundamental difference in the three

basic models used to define "medical necessity." The first and the one most generally embraced by

managed behavioral health care organizations is the "normal function model" (p. 54). The goal in

the normal functioning model is to decrease the impact of a disease or disability, and uses medical

definitions of clinical deviance from the norm to determine which DSM-IV-TR diagnosable

conditions qualify as a diseases or disabilities, according to the unique criteria of the MBHO. Axis

II diagnoses and V-code diagnoses, in particular, rarely qualify as diseases or disabilities. In contrast, many clinicians believe that medical necessity should be assessed using either

what Sabin and Daniels describe a " personal capability" (p. 54) or "welfare" (p. 55) model. In

general, goals of these models are to enhance personal capability and potential for happiness,

respectively. Rather than a medically defined restoration of functioning, these models cast a wider

net, and adopt goals based on clinical necessity, specifically, diminished experience of personal

capability and limits on potential for happiness (Sabin & Daniels, 1994). "Medical necessity" has been defined by Ford (1998) as encompassing the following

qualifications: "for the treatment of sickness or injury, consistent with generally acceptable

medical practice, efficient, in the sense that a less expensive treatment works as well as a more

expensive treatment, and not for the patient's or provider's convenience" (p. 183). Ford reports

that utilization of this definition in the field of mental health is woefully inadequate. He suggests using an alternative definition. This alternative is termed "clinical necessity",

and would require the following attributes for reimbursement: for the treatment of mental illness and substance use disorders, or symptoms of these

disorders, and impairments in day-to-day functioning or for the purpose of preventing the

need for a more intensive level of mental health and substance abuse care or for the

purpose of preventing relapse of persons with mental illness and substance use disorders,

and consistent with generally accepted clinical practice for mental and substance use

disorders, and not for the patient's or provider's convenience. "Clinical necessity" (vs. medical necessity), if embraced by managed behavioral healthcare

organizations, may be one answer to the problem of strict session limitations that place clinicians

in the ethical bind of either having to refer a client, continue to see the client on a self-pay basis or

at no charge, or change the diagnosis in order to provide continued service. Many authors cite 20 sessions as the prototypical, annual outpatient visit benefit maximum (Miller, 1996; Stern, 1993); however, in increasing number of practitioners have expressed a

concern that, unless deemed "medically necessary" in the eyes of the managed care company's

reviewer, even brief term treatment can be either outright denied or initially authorized for only 4-8 sessions, with additional sessions approved only in the case of crises and/or life threatening

behaviors. Wysoker (1999) also draws our attention to recent litigation in which a physician was

successfully prosecuted for failure to challenge the "medically necessary" based denial that

allegedly led directly to the death of a prematurely discharged client. Miller (1996d) asserts that managed care policies (e.g., the 'medically necessary' criteria)

are responsible for decreasing availability of psychological services and making effective treatment

impossible for some clients. Miller and others (Calloway & Hall, 2000; Sabin & Daniels, 1994;

Tubbs & Pomerantz, 2001) cite problematic incidents including allegedly discriminatory denial of

services, under serving those who do have partial access, and specific denial of services to patients

requiring longer-term treatment. Miller (1996c) believes that managed care organizations benefit little from targeting

outpatient services, and that the focus is more appropriately placed on inpatient utilization. He

indicates two primary reasons for this argument. First, outpatient therapy is much less expensive

than inpatient treatment. Second, outpatient therapy already has cost containment procedures in

place. These include co-payments and deductibles for mental health services, as well as relatively

low caps on total mental health-related expenditures (Clark, 2001; Keefe & Hall, 1999). He

concludes that the above-mentioned limitations are likely to lead to dramatic reductions in

treatment services. Miller (1996a) cites several studies indicating that treatment length, when managed care is

factored out of the equation, is important to outcome. The median number of treatment sessions

for managed care clients seen by marriage and family therapists is six (Christensen & Miller,

2001). The dose-effect literature suggests that a minimum of eight sessions are necessary for half

of patients to show improvement (Kopta, Krause, and Orlinsky, 1986), and that those numbers

improve to 74% by the 26th session, and 90% by the 104th session. Keefe & Hall (1999) expound

on the 'dosage model' developed by Haward et al. (1986; 1993) which conceptualizes a 3-stage

process of therapy. These stages are evidenced by subjective well being (remoralization, first few

sessions), decreased symptoms (remediation, 1-6 sessions), and improved life functioning

(rehabilitation, typically several months to years), and illustrate the sequential outcome criteria

observed in successful therapeutic intervention. This author also draws our attention to encouragement of "ultrabrief" therapy (p. 355) by

managed care, and that this ultrabrief form of therapy can result in undertreatment. Brief therapy,

as described by Garfield and Bergin (1994), is considered to be fewer than 25 sessions. Much of

the improvement reported in the literature on brief and ultrabrief therapies is largely attributable to

placebo effects and spontaneous remission. Those with the greatest need for treatment may not be

the rapid responders who improve with brief therapy; rather, they are the clients with more severe

problems such as personality disorders, psychoses, and substance abuse disorders (Daniels, 2001;

Galambos, 1999; Galanter et al., 2000. Not only have outpatient psychotherapy sessions been curtailed, but the inpatient

component of psychological services has also experienced similar constraints . Bezold,

MacDowell, & Kunkel (1996) report that the only significant predictor of inpatient length of stay

was method of payment, with managed care patients' stays being the shortest, as compared to

private pay and government sponsored patients. Intuitively, one may be inclined to assume that

DSM Axes I, IV, and V would be significantly related to length of stay. This, however, was not

the case in this inpatient population. Perhaps a similar phenomenon exists with outpatient clients,

meaning that total number of sessions per episode is related more to method of payment than to

diagnostic severity. The "revolving door syndrome" (p. 1216) is explained by Segal, Akutsu, and Watson

(1998) in their article detailing factors associated with involuntary returns to psychiatric

emergency services within a year of initial service. The authors report that as many as one-third of

admitted patients have repeat admissions within the first year. This revolving door syndrome is

ideally tailored for outpatient managed care clients as well, given that therapy is reimbursed on

only a short-term basis. In contrast to Bezold, MacDowell, and Kunkel's finding regarding

method of payment, Segal et al. reported that clients' initial condition was the best predictor of

involuntary return to psychiatric emergency service. The authors go on to suggest that the

average hospitalization of six days was too brief to have prophylactic effects, and that it may be

that insufficient treatment was related to repeat (multiple) admissions. Perhaps the more severe

disorders outlined by Miller (1996) also lend themselves to this revolving door phenomenon for

outpatient clients. In a similar vein, Wickizer & Lessler (1998), in their article on the effect of treatment

limitations for an inpatient population, found that the odds of re-admission were significantly

increased for each day that utilization managers restricted requested treatment time. Although not

yet examined in the existing literature, it seems possible that the same restrictions, when moved to

an outpatient setting, might lead to similar results, especially given that utilization reviewers

frequently conduct both inpatient and outpatient reviews. In a recent study by Howard (1998), evidence was provided supporting the idea that

utilization review is unnecessary for more experienced providers. He found that, compared to a

no-review control group, doctoral level psychologists used significantly fewer "extra" sessions (all

requests for additional sessions were granted in this study up to the benefit maximum) following

exhaustion of the initially authorized number of sessions than did master's-level providers. He also

reports that the client dropout rate for master's-level practitioners was 18% vs. a dropout rate of

only 7% for psychologists. In a sample of master's-level counselors conducted by Danzinger and Welfel (2000), 48%

of respondents indicated that they had or would prematurely terminate a therapeutic relationship

due to managed care related constraints. On the other hand, the Division 42 psychologists

surveyed by Murphy et al. (1998), when presented with a hypothetical denial of continued

reimbursement for a client whose termination the psychologist assessed to be premature,

participants endorsed the following responses (in order of frequency, multiple responses were

permitted): advocate for more benefits (90%), reduce fee to allow a self-pay option (86%), and

provide pro bono service (69%). Contrary to the managed care philosophy of multiple, carefully monitored, short episodes

of psychotherapy throughout the lifetime, the dose-effect studies cited in related literature

(Herron, Javier, Einstadt, Primavera, & Shultz, 1994) generally point to a positive relationship

(i.e., more is better) between effectiveness and number of sessions. There is an important

limitation to this correlation, however, in that these gains show a pattern of diminishing returns. In

other words, patients tend to improve rapidly at first, and after that, gains are smaller but

potentially more meaningful and long-lasting (Miller, 1996a). Herron et. al. (1994) also state that

this dose-effect relationship is moderated by type of treatment as well as diagnostic category. For

example, psychoanalytic therapy may utilize more sessions to achieve treatment gains than other

models of psychotherapy. Likewise, certain disorders (e.g., Borderline Personality Disorder vs.

Adjustment Disorder N.O.S.) may take longer to yield significant treatment gains. Haas and

Cummings (1994) suggest that for some disorders, brief therapy may not only be ineffective, but

in fact, is contraindicated. Miller (1996d) sees managed care's diminishing return argument for session limitation as a

misconception. He provides several reasons that the argument for the desirability of time limits on

psychotherapy is an oversimplified one. First, the argument points out that placebos and

spontaneous remissions are the most favorable by managed behavioral health care organizations

(this is the group for whom the most improvement is seen for the lowest fiscal investment). Second, the diminishing returns argument puts an end to necessary and potentially

successful longer-term treatment. Miller uses the analogy of pharmacological research on dose-related effects to illustrate the importance of length of treatment as a critical, mitigating factor in

successful treatment outcome. He explains that it is unreasonable to limit the treatment of persons

needing antibiotics to 20 days (the point at which 90% of patients respond) when 99% of patients

respond favorably to treatment within 40 days. Miller points out that it is the least tractable

psychological problems (e.g., Borderline Personality Disorder) which require the longest amounts

of psychotherapy. Therefore, although it may be less economical to treat the more difficult cases,

it is possible to secure favorable results. Miller goes on to explain other misconceptions about requiring brief psychotherapy with

all clients. The most significant is that there is little research indicating the benefits of long-term

treatment. On the contrary, Miller cites two pivotal studies (Smith, Glass & Miller, 1980; Luborsky, Chandler, Auerbach, Cohen, & Bachrach, 1971) which offer alternative views. The

Smith et al. study pointed to client types and problem types as moderators in the lack of

relationship found between duration and therapeutic gain. In the meta-analyses conducted by

other researchers (Luborsky et al., 1971; Orlinsky & Howard, 1986), a statistically significant

relationship between treatment duration and improvement was documented. Ethical Issues. In addition to the profound impact on independent decision-making with respect

to treatment duration, the appearance of managed care has been met with additional ethical

ramifications. These ethical dilemmas have been addressed by a number of authors, and continue

to be a topic of lively discussion among practitioners (Lazarus & Sharfstein, 2002; Goold &

Klipp, 2002). In recent years, several authors (Bilynsky & Vernaglia, 1998; Davidson &

Davidson, 1996; Doherty & Heinrich, 1996; Hanson & Sheridan, 1997; Miller, 1996c;) have

drawn our attention to the serious ethical dilemmas incumbent in working within the parameters

of a managed care entity. Some of these authors are concerned with APA's failure to provide

adequate guidance directly addressing managed care-related issues in its Ethical Principles. Although not directly addressed in the most recent version of the Ethical Principles, these

issues are indirectly addressed throughout the document (Acuff et al., 1999; Daniels, 2001).

Murphy et al. (1998), in their large-scale survey of the membership of Division 42 (Division of

Independent Practice), found that 58% of responding psychologists had encountered ethical

dilemmas related to managed care which were not addressed in the Ethical Principles. Although

documentation of practitioners' ethical concerns is mounting, an additional dilemma has emerged,

in that the current codes of professional ethics which govern practitioners frequently fail to

address these concerns in specific and useful ways (Tjelveit, 2000). Other authors point out the

existence of very similar ethical issues prior to the advent of managed care, and these issues are

now beginning to generate scrutiny sufficient to allow them to be more adequately addressed

(Belar, 2000). Confidentiality. One threat to the autonomous decision making of psychologists is the

encroachment of managed care on clinicians' application of professional codes of ethics. This

includes the utilization reviews (UR) that occur between providers and gatekeepers (e.g.,

MBHOs) to secure preauthorization or re-authorization (Danzinger & Welfel, 2001). These

reviews often require practitioners to provided detailed information about clients' histories,

treatment goals, and presenting problems, as well as therapists' treatment plans (Alleman, 2001;

Bilynsky & Vernaglia, 1998. Retrospective reviews, a related cost-containment measure, are

sometimes used by MBHOs and may result in denial of payment for services previously

authorized and rendered. These reviews are often quite detailed and rigorous, and carry similar

risks to confidentiality. Confidentiality represents a foundational ethical principal on which trust in the therapeutic

relationship is built. The client-therapist relationship is, in large part, based on this important

premise. Managed care policies, however, may seriously impinge on this most basic of

patient/client rights through several mechanisms. The use of largely unregulated information

systems (Davidson & Davidson, 1996) present special risks. Detailed client histories, progress,

goals, and diagnoses are often easily accessible to managed care personnel who were not

originally intended to peruse them (Cooper & Gottlieb, 2000). In addition, the relatively insecure

transfer of information (e.g., treatment plans, progress reports, requests for additional sessions)

via fax machines, voice mail, e-mail and the like is also problematic. Daniels (2001) specifically

recommends that clinicians, under no circumstances, transmit confidential client data in an

electronic format due to the ease with which this information can be accessed by unintended

recipients. Many psychologists find themselves in confidentiality related ethical binds. They are

responsible for maintaining client confidentiality by refusing to provide any information about the

client-therapist relationship to unauthorized parties, and to safeguard that same information once

it has left the therapist's office and gone to a potentially unsecured database at the patient's

managed care company (Murphy et al., DeBernardo, & Shoemaker, 1998). Unfortunately, there is

very little that a psychologist can do to safeguard and control dissemination of the information

once it has left the office. In fact, recent legislation has been drafted to curtail managed care (and

other health-related) organizations from selling patients'/subscribers' social security numbers and

health data for profit (Deborah Peel, M.D., President of the National Coalition for Mental Health,

June, 2001, personal communication). Bilynsky & Vernaglia (1998) suggest that therapists

question managed care companies about their confidentiality policies before joining their provider

panels. Hanson & Sheridan (1997) also point out that case reviewers themselves are frequently

unlicensed, unregulated, and not bound to the same standards of confidentiality as are

psychologists. Integrity. Therapeutic integrity, as defined by Stern (1993) is "the establishment and

maintenance by a competent therapist of the conditions necessary for successful therapeutic

work" (p. 163). He contends that by mandating brief therapy (through session limits, annual dollar

caps, and utilization review) managed care companies frequently contribute to ethical dilemmas

pertaining to this important principle. Stern outlines several ways that therapeutic integrity is

threatened by managed care policies. First, managed behavioral health care companies' reviewers

often pressure therapists to quickly formulate treatment plans and to begin immediate, aggressive

intervention. This can prove less than helpful if a client's presenting problems are complex and

multi-faceted, and if the client is wavering on the decision to fully engage in the therapeutic

process. Quick intervention, necessitated by utilization of brief treatment models, during the early

stages can lead to premature termination (Keefe & Hall, 1999). As a result, clients are less likely

to receive the clinical services they need. Most therapists consider an atmosphere of safety to be pivotal to the therapeutic process

(Stern, 1993). An atmosphere of safety, however, can be difficult to attain when the therapist is

frequently required to justify further sessions to a third party. The therapist's ability to provide a

protected setting for treatment can become easily jeopardized by this process Therapeutic

integrity is likewise jeopardized. Kirschner and Lachicotte (2001) describe explain a variety of

integrity violating practices which have recently evolved in direct response to managed care

imposed limits. Honesty. The virtue of honesty with clients and with managed care companies is subsumed

under APA's Ethical Principle B: Integrity, which was addressed above . Pipal (1995) draws our

attention to the "skill" of finding the correct, reimbursable diagnosis for patients' "subjective

distress" (p. 325). In this case, "correct" is defined as reimbursable. Accuracy does not necessarily

enter into this equation. She asserts that psychotherapists consistently over-diagnose patients,

presumably in an effort to receive reimbursement from managed care companies. She cites a study

by the National Institute of Mental Health Epidemiologic Catchment Area Program (Narrow,

Regier, Rae, Manderscheid, & Locke, 1993) in which the authors found that nearly half of adult

outpatients lacked a DSM diagnosable disorder. She expresses concern with this practice, given

that a documented history of "mental illness" can lead to problems in the patient's obtaining

health, life, and disability insurance, securing suitable employment, and holding political office. The practice of'upcoding has been documented by a number of researchers in recent years

(Cooper & Gotlieb, 2000; Daniels, 2001; Keefe & Hall, 1999). Upcoding involves assigning an

inaccurate, typically more severe diagnosis or Global Assessment of Functioning score to a client

for the purpose of insuring reimbursability for the psychologist's services (Grubbs, 2001).

Gibelman and Mason (2002) report that method of payment (i.e., managed care or private

pay/fee-for-service) significantly impact case assessment and treatment planning. Psychologists,

psychiatrists, social workers, and professional counselors have reported engaging in upcoding to

varying degrees. Wolff & Schlesinger (2002) describe this situation as one of covert advocacy, in

which practitioners who are more concerned about being removed from provider panels are also

more likely to alter case descriptions to reviewers in such a way that will maximize the likelihood

of reimbursement. Messina (2002) describes this process as a means for manipulating around

managed care regulations on behalf of clients whom the practitioner assessed to be in genuine

need of clinical services. In addition to upcoding being a clear a violation of Ethical Principal B

(Honesty)

, both upcoding and downcoding constitute insurance fraud, an illegal activity for which

a practitioner can be prosecuted. In their survey of Division 42 psychologists, Murphy et al., (1998), found that 9% of

psychologists would choose the option of changing a diagnosis in order to secure additional

needed sessions. These authors found that, of the psychologists they surveyed, 63% rated the

following item at least a 7 on a 9-point scale, with 9 being "a great deal" : "To what extent do you

believe psychologists make alterations to a patient's DSM diagnosis or CPT code to protect

patient confidentiality, future employment, or future medical insurance?" (p. 46) In effect, this

means that the surveyed psychologists tend to believe that psychologists in general alter patients'

diagnoses by making them less severe or pervasive. Christensen and Miller (2001) note that the

most common diagnosis issued to managed care clients by the marriage and family therapists in

their study was adjustment disorder. Other authors have suggested that psychotherapy

practitioners may regularly inflate or exaggerate patients presenting problems and/or diagnoses in

order to be reimbursed for services (Buckloh & Roberts, 2001; Danzinger & Welfel, 2001; Ford,

1998; Pipal, 1995). Despite the prevalence of managed care in the contemporary marketplace,

training programs have largely failed to provide newly emerging practitioners with the

documentation skills and general knowledge which will be required of them (Kane, 2001) Informed Consent. Miller expounds on the importance of ensuring that patients are truly

giving informed consent for therapy. This includes educating the patient on what Miller (1996b)

calls invisible rationing: a term he coined which is defined as "a treatment allocation process that

reduces mental health services without informing the client of the reduction." (p. 583) Managed

care companies, for example, frequently advertise that they provide up to 20 sessions of

psychotherapy on a yearly basis (Stern 1993; Howard, 1998). The "invisible" aspect of this benefit

is that those sessions are not merely given at the request of the insured. Rather, they are secured

by clinicians who may spend additional, non-reimbursable hours pre-authorizing treatment,

completing necessary paperwork, conducting concurrent reviews, and maintaining compliance

with credentialling policies, in order for the patient (or the purchaser of the policy) to receive the

full measure of benefits which they purchased in good faith. Cummings, Budman, and Thomas (1998), on the other hand, dispute both the assertion

that the current system of managed care constitutes "invisible rationing" as well as assertions that

short-term therapy values are neither valid nor viable in contemporary practice. They describe

health care rationing as ubiquitous in modern society because they submit that it is impossible to

fully meet every health care demand of every member of a given society. These authors also

contend that all health care rationing can be considered "disguised," (p. 460) and that it is

unreasonable to single out mental health services as significantly more invisibly rationed than

other forms of health care. It is important to note, however, that regardless of the existence of

invisible rationing in areas outside the purview of mental health, failure to ensure clients'

understanding of its potential impact precludes clients from giving informed consent to treatment. A significant barrier to assuring informed consent is the use of non disclosure clauses

These clauses are portions of the managed care/clinician contractual agreement that preclude

therapists from informing clients of alternative, potentially useful forms of treatment which either

are more expensive to the managed care company or are not covered by the clients' behavioral

health care plan (Galambos, 1999). Legislation designed to curtail the use of gag clauses by

managed care organizations is being actively pursued by the National Coalition of Mental Health

Professionals (Karen Shore, Ph.D., former president of NCMHP, personal communication, May,

2001). Dual Relationships. Multiple relationships are defined in Standard 1.17 of APA's 1992

Ethical Principles. It is generally recognized that some multiple relationships are unavoidable, as is

the situation for many providers working within a managed care setting. Psychologists are bound

to refrain from entering relationships which could result in impairment of objectivity, negatively

impact effectiveness, or cause harm to the client. Therapists on various managed care provider panels have existing relationships with said

organization, and are thus well advised to heed the mandates of this Standard. When a third party,

such as a managed behavioral health care organization, is introduced into the client-therapist

dyad, a potentially harmful, therapeutically triangulated relationship is formed (Pipal, 1995). To

whom does the therapist owe his or her allegiance? The client or the managed care organization? Galambos (1999) offers practitioners some guidance in balancing the fiduciary relationship

with clients and the fiduciary relationship with clients' managed behavioral health care

organization. These relationships, by definition, involve mutual confidence that one party acts in

the best interest of the other, and imply that one party retains more influence over the other. For

psychologists, this can result in pitting one's obligation to the managed behavioral health care

organization to provide cost efficient, accurately reported psychological services, against one's

obligation to provide the client with the services that the psychologist believes to be most

appropriate and helpful. These dual fiduciary relationships can become problematic if clients'

expectations of psychologists' behavior conflicts with the contractual requirements of the

managed behavioral health care organization. This issue becomes even more complex when one considers the financial risk-sharing

agreements in which some therapists are participating, whereby the therapist is paid a salary by the

managed care organization to serve a given population (Hanson & Sheridan, 1997). It is possible

that therapists in this situation will become financially motivated to keep treatment as brief as

possible, although this might not be in the best interest of the client. In a related APA Standard

(1.21), third party requests for services are addressed. Psychologists are remanded to clarify the

nature of their relationships with both parties at the outset of services. This includes disclosure of

potential role conflicts (e.g., the above mentioned risk sharing agreement). Doherty and Heinrich (1996) address this issue in a broader fashion. They delineated

several different stakeholders in the client-therapist relationship. Among these are: the

patient/family, the managed care organization, the employer/payer, the government, the clinical

administrator, and society. These authors highlight the values, tensions, and blind spots of each of

the key players and how those are addressed on a day-to-day basis within and outside of managed

care organizations. They recommend a systemic approach to the resolution of the ethical conflicts

of managed care. The importance of creating a health care system that is responsive to the needs

of all stakeholders is highlighted by Mirin (2001). Mirin also highlights the importance of

participation of all stakeholders in the decision-making process. Results of a recent exploration of

a newly established public sector managed care initiative in Los Angeles support Doherty and

Heinrich's (1996) contention. Potentially grave consequences for the seriously mentally ill are

described by Mowbray, Grazier, Kyle and Holter (2002), and largely parallel those of the

deinstitutionalization of psychiatric patients during the 1960's. Many researchers strongly

encourage careful consideration of the array of stakeholders who will be effected by managed care

implementation, particularly in the increasingly complex public sector (Rothbard, McFarland,

Shern, Morrisey, Leff, & Wylie, 2002; Sullivan, Young, Fortney, Tillipman, Mrata & Koegel,

2001). Ivan Miller (1996 a,b,c,d) is rather outspoken on the subject of dual relationships inherent

in managed care. He advocates for clearly explaining to clients the divided loyalties of the

therapist in relationship to the patient's managed care organization. In other words, Dr. Miller

believes it is the responsibility of the therapist to make the client aware of any fiscal arrangement

with the patient's managed care company which may in any way affect treatment decisions. For

example, if a provider is only retained on a panel as long as he or she maintains a "reasonable"

average length of treatment, the ethically practicing provider would make the patient aware of

that arrangement. Manual-Based Treatment Managed behavioral health care organizations can present an assortment of ethical

dilemmas described above. In addition, some MBHOs are embarking on a method to standardize

individual and group (Mitchell, 2001) therapy through the use of manual-based treatments

(Margues, 1998). Magellen Health Services, the largest managed behavioral health care

organization in the United States, provides several reasons for use of manual-based treatments,

including a reduction in the variability of practice, increased consumer satisfaction, and decreased denials of care. Other authors (Strosahl, 1998) have noted that the mandated use of manual-based

treatment protocols by managed care companies is on the rise, a trend that is likely to continue. Efficacy vs. Effectiveness. One significant issue in the use of manual-based treatments is

that of proven utility. The utility of a given treatment can be assessed by one of two basic

methods. Either efficacy or effectiveness studies (or preferably both) should be conducted to

explore the utility of a given, standardized treatment protocol. Carroll (1997) defines efficacy as

"results obtained under ideal treatment conditions, such as those present during rigorous clinical

trials." (p. 352) Effectiveness, on the other hand, is defined as "the results obtained under normal

conditions of treatment delivery." (p. 354) Efficacy, Stone (2001) points out, is not enough,

particularly in a managed care environment in which meticulous resource allocation is a

fundamental goal. Unfortunately, much of the manual-based research involves efficacy studies

rather than effectiveness studies; therefore, the actual clinical utility of the given approach outside

an intensive research setting remains unclear. Strosshal (1998) highlights several problematic aspects associated with the widespread

utilization of manual-based psychotherapies for behavioral health program directors, line

clinicians, and consumers of behavioral health services. One concern is the tendency for manual-based approaches to be effective only with relatively "pure" versions of a given disorder. When

clients have co-morbid diagnoses or present with a relatively more complex clinical picture, the

utility of the approach fades. A related problem is the complaint of the restrictive nature of

manual-based treatment protocols. They are not seen as "user friendly", and the document is often

rather unwieldy and difficult to access when immediately needed in order to make a complicated

or pressing clinical decision. In addition, the cost to train a clinician in one of these models can

approach figures which make it inaccessible to many, particularly in large organizations where

numerous practitioners would require this training. Locus of Control and Leadership Style. The introduction of ethical dilemmas due to mandated use

of manual-based treatments creates a working atmosphere that some psychologists may

experience as generally unaffected by their actions or goals. Psychologists' perceived loss of

control over decision making was identified as one of the top four areas of concern identified by

Rothstein, Haller, Osna, and Bernstein (2000). Within one year of the installation of managed care

for Medicaid recipients in Iowa, psychologists again reported both decreased levels of job

autonomy and job satisfaction (Russell, de la Mora, Trudeau, Norman, Norman, & Schmitz,

2000). Managed care related loss of control over clinical decisions emerged as one of the five

issues of greatest concern identified by 156 members of the Christian Association for

Psychological Studies (CAPS) clinicians (Greggo, 2001). Results of research conducted by Mirabella (2001) indicate that managed care influence, in

and of itself, did not negatively affect psychologists' level of job satisfaction. Autonomy, on the

other hand, was a significant predictor of job satisfaction. The measurement of managed care

influence in this study, however, was somewhat limited and confounded. The three indicators of

managed care influence examined by the author were: percent of time spent in managed care,

perceived loss of autonomy due to managed care, and perceived satisfaction in working with

managed care. Given the significance of considering age or number of years in practice as an

important co-variate when examining psychologists' job satisfaction, as documented by Johnson

(2001), it is possible that Mirabella's results may be incomplete. Literature on optimally effective models of leadership have demonstrated workers' clear

preference for more participatory versus authoritarian models (Hendricks, 1996). One may liken

managed care organizations, particularly at the case manager level, as functioning in an

administrative leadership position with respect to practitioners. Practitioners are obligated to

provide detailed reports to case managers to demonstrate effective job functioning, which the case

manager determines based on the client's progress. Managed care representatives, at their

discretion, delegate tasks to practitioners. Practitioners who do not meet expectations may be

disciplined by managed care organizations via decreased referrals and/or removal from the panel.

Practitioners' paychecks are distributed by managed care entities. It is in this sense that managed

care organizations largely mirror the role of traditional management. Theory and research in the area of leadership style effectiveness has a long history of

examining autonomy and participative decision making as critical, moderating factors (House &

Mitchell, 1974; Hersey-Blanchard, 1982; Kerr & Schriesheim, 1974). A brief discussion of

taxonomies of leadership style is illustrative of how crucial the autonomy/locus of control

construct becomes when evaluating job satisfaction. Based primarily on expectancy theory, Path-Goal leadership theory was described in the following manner by House (1973): "the force of an

employee to engage in behavior is a function of his [sic] expectation of a specific outcome and the

value of that outcome". A logical application of this concept to the field of psychology becomes

clear when one considers a typical scenario regarding, for example, a request for authorization of

continued sessions for a given client. An expected denial of the request or perception of the

necessity of fabricating a more reimbursable diagnosis in order to be granted authorization to

continue treatment coupled with the value a practitioner places on the decision (e.g., that

continued treatment is in the best interest of the client) can lead to an untenable situation. The acceptance of requests for pre-authorization and continued authorization are

necessary for therapists to do their jobs. Influence over the acceptance of this request, however,

may be largely out of the hands of the practitioner working for some managed behavioral health

care organizations, unless he or she is willing to sacrifice professional ethics and/or personal

values to fabricate a diagnosis which will ensure authorization. Practitioners working with many

managed behavioral health care organizations have experienced problematic results, particularly in

the area of retaining professional autonomy. Rather than making clinical decisions based solely on

his or her own perception of the best interest of the client, a managed behavioral health care

organization may influence that decision. This change in autonomous clinical decision making as a

result of managed care participation has been identified as problematic by a number of researchers

(Buckloh & Roberts, 2001; Danzinger & Welfel, 2001; Glosoff et al., 1999). Early research and theorizing explored the relationships among job satisfaction, worker

autonomy, and management styles. House (1974) described locus of control for the employee and

the type of formal authority system as factors on which satisfaction with management and

performance motivation hinge. Stinson & Johnson (1975) suggested that the factors influencing

job satisfaction of highly educated (e.g., psychologists) and highly independence-driven

employees' may differ from those of other types of workers. Leadership or management styles

(e.g., that of the MCO) can also significantly impact the satisfaction of employees. For example,

Doltich & Cairo (1999), in their manual describing strategies for increasing the effectiveness of

leaders, describe leaders who need to be in control as one of the six most common issues

underlying problematic management styles. This style of leadership whereby worker autonomy is

discouraged, can be problematic for psychologists if their levels of personal autonomy and

independent decision are diminished. Early models of the effectiveness of various leadership styles can be helpful in

understanding basic concepts that relate to worker satisfaction. The the Leadership Behavior

Description Questionnaire (LBDQ) posits a two-dimensional taxonomy of leadership styles

comprised of combinations of high and low "consideration" (employee centered) and "initiating"

(production centered) structures. Degree of autonomy was identified as a significant situational

variable moderating scores on this instrument (Kerr & Schriesheim, 1974). In a more recent

application of the theory underlying the LBDQ, Wilkinson (1990) describes the four basic

categories as (1) directing, (2) coaching, (3) supporting and (4) delegating. The "directing" style

of leadership was directly and negatively related to job satisfaction. The directing style couples

heavy emphasis on production (e.g., continued, judicious use of therapy sessions) with low levels

of consideration for the employee. Interestingly, regardless of therapists' measured locus of

control, lower levels of direction were associated with higher levels of satisfaction. The conceptualization of management is in the process of undergoing a transformation in

which coaching, mentoring, and counseling comprise the three major roles of contemporary

leadership (Hendricks, 1996). Hendricks (1996) offers guidance for managers facing the problem of dealing with the authority-driven subordinate. Recognition of knee jerk obedience, traditionally

seen as a laudable employee characteristic, as a problem, is a potent example of the significant

changes in the definitions of the quintessentially ideal team setting of the contemporary

marketplace. Ideal employees are no longer automatons; rather, worker autonomy is now

routinely nurtured by many contemporary workplace leaders. Seeing employers as teammates and

establishing shared ownership of goals are identified as criteria for evaluating the effectiveness of

'"coaches", a term that is coming to be interchangeable with the increasingly antiquated term

"manager". This fairly subtle change in verbage highlights the importance placed on fostering and

rewarding independence in employees. A factor analysis of the Survey of Counselor Satisfaction, an instrument recently

developed by Parr et al, revealed that therapists' perceived level of independence was an

important predictor of job satisfaction. Parr et. al. (1996) highlight the significance of the 18-item

Empowerment factor. The SCS results collected from 167 Association of Counselor Education

and Supervision (ACES) members indicate that the Empowerment factor was rated as

significantly more desirable than the other factors. Responses that address the respondents' belief

that his or her work is sufficiently potent to make a difference contributed, in part, to the

Harmony factor, as well, and are similarly reflective of the influence of a a locus-of-control

construct on counselors' job satisfaction. The locus- of-control construct, though labeled in

different ways across various studies, is beginning to emerge as an important ingredient in the

mental health practitioner career satisfaction equation One byproduct of effective interaction of autonomous employees with effective leadership,

is the establishment of a collaborative working atmosphere. In Hargrove's (1995) book, Masterful Coaching: Extraordinary Results by Impacting People & the Way They Think & Work

Together

, a major premise is the mission critical nature of facilitating collaboration in the

workplace. Breakdowns in morale are attributed to a failure in this collaborative process. By

definition, collaboration requires concerned parties to establish a common mission. For the

purpose of the present study, these concerned parties are the managed care organization and the

therapist. In the MCO/psychologist scenario, true collaboration is frequently precluded by

commitments to often radically competing and mutually exclusive goals. Cost containment, a

primary mission of MCO's case reviewers, can be directly at odds with the primary mission of the

psychologist. Moving beyond the mere restoration of previous level of functioning toward the

enhancement of emotional growth and development of the client as well as prevention of

recurrence of the original presenting problem is more descriptive of the general treatment goals

that clients and psychologists may envision. Success, in terms of therapeutic effectiveness, may be

defined quite differently by MBHOs, their employees, (e.g., psychologists), and clients. Another significant barrier to the establishment of a collaborative atmosphere, according

to Hargrove, is the failure of team members (i.e., MCOs and psychologists) to reveal the process

by which they arrived at their decision, and the data on which that decision was based. In fact,

Hargrove's primary ground rule for collaborative conversation is mutual sharing of relevant

information. Resistance of MCOs to make providers and clients aware of the decision-making

criteria used in rendering authorization for initial sessions, continued sessions, and changes in level

of care (e.g., outpatient, day treatment, inpatient, or residential), as well as the use of gag clauses

previously described, coupled with practitioners' fabrication of reported diagnoses may preclude

establishment of this necessary precursor for collaboration (Acuff et al., 1999; Sabin & Daniels,

1994). In addition, this author draws attention to the deleterious effect that high stakes can have

on developing a collaberative working atmosphere. The MCO, therapist, and client each will be

effected by authorization decisions. The MCO is under considerable pressure to contain costs and

please shareholders. The psychologists' primary function is to facilitate healing/growth for his/her

client. Finally, and arguably most importantly, the patient desires, deserves, and genuinely needs

relief from his/her presenting problem or concern. Clearly, the stakes are high for all parties

concerned. Job Satisfaction of Mental Health Professionals As is true of the collaborative management style construct explained above, career

satisfaction has long served as a major focal point in the field of industrial/organizational

psychology. Levels of career satisfaction, as well as factors which directly or indirectly influence

those levels, have been examined for a broad range of occupational fields. Levels of career

satisfaction of mental health professionals, although not extensively researched as yet, have begun

to receive more empirical investigation in recent years (Dupree & Day, 1995; Gibelman & Mason,

2002; Greggo, 2001; Kalman. & Goldstein, 1998; Riffe, 1999 ). Psychologists, psychiatrists,

professional counselors, substance abuse counselors, and particularly rehabilitation counselors

(Garske, 2000) have, in the past five years, been the subject of career satisfaction studies. A fairly limited array of variables has been identified as moderators of mental health

professionals' career satisfaction. These variables include: gender (Black & Holden, 1998), age

(Riffe, 1999), private practice versus public sector work setting (Dupree & Day, 1995),

satisfaction with clinical supervision (Evans & Hohenshil, 1997), perceived control over desired

role functioning (Levinson, 1990), and participation in managed care (Parr, Bradley, Lan, &

Gould, 1996; Riffe, 1999). Weitz and Eugene (2000) point specifically to the socioeconomic

impact of managed care as a primary contributor to general sense of dissatisfaction among

psychologists. Herzberg's major contribution to the job satisfaction literature was his well-known and

extensively researched theory of job satisfaction in which 'hygiene factors' (e.g., company policy,

supervision, salary, security) contribute to job dissatisfaction

, while 'motivating factors' (e.g.,

recognition, achievement, advancement) contribute to job satisfaction

. Accordingly, one may

reasonably posit that managed care organizational policies and decreasing monetary remuneration

may contribute to psychologists' job dissatisfaction, as well. Research investigating organizational role theory has illuminated the concepts of role

conflict and role ambiguity and their impact on job satisfaction (Biddle, 1986). Similarly, the focus

of cognitive role theory is on the relationship between role expectations and interpersonal,

personal, and organizational factors. The function of the "role sender" is important in this theory,

in that different role senders (e.g., case reviewers, peers, clients) may engender a wide range of

potentially contradictory role expectations. Role conflict is defined as "the incongruity of the

expectations associated with a role, such as expectations from role senders which are

incompatible with those from another sender and/or the person him/herself". The role senders of

interest in this study are case reviewers and clients, in that they may or may not contribute to

experienced role conflict for the psychologist. Intrasender, intersender, and interrole have been identified as types of role conflict that are

significantly related to decreased job satisfaction (Coll, 1990). Role conflict, in turn, was found to

be positively correlated with powerlessness. Gonzales (1975), Jackson and Schuler (1985), Fisher

and Gitelson (1983) and Monnett (1980) also found a significant correlations between decreased

role conflict and increased job satisfaction. Monnett specifically concluded that participatory decision-making contributed positively to the job satisfaction of counselors. Although the strength

of the relationship varied across occupational fields, Jackson and Schulers' (1983) review of the

literature in this area found a relationships among role conflict, role ambiguity, and job satisfaction

to be strong, negative, and consistent. In his 1990 study of college counselors, Coll found a significant correlation between role

congruence, which included both the elements of role conflict and role ambiguity, and job

satisfaction. In addition, this researcher discovered a significant, positive correlation between

moral values and role conflict. The ethical dilemmas highlighted earlier, consequently, may

contribute to psychologists' perception of role conflict. Perceived organizational policies and

practices in this study were significantly correlated with role congruence. Applied to the managed

care organization, this may indicate the possibility of a negative impact on psychologists' overall

experienced level of role congruence. To illustrate, Coll described specific areas of role conflict

experienced by college counselors as "I receive incompatible requests from two or more people";

"I have to buck a rule or policy in order to carry out an assignment" and "I have to work on

unnecessary things" (p. 98). These three items from Coll's Role Questionnaire closely echo

frequently reported frustrations experienced by mental health professionals in the context of their

managed care involvement. A growing body of empirical research has recently emerged linking higher levels of

involvement with managed care and decreased career satisfaction (Russell et al., 2000). In her

investigation of 442 clinical social workers, Riffe (1999) found statistically significant and

negative correlation between job satisfaction and amount of practice reimbursed through managed

care. The author also identified managed care infringement on the application of independent

clinical judgement as an important area for further study, in terms of its contribution to decreasing

satisfaction. In keeping with Riffe's suggestion, the proposed study is designed, in part, to

evaluate the contribution of counselor locus of control to levels of career satisfaction. Unfortunately, the measurement of level of involvement with managed care in the Riffe

(1999) study is obscured because, regardless of the percentage of clients covered by managed

care, the response to the questions would vary little. The following Likert-like items were used:

(1) Funding sources specify the type of client I work with, (2) Funding sources influence the

length of time I treat a client, (3) Funding sources limit the types of treatment activities to the

detriment of my clients, and (4) I find that the demands of funding sources conflict with

professional ethics. The percentage of cases in which participants engaged in treatment comprised

the index of "funding source influence" (p. 46). Using this formula to determine level of managed

care influence, a caseload comprised of 1% and a caseload comprised of 100% managed care

clients could net identical scores. The author's use of "percentage of cases in which participants engaged in brief treatment"

(p. 47) also is somewhat equivocal as an index of managed care influence, in that brief term

therapy, although preferred by many managed care companies, is not exclusively used with

managed care clients. Rather, brief therapy is used with non managed care clients, as well.

Therefore, the use of responses to this item as an indicator of funding source influence is less than

satisfactory. Predictably, analysis of this variable revealed no significant correlation with

satisfaction. An additional psychometric concern is Riffe's (1999) use of a very small number of items

(i.e., five) to measure job satisfaction. For the above mentioned reasons, although her study does

point to areas for more thorough investigation, its results may or may not accurately represent the

influence of clinician's managed care involvement on their levels of career satisfaction. Another

noteworthy finding was the reported correlation of -.24 (p < .001) of autonomy with funding

source (ostensibly managed care). Given that eight years have passed since these data were

collected and analyzed, it is reasonable to suspect that the results of a similar study conducted

today might reflect the growing influence of managed care outlined above. Similar to Riffe's (1999) study, Kalman and Goldstein (1998) found that psychiatrists'

participation in managed care was associated with declining professional satisfaction. Again, the

results are difficult to accurately interpret or generalize for a number of reasons. First,

respondents' level of participation in managed care was reduced to a categorical (yes/no) variable,

rather than a more readily interpretable interval score (e.g., percentage of income derived from

managed care, percentage of caseload from managed care referrals, number of work hours per

week invested in managed care activities). Further, professional satisfaction was assessed using a

single item. Other findings of interest in this study included a slight decline in income and a

movement from the provision of psychotherapy to visits that mainly consist of assessing tolerance

and effectiveness of medication. Additionally, the study was based on data collected from a

random sample of Cornell Department of Psychiatry faculty members at the Manhattan campus.

Generalizability of these results is limited at best. The Survey of Career Satisfaction (SCS), an instrument with great promise specifically

designed to tap dimensions of career satisfaction for mental health professionals, was developed

by Parr, Bradley, Lan, and Gould (1996). An exploratory factor analysis on this 52-item

instrument revealed a five-factor solution that the authors subsequently labeled (1) Empowerment,

(2) Administration, (3) Harmony, (4) Stress-freeness and (5) Security. Number of items per scale

ranges from 3 to 18. Reliability coefficients for scores on these scales are .96, .93, .91, .91, and

.71, respectively. Summary The introduction of managed care into the fabric of the therapeutic relationship has been

met with considerable concern by mental health professionals. The complaints and concerns of the

professional community seem to fall broadly into two general types: those effecting the

practitioner personally, and those effecting the client and/or therapeutic relationship. Personal

variables of concern included decreased income, extensive paperwork requirements, and loss of

professional autonomy. Variables affecting the client and/or the therapeutic relationship include limits on treatment

modality (i.e., individual or group treatment vs. family or marital therapy) as well as restriction of

treatment duration. The brief therapy models and/or manual-based treatment regimens prescribed

by managed care organizations have been found to be effective for a circumscribed group of

clients and presenting problems. However, practitioners trained in the more traditional models of

treatment are frequently precluded from applying those models regardless of whether or not

longer-term treatment is clearly indicated. Ethical dilemmas engendered by the use of managed

care are cited as anothe