mgdcare

For a number of years we here at Family Institute of Westchester have been involved
in discussions about where family therapy training is going. We’ve periodically
entertained a number of possible alternatives to our traditional training: for a while
we even explored how we might re-work our entire program to accommodate what
seemed to be the “market’s” demand for exclusively short-term, solution-focused
therapy. We looked at “niche marketing” for the Institute—i.e., maybe we should find
the one thing we did best and market it intensively; and, truth be told, we once
discussed seriously whether our time had come—perhaps we had to acknowledge that
training in family therapy was obsolete and we should close our doors. Many people
in the field have pointed out that the world of managed care no longer provides the
security with which many therapists had grown comfortable. I look back to when I
began practice in the seventies. My first clients, a college student and her parents,
paid $12. I was thrilled. It even got better.

By the mid-eighties, in order to satisfy the minimal demands of the insurance industry
most psychotherapists discovered the catch-all “adjustment disorder” diagnosis and
the world was their oyster!   Many family therapists believe that we sold ourselves
to the medical model because the marketplace demanded it. If insurance companies
were willing to pay, we were willing to play. It seemed reasonable for believers in a
systems model to buy into the medical model, as long as it paid the bills. But with the
advent of managed care we panicked. What were we to do? If we joined   panels we
sold our souls. If we didn’t, we feared we’d go broke. And certainly, how could we
expect that people would consider getting trained as family therapists if they couldn’
t anticipate earning a living at it. Personally I had removed my name from the few
panels I was on because I found it demoralizing talking to the disembodied voice of
some clerk on the telephone who was making treatment decisions. And writing the
reports was not only sheer torture; it bordered on the dishonest. And yes, people
called and asked whether I was on PruCare or on Oxford, or VBH, and when I said no
they often didn’t make the appointment.

Something had changed. Potential clients seemed entrenched in the belief system that
therapists had never discouraged, and from which they had long benefited: the
insurance company was in charge of the help they needed. If we can only have a few
sessions, if we have to see only those on an approved list, if we need to be medicated,
if our confidentiality is compromised, if our mental health needs are dictated by the
deal our company has struck, well...so be it.

But now for the (real) good news. As rapidly as we felt this new onslaught is nearly
as quickly as we can look beyond it. As one therapist has suggested, “...the managed
care revolution is the best thing to happen to therapy since the great reimbursement
giveaway...it may actually save the field.” Her point is that as we disengage ourselves
from the restrictions of the medical model we will find new and creative ways to
practice. I cannot agree more. While it may be true that doing therapy is no longer the
equivalent of a first-class ticket to the good life, what is true is that with creativity
and flexibility family therapists have much to offer—and we at FIW continue to have
much to teach them.

So what does all this mean for our continuing training at Family Institute of
Westchester? Managed care companies are not going to pay for the problems endemic
to the life cycle; they’re not going to pay for couples desperate to make some meaning
out of their relationship; they’re not going to pay to learn how to raise children,
impart values and feel less anxious in a terrifying world; they’re not going to pay a
family attempting to regain their equilibrium after a company downsizing; nor are
companies likely to write checks for lesbian couples contemplating adoption, black
couples assailed by every-day racism, single women coming to grips with living in a
married world, or families coping with a mother’s chronic illness or contemplating a
future after the death of a loved one.

These are the problems family therapists know, what we practice and we teach.
There is a world of “consumers” out there who will buy the “product” and still lots
of folks who want to learn the skills to provide it. Offering a family therapy that
meets the needs of couples and families, regardless of whether their insurance
company chooses to pay is a goal of our training at FIW. Most of us now practicing
therapy were on the client side at a time when insurance coverage was non-existent.
We paid for therapy because we believed in it; few of us regret the thousands of
dollars spent and we are still believers.

Family therapy in the age of managed care: Where does FIW stand?

by Elliott Rosen, Ed.D., L.M.F.T.,
Director Emeritus