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Book Reviews |
Key Words: Books Reviewed
Sperling and colleagues have written a pragmatic, concise, thorough manual for the psychodynamic clinician who is entering upon work with managed care organizations. Remaining neutral as to the advisability of engaging with managed care, the authors describe how, within constraints, it is possible to do some meaningful work.
The book can be read in its entirety or sampled for relevant chapters. Illustrative case vignettes are scattered throughout.
The first of eight chapters explores some of the implications of making the change to a treatment triad. A case vignette has the therapist taken off the panel of a company that had proven impossible to work with in good faith. An overview of treatment and ethical dilemmas follows. Such dilemmas are explored throughout the work, but there is perhaps too little examination of the pitfalls awaiting the unwary clinician who attempts to accommodate the demands of managed care.
The second chapter summarizes the history, structure, and agenda of managed care as these are reflected in interactions with therapists. The following chapter clarifies insurers' conception of medical necessity, describing the emphasis on functional impairment and the lack of appreciation for psychodynamic considerations on the part of care reviewers. A graph dividing possible cases into quadrants with orthogonal dimensions of functional and intrapsychic impairments illustrates the points at which managed care may be approached for support with realistic expectation of success.
Perhaps best fulfilling the intention announced in the title are the chapters "Transforming Psychodynamic Concepts into a Managed Care (Functional) Language" and "Documenting Psychodynamic Treatment in a Managed Care Format." These constitute a detailed guide to the formulation of treatment plans in the concise, "atheoretical," functional language likely to win approval of managed care. The authors provide examples of treatment plans in which elaborate dynamic formulations are condensed into a format that gives managed care the "just sufficient information." There follows a thoughtful consideration of what can and cannot be accomplished within the temporal constraints of short-term treatment.
A chapter on the use of outcome studies provides a good overview of the many scales that might be used to demonstrate both improvement and the need for continuing work in therapy. The limitations and ease of administering each instrument are summarized. Unfortunately, the authors do not discuss whether, in their experience, using these scales helps secure support for treatment.
The final chapter revisits the central concepts in a "frequently asked questions" format, describes current developments in managed care, and predicts likely aspects of its evolution. The reference section includes an annotated bibliography, an appendix with sources of rating instruments, and a glossary.
Though somewhat dry and redundant, the Strategic Guide admirably fulfills its stated task. Readers will find lucid, practical guidance in the difficult task of succeeding as effective and ethical psychodynamic clinicians in the brave new world of managed mental health care.
As the authors of this book acknowledge, the experienced clinician looking for a more general guide to coping with managed care or getting on provider panels should look elsewhere. In-depth consideration of the impact of managed care on the psyche and culture of clinicians is also relegated by default to other works. Its strength is greatest for the therapist with a psychodynamic practice and limited experience working with managed care who is contemplating entering the fray; and for such it is highly recommended. it may also be of value to the new therapist of any theoretical background who is learning to deal with managed care.
FOOTNOTES
Dr. Feldman practices in Mentor, OH, as part of University Mednet and is Clinical Assistant Professor of Psychiatry at Case Western Reserve University School of Medicine, Cleveland, OH.
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