Academic Psychiatry 24:228-230, December 2000
© 2000 Academic Psychiatry
Teaching Brief Therapy in a Managed-Care Environment
Nancy Kaltreider, M.D.,
Ellen Haller, M.D.,
Jacquelyn Chang, M.D. and
Judy Eastwood, L.C.S.W., Department of Psychiatry, University of California, San Francisco, CA
Key Words: Managed Care • Brief Psychotherapy • Letters
TO THE EDITOR: Teaching in a managed-care environment raises concerns that the quality of psychiatric education will be diminished, with a resultant negative impact on both residents and faculty (1). As academicians, we feel a responsibility to survive in the new health care era by providing teaching about appropriate services delivered effectively and efficiently (2). The complexities of teaching brief dynamic psychotherapy under managed care can include provider discrimination against trainees, inappropriate case assignment, inadequate treatment reauthorization, and abundant paperwork. Rather than endlessly debate the health care delivery system, we chose to design a model teaching program for advanced residents that would emphasize the value of psychodynamic therapy while providing a realistic experience of managed-care constraints and ethical dilemmas. Our faculty participation as direct providers of patient care in the system encouraged creative solutions to clinical dilemmas and a sense of camaraderie.
The brief dynamic psychotherapy teaching experience occurred within the WomenCare Mental Health Clinic, a specialized faculty outpatient clinic in the University of California at San Francisco (UCSF) Department of Psychiatry system, in which about 85% of the patients served are covered by managed-care contracts. A 6-month demographic sampling of our patient population (Haller E, et al: Developing an academic women's mental health clinic in a managed-care environment, unpublished) found that they ranged from age 19 to 71 (median: 37), were mostly Caucasian (72%), single (44%) or divorced (16%), heterosexual (83%), had a college (35%) or graduate school (32%) education, and were employed in responsible positions. Diagnoses were most commonly in the depression/anxiety spectrum, and the average number of treatment sessions was 7.6 for faculty patients (a mixture of medication management and psychotherapy cases) and 12.0 for resident patients (psychotherapy as the primary treatment modality).
The teaching challenge.
From its inception, the faculty of the WomenCare Mental Health Clinic conceptualized the clinic as an excellent training site. It had been increasingly difficult in recent years to identify candidates for brief psychotherapy in the UCSF general-outpatient psychiatry clinic; in contrast, the WomenCare Clinic attracted motivated, employed patients, many of whom had circumscribed problems that appeared ideal for a brief treatment approach including dynamic psychotherapy and medications as indicated. Self-pay patients are eligible for a fee reduction when in treatment with a resident, making conversion to self-pay a reasonable alternative for those patients when they were no longer covered under medical necessity. The clinical experience in a supervised setting was excellent preparation for the residents' eventual transition to clinical practices mandating time and outcome accountability.
We were not naïve, however, about the potential disadvantages of trying to teach in a managed-care environment. Foremost was the overwhelming paperwork, daunting to both faculty and trainees. We worried that residents might require more time than faculty to reach the same treatment outcome, thus using up the patients' limited authorized visits. In the initial visit, we had to set a realistic-length contract and include discussion of possible conversion to self-pay; without a well-formed treatment alliance, we were concerned that patient disappointment in the inadequacy of managed-care treatment coverage would land solidly on the vulnerable resident. Even with early discussion defining the boundaries of "medical necessity," many patients had a strong "conversion reaction" when later changing to self-pay. We knew that patient confidentiality is already compromised in a managed-care setting, and teaching that involved supervision, seminars, and tape recording had the potential to add another level of stress for patients.
A working plan.
With a realistic idea of our context, we worked together to design a teaching plan that would provide an opportunity for residents to learn focal psychotherapy skills in a supportive faculty environment. We decided to use the Mann (3) model of time-limited dynamic therapy because the fixed contract makes a virtue of understanding the psychological meanings of limited time and tends to produce clear therapy phases of alliance/focus, working through, and termination. Not all patients are appropriate for the intensity and fast pace of such a therapy, so we decided to have the paid clinic faculty do the initial phone-screening and evaluation interview, including all the entry paperwork. The evaluation interview includes a review of the treatment constraints in the managed-care system by the faculty person. A demonstration video of a typical discussion is shown to residents to familiarize them with how the contract has been discussed. By mid-year, residents are ready to take over the evaluation interview as well. After evaluation, cases that are judged to have good brief psychotherapy potential based on a clear focus, psychological-mindedness, and a history of significant relationships are transferred to a resident for a 10-session dynamic psychotherapy. The faculty interviewer is available to the resident to discuss the formulation, focus, and likely transferential issues. Cases that do not enter the teaching system continue to be followed by the faculty evaluator.
We feel that effective brief therapy is a complex skill, best honed out of years of clinical and theoretical exposure. Our clinic offers this year-long elective to fourth-year residents, male and female, and we have had four residents for each of the last 3 years. Each resident carries two cases at a time and is assigned to a weekly hour with an outside volunteer faculty supervisor familiar both with brief therapy and working in a managed-care system. A weekly 1-hour teaching conference is attended by residents, clinic faculty, and most of the volunteer faculty. Presentations include clinical cases in progress, by use of video/audio tapes and case summaries; review of theory, by use of previously videotaped cases; discussion of care dilemmas with an emphasis on applying traditional medical ethics to the emerging pattern of practice; and a focus on women's unique issues in therapy and psychopharmacology. Topics especially relevant to managed care included patient advocacy and education, abandonment, treatment limitations under "medical necessity," and the use of flexible patient contracts to maintain a longer- term relationship (4).
The teaching environment allows the faculty to model our approach to the regulatory frustrations, and the team approach combats demoralization. Because the supervising clinical faculty also treat managed-care cases in their own caseloads, they avoid the demonization of managed care that could sidetrack any creative approach to patient needs. Our weekly case conference and seminar for faculty and residents uses AMA guidelines to understand and debate conflict-of-interest and other ethical issues. Patient symptom-reduction, achievement of treatment goals, and outcome satisfaction reinforce the learning experience that considerable benefit can be achieved in a focal therapy. We also openly discuss what characterologic or complex change will not likely occur in this model and encourage referral for long-term treatment when those needs clearly emerge—from the patient's perspective (as differentiated from the resident's need to prolong therapy).
Results.
Residents often maintain some ambivalence about the sufficiency of brief, time-limited therapy even after exposure to theory and practice in the third year, but they now have an experiential basis upon which to evaluate the best candidates and most effective techniques. The teaching conference provides an invaluable environment for both support and learning. Through presentations of audiotaped excerpts of difficult moments in the therapy, residents are able to learn from both supervisors and peers. The realization that a number of approaches might all be dynamically informed is reassuring.
Not surprisingly, residents grow considerably in their familiarity with managed-care issues. During the course of the year, residents become comfortable discussing the concept of medical necessity with patients and with completing managed-care paperwork. In some circumstances, they learn to adapt to a patient's wish for more structured and less dynamically- oriented psychotherapy. Residents derive solace from the hope that a successful brief therapy might pique a patient's interest in pursuing more explorative work in the future.
At termination, 68% of the patients treated within the 6-month sample period by faculty and residents indicated that they were "very satisfied," and 23% indicated that they were "mostly satisfied." The managed-care systems did provide our patients with a collaborative model of health care and relatively easy access to psychiatric services. The Department of Psychiatry's development of in-house centralized services for managed-care referrals and for utilization review facilitated good communication with the teaching program. Patients with managed-care insurance were disadvantaged by the differentially higher co-pay for mental health services as compared with general-medical visits and the need to accept the transition from medical-necessity coverage into self-pay when sufficient clinical improvement occurred.
Discussion and Conclusions.
It is important to choose teaching goals that are aligned with a particular clinical setting. At the administrative level, an academic department has a responsibility to educate the managed-care companies about how teaching carefully supervised residents can improve patient care. It has been particularly helpful to work with managed-care companies in which case assignment and treatment reauthorization are done in house, so that the administrative staff can understand our clinical and teaching goals. As faculty, we have tried to discourage an "us vs. them" mentality, but rather chose to focus on quality of care and patient advocacy. We have worked as a team rather than dumping the "scut" on the residents. Our own direct managed-care clinical experience allows us to share realistic vignettes and approaches to providing the best care possible. Residents who leave our program are competent, enlightened, and wary—not a bad preparation for the current world.
ACKNOWLEDGMENTS
Portions of this letter were presented at the Annual Meeting of the American Psychiatric Association, Washington, DC, May 19, 1999.
REFERENCES
- Pardes H: The future of medical schools and teaching hospitals in the era of managed care. Acad Med 1997; 72:97- 102[Medline]
- Faulkner L, Bloom J: Ensuring the survival of psychiatry in the new healthcare era. Academic Psychiatry 1999; 23:82-87[Abstract/Free Full Text]
- Mann J: Time-Limited Psychotherapy. Cambridge MA, Harvard University Press, 1973
- Hoyt M: Brief Therapy and Managed Care: Readings for Contemporary Practice. San Francisco, CA, Jossey-Bass, 1998
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