Marriage and family therapists evaluate managed mental health care: a qualitative inquiry

This study examined the experiences of 26 marriage and family therapists working in managed mental health care. A qualitative strategy was used to explore therapists' perspectives regarding practice in a managed care environment. Using an open-ended, semi-structured, mailed questionnaire four themes emerged from the data. These are the adaptations of clinical practice, issues of treatment duration/abandonment, effects of managed care on the therapeutic relationship, and issues of diagnosis. Recommendations are drawn from the findings and discussed.     

AN ALTERNATIVE TO MANAGED CARE: A "GUILD" MODEL FOR THE INDEPENDENT PRACTICE OF PSYCHOTHERAPY

As health care is reconfigured by HMOs and managed care organizations, family therapists often have to decide whether or not to cooperate with the new power structures and their ways of doing things. The chief concern of many therapists is the ehtical bind created when the managed care orgranization demands breaches of confidentiality or makes decisions about the course of treatment that may not, in the therapist's opinion, be in the best interest of the family. Associations of independent, nonmanaged care psychotherapists are springing up in response to these dilemmas. This paper describes the philosophical evolution and organizational development of one such association.     

Evaluation,Accountability and Clinical Expertise in Managed Mental Health Care

In this article, the author identifies a number of policies and practices of managed mental health care organizations that, if allowed to continue unchecked, will have deleterious effects upon the American family. Since this industry is not regulated by either state or federal statutes, managed care organizations have had free reign to disallow coverage for a variety of DSM-III-R diagnostic categories and V-Code conditions. Some organizations severely limit the number of collateral contacts their therapists can schedule with clients' family members and others prohibit their therapists from working with more than one family member at any given time. The author also highlights the complex relationship that exists among insurance companies, managed care organizations, the medical profession and the pharmaceutical industry. He then offers some hypotheses about the nature of these relationships and the reasons for their existence. Finally, the author calls for social work to take an active role in bringing these issues to public awareness and suggests that social workers become advocates for the American family in this era of managed care.     

Global Mental Health in Action: Reducing Disparities One Community at a Time

There are great disparities in mental health care around the world. Traditional approaches to mental health care have not been found to be transferrable to many parts of the world and are inadequate to address these disparities. Unconventional approaches are needed that match the traditions of care‐seeking and care‐giving within the communities where they are delivered. The authors review the global mental health literature and discuss how marriage and family therapists are in a particularly good position to have worldwide impact on mental health disparities. Five principles of global mental health are presented along with an example of how these principles are applied through the Reducing Mental Health Disparities One Community at a Time (RD1CT) model.     

Individual versus family psychotherapy in managed care: comparing the costs of treatment by the mental health professions

In an effort to understand how psychotherapy is practiced in the "real world," outpatient claims data were examined to determine the cost of individual and family therapy provided by marital and family therapists, master's nurses, master's social workers, medical doctors, psychologists, or professional counselors. Claims for 490,000 unique persons over 4 years were obtained from CIGNA. Family therapy proved to be substantially more cost-effective than individual or "mixed" psychotherapy. Physicians provided care in the fewest sessions, marital and family therapists had the highest success (86.6%) and lowest recidivism rates (13.4%), and professional counselors were the least costly. Outcomes were overwhelmingly successful, with 85% of patients requiring only one episode of care.     

Comparisons of marriage and family therapists, psychologists, psychiatrists, and social workers on job-related measures and reactions to managed care in Iowa

This study compares marriage and family therapists (MFTs) to psychologists, psychiatrists, and social workers on job-related measures, such as job autonomy, job satisfaction, burnout, and intention to stay in their present position, as well as on reactions to a managed care initiative in the state of Iowa. Findings indicate that MFTs scored significantly lower than other practitioners on job autonomy and intention to stay in their present position, but there were no differences in job satisfaction or burnout. Marital and family therapists also reported less dissatisfaction with the managed care initiative than psychiatrists, although virtually all practitioners were dissatisfied with the managed-care program. These findings indicate some dissatisfaction within the MFT profession and may be relevant to practitioners seeking to change or expand their practice, as well as to the needs of MFTs in their training programs.     

Expanding Systems Thinking: Incorporating Tools from Medical Sociology into MFT Education and Research

The field of marriage and family therapy has historically focused on dynamics within family systems, and at times the role of social and cultural factors external to the family. To date, however, little scholarship has examined how therapists themselves are embedded within a mental healthcare system. The purpose of this article is to demonstrate how structural components of the mental healthcare system shape the practice of therapy. We draw from the field of medical sociology to illustrate how three dominant structures—managed care, diagnosis, and evidence‐based models—are intertwining and mutually reinforcing systems that have significant and long‐term implications for systemic therapists and researchers. We recommend incorporating a sociological understanding of such structures into MFT education and research.     

The development of core competencies for the practice of marriage and family therapy

In response to a series of national policy reports regarding what has been termed the "quality chasm" in health and mental health care in the United States, in January 2003, the American Association for Marriage and Family Therapy convened a task force to develop core competencies (CC) for the practice of marriage and family therapy (MFT). The task force also was responding to a call for outcome-based education and for the need to answer questions about what marriage and family therapists do. Development of the CC moves the field of MFT into a leading-edge position in mental health. This article describes the development of the CC, outcomes of the development process for the competencies, and recommendations for their continued development and implementation.     

THE MARGINALIZATION OF FAMILY THERAPY: A HISTORICAL AND CONTINUING PROBLEM

Family therapy, and marital and family problems, are mariginalized in the larger fields of mental and physical health care, which is a misfortune both for family therapy and for other mental health professions. The early family therapists, who had multidisciplinary backgrounds, attempted toestablish a new, nondisciplinary paradigm and also tried to expand the perspectives of the more traditional mental health disciplines. More recently, family therapists have exerted greater effortsto establish marriage and family therapy as a differentiated, autonomous profession. These alternatives each involve dilemmas for the family therapy field. The positive side of becoming a distinctive profession is greater internal strength and clear professional identy; the downside is the threat of increased marginalization in rlation to the other professions, a tendency toward intellectual isolation, and hence restricted opportunities for invigorating new challenges. Family therapy now needs to develop new modes of interchange, collaboration, and selective integration with otherhealth care professions. Such interchange will be beneficial both to family therapy and to other professions.     

The mother market

Giving a woman good prenatal and maternity care can capture the health-care spending of her entire family for life. The next decade will bring several challenges to those who market maternity products and services, including fewer new moms, fewer babies in many markets, more minority mothers, and the end of childbearing for the baby-boom generation. The biggest challenge will be to provide a wide range of high-quality childbirth options in the cost-conscious world of managed health care.     

NAMI'S managed care report card. National Alliance for the Mentally Ill

This article reports on the National Alliance for the Mentally Ill (NAMI) national report card to examine quality of care under managed care. The national report card will provide a summary of state policies underpinning the move of managed care into the public mental health system, and directly probe consumer and family member perceptions and experiences of managed care and the policies and practices of managed care organizations.     

Family therapy saves the planet: messianic tendencies in the family systems literature

It is not unusual occasionally to hear individual family therapists describe their work as an effort to "save the world." The messianic notion that family therapy should be the world's salvation is not simply a fancy of individual clinicians, but is deeply imbedded in several of our field's most fundamental theories. This article explores messianic arguments in the work of some of family therapy's most important thinkers, including von Bertalanffy, Bateson, and Keeney, and then discusses the implications that these arguments have for the clinical and theoretical development of our field.     

An Interview with Joyce Edward: Exemplary Clinician, Advocate, and Scholar

Over the years, noteworthy social workers have been interviewed for the Clinical Social Work Journal. This article features an interview with Joyce Edward who is recognized for her many extraordinary contributions to clinical social work. Joyce has co-written or co-edited three exceptional books for the social work clinician, she has been an esteemed teacher and a vocal activist for quality mental health care. In this interview Joyce reflects on family influences, her work as a social caseworker, the psychoanalytic luminaries with whom she trained, her concerns about the clinical education of today's social work students, and finally, her perspective on managed mental health care.     

Group therapists' countertransference reactions to multiple deaths from aids

Group therapists for those with HIV Related Diseases are becoming the “professional” survivors of this world-wide epidemic. From their experiences we may learn a great deal more about the effects of multiple deaths on mental health care professionals. As therapists they are constantly eliciting and listening to the fears, hopes, agonies and terrors of those with this disease. They become the bereaved. Witnesses to the deaths of many of their group members, they struggle with a wide range of emotional responses while at the same time assisting surviving group members in their struggle to live with these deaths. Mourning reactions and countertransference phenomena are in abundance as these therapists grapple with these group processes. This article identifies and examines these therapists' responses by focusing on clinical illustrations drawn from their bi-weekly supervision sessions.     

LEARNING ABOUT GRIEF FROM NORMAL FAMILIES: SIDS,STILLBIRTH, AND MISCARRIAGE*

Family therapists can learn a great deal that would be of utility to them in their clinical work from normal families grieving over the death of an infant. When a baby dies, families begin a long and difficult journey, a search for security and meaning in a world that for them has gone insane. The researcher discusses 10 probing, extremely difficult questions family members commonly pose in the aftermath of an infant death and offers guidelines that could be helpful to family therapists hoping to be of service to families in the process of healing and growing through this tragedy.     

What White Mental Health Professionals Need to Understand About Whiteness: A Delphi Study

This Delphi study surveyed an interdisciplinary panel of diversity expert trainers (N=20) about what white mental health professionals need to understand about whiteness. The panel endorsed 162 items that included what white mental health professionals need to understand about historical and contemporary whiteness within the mental health fields and larger social systems, self of the therapist work for white therapists, as well as challenges to understanding whiteness in clinical training and practice. More specifically, the panel provided guidance on the cognitive and emotional transformations necessary for white mental health professionals to address whiteness, as well as the challenges to those transformations. The researchers provide clinical training implications for marriage and family therapists (MFTs) and other clinicians based on the results.     

Action-oriented evaluation of an in-home family therapy program for families at risk for foster care placement

The purpose of this study was to conduct an action-oriented evaluation of an in-home family therapy program serving families deemed at risk for the placement of children in foster care. In this study, feedback was solicited from both clients and therapists. Results indicate "duality" associated with several aspects of in-home family therapy, including the opportunity to observe families in their own homes versus the vulnerability some families feel when therapy is conducted in-home; therapists suggesting that sufficient training is required for in-home family therapy to be effective versus clients' opinions that therapists' lived experiences are more relevant; and the importance of the therapeutic alliance versus feelings of abandonment upon termination. Implications for researchers and practitioners are discussed.     

Developing culturally effective family-based research programs: implications for family therapists

Recently, some family scholars have developed greater sensitivity to the relative neglect of families of color in clinical and empirical research. Consequently, a proliferation of research elucidating many nuances of ethnic families has come to the forefront, containing a wealth of knowledge with useful implications for family therapists and other mental health providers. The findings of these studies hold enormously important implications for how family therapists can better engage and accommodate families of color in therapy. In this article we discuss some of the etiological and methodological issues associated with planning, conducting, and disseminating family-based prevention and intervention research programs with ethnic minority families.     

FAMILY SYSTEMS THERAPY IN A PRIMARY CARE MEDICAL SETTING: THE ROCHESTER EXPERIENCE

Collaboration between family therapists and physicians has attracted increasing attention in the field of family therapy. Family therapists practicing in medical settings encounter many stimulating oppoutunities and challenges. This paper focuses on the experience of the authors providing family therapy in a primary care medical setting which is also a family medicine residency program. The authors discuss the role of physician and patient expectations in treatment as well as the influence of the medical context on the development of family therpists.