ABSTRACT

Therapists increasingly are encountering the challenge of working with managed care. These different insurance arrangements-which all regulate the costs, site, and utilization of services (Hoyt, l995a)-now cover more than 150 million Americans, with numbers expanding rapidly. For better or worse, they provide a context for treatment. In addition to collaborating with clients on goals and direction for therapy, mental health providers often must negotiate with case managers and utilization reviewers from managed care companies in getting authorization to imple-

ment treatment plans. Moreover, therapists are being asked more and more by managed care companies to demonstrate their effectiveness with outcome data (see Pincus, Zarin, & West, 1996; Rainer, 1996; Sperry, Grissom, Brill & Marion, 1997; VandenBos, 1996) . Some of the basic characteristics of psychotherapy under managed care are outlined in Table 5.1. 1 Therapists who identify themselves as "postmodern" or "constructive" -including those who may situate their practices under the rubrics of solution-focused, narrative, possibility, and neo-Ericksonian ap - proaches-usually work with clients in a collaborative, competency-based manner (see Friedman, 1993, 1995, 1997; Hoyt, 1994a, 1996b, 1998/ 1998). (Some strategic, cognitive-behavioraL and other therapists also might include themselves in this broad category.) While there are important technical differences between various postmodern therapies, they share certain assumptions : the belief in a socially constructed reality with an emphasis on the reflexive nature of client-therapist dialogue, a move away from hierarchical distinctions in favor of greater client-therapist egalitarianism, and a search for and utilization of client competencies rather than a pursuit of putative pathology and the reification of diagnoses of deficit and dysfunction.