Psychodynamic psychotherapists' experience of managed care : reconsidering professional autonomy and ethics

Mental health care services are becoming increasingly re-organized under what generally has become known as managed care. This study examined psychodynamic psychotherapists' experience of the impact of managed care on their conduct of long-term psychotherapy in an independent practice setting. An existential-phenomenological approach, which incorporated some concepts from Bourdieu's reflexive sociology, was used to investigate the experience of these psychotherapists. The purpose of this study was to describe the life-world of these psychotherapists and how their professional practice was affected by specific practices of managed care review. This inquiry aimed to articulate the needs and interests of psychotherapists and to demonstrate the relevance of this method of inquiry to decision-makers in the mental health system. Empirical phenomenology guided the selection of research participants and data analytic procedures. Ten self-identified psychodynamic psychotherapists, five from Tennessee and five from Massachusetts, participated in this study. All participated in an open-ended interview about their experiences with managed care. Phenomenological thematic and hermeneutic narrative procedures were used to analyze these interviews.

Each participant discussed general situations related to the impact of managed care and specific transactions with managed care reviewers. Each interview was divided into a series of these situations/transactions. The analysis of interviews produced four themes describing the experience of managed care: autonomy, change in therapeutic relationship, change in self, and ethical! moral stance. Dynamic interactions of experiential themes were presented for each of the situations/transactions discussed by all ten participants.

Results were discussed with reference to common experiences and concerns of the participants and to the differing strategies they adopted in response to managed care. The diversity of results leads to a reconsideration of the concepts of professional autonomy and ethics. An examination of psychotherapist's life-world suggests that autonomy is relative to the specific practices of managed care review. Formal ethical standards and guidelines may be best understood in relation to psychotherapists' professional ethos and personal values.