Managed Care and Family Therapy

Kilian Frisch

The decision of whether or not to participate in managed care networks involves a choice of the worlds and worldviews within which we ply our trade. In the current issue of New Therapist magazine (http://newtherapist.webjump.com/), Kenneth Gergen (2000) asks whether therapy will "simply be an industry or can it further its definition as a unique and professional community?" (p.22).

I have been able to work outside of the managed care world because of my community memberships. These include memberships with the people I see professionally, memberships with a group of professionals here in Philadelphia, and on-line memberships which affirm the values which make my life better.

How do I deal with managed care and HMO's? I don't. About ten years ago I signed on as a provider for a managed care company in California, thinking that I might supplement my income with an occasional case from this company. At that time I was seeing someone who was working very hard with a number of difficult "stories" in her life. She was paying my full fee at the time of each session. Some months later, she came in and said that I was an in-network provider for her mental health coverage. She said that when she discovered this with her HR representative at work, they also saw the rate at which in-network providers were compensated. The HR rep said, "I wouldn't work for that."

A couple of things happened as a result. Firstly, I had to refund several hundred dollars to the person. This adversely affected our work together because she was embarrassed to be seeing me for such a low rate, since she knew and had been happy to pay my regular fee. I was very uncomfortable with the complications which accompanied this development, and I resented the intrusion of a third party into my work.

Secondly, I looked at the numbers and realized that if I began to see more people under the managed care agreement, our family income would be drastically reduced. Given our circumstances at the time, there wasn't much "give" in our budget as it was.

So I did the simple thing. I realized that I had a low volume practice, and that I couldn't afford one, let alone multiple, situations where I would be paid according to a managed care rate. I resigned from the managed care panel and resolved to have a practice unencumbered by such entaglements. The simplicity of the situation made the decision easy. It was impossible for me to be a "little bit" of a managed care provider.

Another development occurred in the way I work. I became enlivened by the ideas of narrative practice, which resulted in a change in the way that I scheduled people. Previously, I wanted people to come in regularly, weekly, so that treatment proceeded but also so that my income stream could be regularized. The question became, "Whose needs take precedence?" Consequently, I began to ask people when they might want to return for a session. While preferable in terms of my values, this shift introduced another element of uncertainty into the the picture of how I worked and made a living.

So what do my practice, and my practices in relation to my practice, look like? There are very few regular appointments on a weekly basis. Those folks who like to schedule their lives and therapy that way, do that. I work or am available to work, from 8 AM until 9 PM. Evening and weekend hours are a must. There is another curious story here - my office has come to resemble something of a drop-in clinic. Folks will often call with a desire to come in on relatively short notice: sometime in the same day or a day or two later. Others like to schedule themselves a month or so further out, knowing that once an appointment is scheduled, they'll have a chance to take a look at how things are working regardless of whatever else is going on in their lives.

People stop coming in when things work well, and they return when circumstances suggest that coming back seems like a good idea. So a lot of my work proceeds on the principle of "one session at a time."

I also choose to see people for a reduced fee if they seem willing to work and put their therapy relatively high in their list of priorities.

Some other unforeseen developments have opened up as a result of my listening to the people who find their way into my office. One fellow was struggling with the different worldviews presented by the narrative metaphor, and he suggested that I start agroup for people to share their knowledges about narrative work with each other, or in his words, "to help get some traction with this work." I called up some other men with whom I had worked or was working, and we started meeting on a monthly basis. One of the group members is a fellow in his thirties with four young children. He and his wife were struggling in many ways, one of which was financial. Two group members underwrote couples therapy for this man and his wife for a period of two years. That would not have happened had I not taken the first fellow's suggestion about starting a group.

The number of groups has now grown to four. This venue provides much flexibility and possibility for the group members and myself. Each group figures out how to meet in its own way. One group meets on the third Thursday of each month, another meets every three weeks on Mondays, another has to be more flexible but finds one evening a month when they can all get together.

What does this mean for me? Well, the first thing that comes to mind is that I've had to reconfigure most of my ideas about security. I always feel better after one of our narrative group meetings, because I witness the collective and synergizing efforts of people working to live their lives differently. I also get scared when I look at my appointment book at the beginning of the week and it's not as full as I want, or as full as I need it to be in order to pay the week's bills. I can be affected by the fear that wants me to get mobilized and "make something happen," or I can try to deconstruct the various ways the stories of fear have operated in my life. It's far better to concentrate on honoring the stories which connect with respect for other people, and to pay attention to what I need to do to challenge stories of fear in my life and in the lives of the people I see. The groups contribute a great deal to my life in this respect.

Secondly, I have a membership with a narrative study group, which I lead. I called some colleagues and asked whether they would be interested in learning more about narrative practice. Over the past four years, this group has become a micro-culture of shared meanings, having less to do with becoming narrative therapists than with engaging in discussions which reflect our values in therapy and life. This process presents a viable alternative to the potentially monolithic model of the world of managed care.

Thirdly, I belong to three different online communities. One is a family listserve which weaves the disparate elements of my far-flung family together. While our views on everything run the full spectrum, I am amazed at what binds us. It's about love.

I also belong to two online groups composed primarily of ex-Jesuits, which reminds me of dedication to a set of ideals and sacrifice.

Lastly, I have recently joined a postmodern therapies list,and have participated in discussions which link postmodernism with an examination of the practices of therapy.

These disparate threads and memberships constitute my communities. My membership in these communities is reflected in my therapeutic practice so that the distinction between life and practice has ceased to be much of a distinction. In the above-mentioned article, Gergen suggests that we define therapy as a "process that acquires its efficacy in a particular context of cultural meanings." I prefer to have a hand in the creation of those meanings, rather than to have them imposed upon me by the industry of managed care. I could not do that without my memberships.

References

• Gergen, K. (2000, Jan./Feb). Ghost in the therapy machine: An interveiw with Kenneth Gergen. New Therapist, 6, 21-25.

Kilian Fritsch, Ph.D., is a clinical social worker in private practice in Philadelphia. He works with his wife/partner, Sandra, a psychologist. Kilian is also the Director of the Center for Narrative Studies, which provides training in narrative practice.