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Cohen, J. Gillham, J. Marecek, J. (2004). The Elephant in the Consulting Room: Managed Care and the Practice of Psychotherapy. J. Amer. Psychoanal. Assn., 52(2):451-452.
Psychoanalytic Electronic Publishing: The Elephant in the Consulting Room: Managed Care and the Practice of Psychotherapy

(2004). Journal of the American Psychoanalytic Association, 52(2):451-452

The Elephant in the Consulting Room: Managed Care and the Practice of Psychotherapy

Julie Cohen, Jane Gillham and Jeanne MarecekAuthor Information

Therapists are constrained in many ways by managed care—by limits on the number of sessions, by restrictions on the problems that qualify for reimbursement, and by pressures to use inexpensive and brief forms of treatment. We ask how such constraints alter processes at the heart of therapy—how therapy begins and ends, how the therapist-client relationship develops, and how clients and therapists conceive of their work together. We addressed these issues through intensive interviews with sixteen therapists from diverse theoretical backgrounds. The interviews were analyzed using an interpretive approach derived from grounded theory (Glaser and Straus 1967).


For every therapist interviewed, some aspects of managed care were in conflict with their ethos of good care. This fundamental conflict was the root of deep discontent. Some reported that managed care restricted therapy to superficial goals and quick-fix solutions. Some reported that managed care policies disallow the types of therapy they deem most effective (e.g., psychodynamic therapies). Some could no longer continue various practices that promote and support client change, such as school consultations, family meetings, home visits, and formal clinical assessments. Such exclusions were based on financial considerations, not scientific evidence of efficacy.

Therapists also voiced a variety of ethical concerns. As they saw it, they often had to choose between honest reports about their clients and good care. To provide adequate care, they felt it necessary to conceal certain elements of their work, misrepresent diagnoses, and distort reports of clients' progress. Some therapists drew their clients into misrepresenting diagnoses and into other deceptions, a practice that may ultimately erode public confidence in the profession. Others found themselves bound by “gag” rules that prevent them from providing clients accurate information about their problems and their treatment.

Some therapists reported that clients who had entered therapy through the managed care system had received distorted ideas about therapy.

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Psychotherapy had been portrayed as a procedure akin to a dental visit, not an open-ended and collaborative process of self-discovery, growth, and change. Moreover, managed care referral practices discouraged clients from active involvement in selecting a therapist, thus undermining the efforts of progressive therapists to increase clients' autonomy and to ensure that they make informed choices about treatment.


For many therapists, it is a matter of principle that they treat managed care clients just as they would private fee-paying clients. Yet their narratives about their work are replete with concrete instances in which their practice of therapy shifted dramatically under managed care: setting a diagnosis, defining the goals of treatment, establishing the therapeutic alliance, selecting a therapeutic modality, and managing the termination process. A question for future research is how therapists balance their abstract commitment to good care and the quite different reality imposed on them by managed care.


GLASER, B., & STRAUS, A.L. (1967). The Discovery of Grounded Theory. Chicago: Aldine.

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Article Citation

Cohen, J., Gillham, J. and Marecek, J. (2004). The Elephant in the Consulting Room. J. Amer. Psychoanal. Assn., 52(2):451-452

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