Perceptions of Empathy and Client Satisfaction with Managed Behavioral Health Care

Over the past decade there have been revolutionary changes in the provision of mental health services in the United States. These changes result from numerous factors, most notably the advent and subsequent expansion of the principles of cost containment and the growth of managed care organizations. The rapid growth of managed care has affected all dimensions of the mental health services spectrum: clients, social workers and other service providers, colleges and universities that train mental health professionals, employers who purchase insurance for their workers, the larger health insurance industry, even the national economy as a whole. Although the exponential growth of managed care has revolutionized all facets of the mental health environment, change is most poignantly evident in the actual provision of mental health services to clients. Over the past 10 years managed care has significantly shifted the focus of mental health services away from traditional, long-term psychotherapies to short-term, highly focused interventions (Austad & Betman, 1991; Bennett, 1986). In addition to this shift to a short-term focus, there has been a concurrent emphasis on group therapies to complement and sometimes even to replace individual therapies (Folkers & Steefel, 1991; Sabin, 1981). More important than this shift to group therapies, however, is the recent development of standardized treatment guidelines and protocols. These guidelines indicate the "preferred practices" or interventions to use for a particular client problem (Bartlett, 1994). The introduction of these standardized treatment guidelines in the mental health arena is one of the more controversial innovations brought about by managed care and has elicited widespread criticism. Critics of the use of standardized treatment practices cite numerous reasons for their opposition. They suggest that standardized treatment guidelines fail to take into account the unique nature of clients' needs and rob the practitioner of the autonomy to determine the intervention most suited to meet the clients' needs (Bartlett, 1994; McIntrye, 1994). Furthermore, they suggest that the use of standardized, "recipe-like" interventions depersonalizes the therapeutic process and threatens to eliminate empathy from the helping relationship (Bohart & Greenberg, 1997b). Obviously these strong allegations challenge the direction in which managed behavioral health care is evolving. This article describes a study that sought to address these concerns by examining clients' perceptions of empathy in the therapeutic relationship and how those perceptions affected clients' overall satisfaction with the mental health services they received within a managed care setting. The results of this study offer insights into the appropriateness of standardized treatment practices as well as the future evolutionary direction of managed behavioral health care. Review of the Literature Although prepaid, managed care style health plans originated nearly a century ago, it was not until the late 1960s that the contemporary model - the health maintenance organization (HMO) - began to proliferate. The term and concept of a health maintenance organization was first used by Dr. Paul Elwood in 1969 to describe prepaid plans that he believed would counter the "perverse incentives" that caused excessive cost and utilization of medical services under Medicare and Medicaid (Giles, 1993). After the establishment of the federally funded Medicare and Medicaid programs in 1965, health care costs began to spiral wildly out of control and were increasing annually at a pace two to three times the general inflation rate. Mental health and substance abuse services were especially prone to rapid cost escalation. At the same time, increasing numbers of workers demanded health care coverage from their employers, thus further exacerbating the financial pressure (Starr, 1982). These two factors - escalating costs and increasing demand for employee coverage - combined to create a fiscal disaster in which huge portions of the federal budget and of pretax corporate profits went to health insurance costs. …