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Managed Mental Health Care: Major Diagnostic and Treatment Approaches
Am J Psychiatry 2000;157:478-479. doi:10.1176/appi.ajp.157.3.478
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Davenport, Iowa

edited by S. Richard Sauber, Ph.D. Philadelphia, Brunner/Mazel, 1997, 377 pp., $34.95.

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This book is the eighth in the series on Mental Health Practice Under Managed Care edited by Dr. Sauber. The current volume has 15 authors, most of whom are psychologists (two are psychiatrists).

This is a very well written, coherently organized textbook for any mental health practitioner working in the United States today. In fact, all residency programs in psychiatry ought to make this a standard textbook, especially for teachers who, like me, never dreamed or heard of managed care in our training days. This work is a basic training/survival kit that will help the reader navigate the alligator-infested morass of managed care.

I started with the appendixes, which include an invaluable glossary of managed health care terms and definitions. The 13 chapters cover such topics as "The Paradox of Change: Better Them Than Us!" a very blunt, in-your-face, "tough love" kind of therapy for those among us who dig our heels in as a response to the advent of managed care. Skillfully using our own psychodynamic psychobabble, Dr. L’Abate urges us to grow up. I found this chapter very helpful in my own struggles dealing with a practice I was neither prepared for nor helpfully trained to cope with. I have seen colleagues bitterly drop out of medicine altogether or seek locum tenens positions or positions in state-run mental health institutions because they could not handle the reactions this chapter addresses.

The fourth chapter, "Maximizing Psychotherapeutic and Psychopharmacological Outcomes: The Psychiatrist’s Role in Managed Care," more than any other in this book, forced me to totally reassess the direction of my professional and personal life.

The chapters on brief group therapy, distance writing, computer-assisted training, and marital and family therapy approaches are "state-of-the-art." The chapter on children by William L. Buchanan, Ph.D., is a very lucid and clinically sound piece. I found heartening his statement that "medication should never be the primary intervention for a child’s mental disorder and…other types of psychological treatment should always be the primary focus of therapy." Being a "full-service" solo practitioner, I do all these other types of psychological treatment; I cannot imagine doing otherwise, even though most managed care companies do not pay for contacts with the school or family therapy. I use Dr. Buchanan’s time-out flow chart for the school-age child regularly in my practice. Parents and children all tell me they like it.

The chapter on anxiety disorders by David A. Gross, M.D., and Andrew Rosen, Ph.D., deserves special mention because it is quite outstanding in its applicability and scholarliness. Using the programmed genome and permissive diathesis and stress diathesis models as paradigmatic springboards, they skillfully guide us through all aspects of caring for anxiety disorders.

In her chapter on the treatment of alcoholism, Judith Lewis advocates the dictum that every alcoholic ought to receive treatment based on the least intrusive possible alternative. She cites W.R. Miller’s now well-known quote from 1985 that "the absolutely consistent testimony of…controlled studies…is that heroic interventions—those in longer, more intensive residential settings—produce no more favorable outcomes overall than treatment in much simpler, shorter, and less expensive settings."

When I finally put this book down, I realized that what I had just read was good common sense. It validated my faith in the old saying, "The best care of a patient is caring for the patient." Practicing good medicine is not about being managed, it is about going back to our Hippocratic roots and never making the seductive security of financial redoubts become redoubtable oppressors managing the mortgaging of our professional and personal souls.




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