The Impact of Managed Care on Mental Health Counselors: A Survey of Perceptions, Practices, and Compliance with Ethical Standards.

A sample of 108 mental health counselors in four states was surveyed about their experiences and perceptions of the impact of managed care on their work with clients and the effects of managed care on their compliance with professional ethics. The majority reported that managed care has negatively affected their work with clients and that the protection of the confidentiality of client disclosures has been the most troublesome ethical issue. The study revealed gaps in accuracy of diagnosis, appropriateness of treatment, management of termination, and informed consent procedures with managed care clients. It also showed limited use of ethics codes and other resources developed to help professionals resolve ethical questions responsibly.

The advent of managed mental health care into community mental health has caused "an upheaval in the practice community" (Acuff et al., 1999, p. 563) and has engendered intense emotion among counselors and other mental health professionals. Research has shown that the majority of mental health professionals find the requirements of managed care organizations (MCOs) a substantially negative influence on their practice (Murphy, DeBernardo, & Shoemaker, 1998; Phelps, Eisman, & Kohout, 1998; Russell et al., 2000; Sank, 1997) and a challenge to compliance with professional ethical standards (Bilynsky & Vernaglia, 1998; Phelps et al., 1998; Murphy et al., 1998; Rothbaum, Bernstein, Haller, Phelps, & Kohout, 1998; Watt & Kallmann, 1998; Wineburgh, 1998). While some practitioners are bypassing managed care and bypassing managed care methods of providing clients with effective and cost efficient mental health services (Bittner, Bialek, Nathiel, Ringwald, & Tupper, 1999), most are trying to identify ways to practice responsibly within a managed care system. Because of its dominance in the marketplace, eschewing managed care is not an option for most mental health counselors in the foreseeable future (Acuff et al., 1999; Corcoran & Vandiver, 1996; Richardson & Austad, 1991). According to Kiesler (2000), 88% of U.S. citizens with private insurance are enrolled in behavioral health plans nationwide and in California that number rises to nearly 100%. Moreover, governmental programs such as Medicare and Medicaid are also moving toward managed care systems.

A growing body of literature has identified the numerous ethical challenges that managed care presents to mental health professionals (Acuff et al, 1999, Cooper & Gottlieb, 2000; Glosoff, 1998). These challenges fall into two broad categories: (a) difficulties in supporting the client's right to quality care as a priority over the professional's relationship with the reimburser and (b) problems in protecting the privacy of client disclosures. Managed care presents mental health professionals with conflicts-of-interest and a feeling of divided loyalties (Strom-Gottfried, 1998; Watt & Kallmann, 1998) as they try to promote the welfare of clients. Because treatment plans must conform to MCO protocols (Miller, 1996) and be approved by MCO representatives in order to get payment for reimbursement, counselors are not free to plan and implement treatments independently. When their professional judgments differ from MCO protocols, counselors feel pressured to decide whether to use treatment plans they view as inferior (thereby risking harm to the client) or risk the denial of reimbursement (and lose a source of income).

Other aspects of quality care can also be at risk. When client diagnoses do not fall within reimbursement guidelines, mental health professionals feel pressure to choose between honest and accurate diagnosis without third party reimbursement payment and deceptive diagnosis in order to gain reimbursement. Specifically, practitioners may be tempted to "upcode" (Cooper & Gottlieb, 2000, p. 199), giving an acute problem a more severe diagnosis than presenting symptoms warrant for an acute problem, or to "downcode" (p. 199) to an acute problem when the client presents with an unreimbursable Axis II diagnosis. Wylie referred to this practice as "diagnosing for dollars" (Wylie, 1995, p. 22). This dilemma is particularly salient because many clients have neither the resources nor the inclination to pay for mental health care out-of-pocket.

The next risk to client rights to quality services under managed care is the threat to client autonomy when free access to providers is restricted. The American Mental Health Counseling Association Code of Ethics (2000) states:

   Mental health counselors offer clients the freedom to choose whether to
   enter into a counseling relationship and determine which professionals will
   provide counseling. Restrictions that limit clients' choices are fully
   explained. (Principle 1.C)

In the current marketplace, many managed mental health care organizations not only limit the client's choice to a select group of professionals, but also they rarely inform clients as to the criteria and qualifications used to select participating professionals (Miller, 1996). These issues threaten both the client/counselor relationship and the effectiveness of the therapeutic enterprise (Haas & Cummings, 1991).When counselors are forced to inform clients that their insurance will not pay for recommended services, clients sometimes blame them and feel that professionals do not have their best interests at heart (Bilynsky, & Vernaglia, 1998). In some situations, the contracts that mental health professionals sign with MCOs stipulate that they may not discuss with clients alternative treatments outside the boundaries of approved services (Wineburgh, 1998). Such contracts are said to include "gag clauses" (Wineburgh, p. 436) and have been energetically challenged in court. Obviously, gag clauses are in direct contradiction to the informed consent provisions of AMHCA Ethics Code (Principles 2.E) and the American Counseling Association Code of Ethics (1995, Section A.3.a).

Challenge to client privacy, the second major category of ethical issues in managed care, has two major dimensions. The first involves the scope and depth of information that must be disclosed to the MCO for authorization, and the second involves the confidentiality of that information once it is released to the health plan. Managed care organizations typically require practitioners to provide detailed diagnostic and treatment information and to communicate with them frequently in order to secure approval for payment of services. Kremer and Gesten (1998) found that these requirements compromise client openness. The clients in their study were significantly less willing to self-disclose personal information under managed care confidentiality circumstances than under the traditional fee-for-service arrangement. Furthermore, mental health professionals have almost no control of what happens to this information after it is transmitted to the MCO (Davidson & Davidson, 1996; Glosoff, 1998; McDaniel & Erlen, 1996; Strom-Gottfried, 1998). The AMHCA Code of Ethics (2000) specifies that counselors must disclose the minimal amount of information necessary (Principle 3.C) and must secure the safety and confidentiality of counseling records (Principle 3.H). The ACA Code of Ethics (1995) specifies that counselors take steps to ensure that the recipients of counseling records are sensitive to the confidential nature of those records (Section B.4.e). Managed care makes compliance with these standards exceptionally difficult. The best that most can offer when clients feel compelled to utilize managed care benefits is comprehensive informed consent so that clients fully appreciate the ramifications of using MCO reimbursement (Remley & Herlihy, 2001; Welfel, 1998).

Unfortunately, there is little empirical evidence of the impact of managed care on practicing mental health counselors and not a single survey of their experience in complying with AMHCA or ACA standards has been published, although some counseling literature has begun to emerge (Glosoff, 1998; Glosoff, Garcia, Herlihy, & Remley, 1999; Lawless, Ginter, & Kelly, 1999). All other surveys to date have used psychologists, social workers, and psychiatrists. In other words, even though there is ample evidence that managed care raises difficult ethical dilemmas for mental health professionals, the voices and experiences of counselors in this environment have not been examined. The current study addresses that gap and examines how licensed mental health counselors perceive the impact of managed care on their practices, and the ethical challenges it presents them. We also explore whether counselors admit behaviors inconsistent with AMHCA and ACA ethical standards when dealing with managed care systems. We address the following research questions:

1. What level of involvement do mental health counselors have with managed mental health care and what is their experience in getting accepted on provider lists?

2. How do counselors perceive the effects of managed care on the quality of services they provide, including length and type of treatment, diagnosis rendered, and approach to recordkeeping?

3. How frequently do counselors experience ethical challenges when dealing with managed care and what strategies do they use to assist them in answering these challenges?

4. What types and frequency of ethical issues have counselors experienced or perceived as problems when dealing with clients utilizing managed care reimbursements?

METHOD

Procedure

The researchers surveyed mental health counselors in four states--Connecticut (Licensed Professional Counselor or LPC), Florida (Licensed Mental Health Counselor or LMHC), Ohio (Licensed Professional Clinical Counselor or LPCC), and Nebraska (Licensed Mental Health Practitioner or LMHP). These states were chosen to represent a diversity of geographic areas, lengths of time since the enactment of licensing legislation was enacted, and counselors' scope of practice. Florida has licensed professional counselors since 1981, Ohio since 1984, and Nebraska since 1986, but Connecticut has had such a law only since 1997. The scope of practice in Nebraska and Connecticut is limited to treatment of emotional and mental disorders, but in Florida and Ohio, practice encompasses both diagnosis and treatment of mental and emotional disorders.

Licensure lists were obtained from the four state boards and 150 counselors were randomly selected from each licensure list. The Ethics in Managed Care Questionnaire (EMCQ), developed by the authors, and a return envelope were mailed to the 600 participants along with a cover letter explaining the study and instructions for completion. The envelopes were coded by state in order to track response rate and no other identifying information was included on the forms. In fact, participants were explicitly asked not to place identifying information on the materials.

Instrument

The EMCQ consists of 34 items. Six items seek demographic information including age, gender, race, type of license, work setting, and highest degree earned. The next seven items deal with counselor participation in managed care provider lists and the percentage of their clients who belong to managed care plans. The remaining items were constructed based on research from other mental health professions. They focus on potential ethical problems managed care presents and counselors' responses to those problems. The structure of these items varies but includes Likert-type scales, rank-ordering items, and yes/no checklists. Specifically, this group of items examined counselors' perceptions of the effect of managed care on practice, the accuracy of diagnosis, resources counselors use when faced with ethical challenges, and the types of ethical issues they experience as most salient under managed care.

Validity and Reliability

As a basic test for construct and face validity, six mental health counselors with expertise in managed care assessed the instrument's clarity and appropriateness to its purpose. As a result, the wording of two survey items was changed to provide greater clarity. As an additional check on face validity, a pilot use with four professional counselors (LPCs) was implemented. The pilot revealed no additional problems with face validity or clarity of content. As a check of internal consistency, a Cronbach's alpha was computed ([Alpha] = .70). There is no agreed upon acceptable level of reliability, but Conway, Jako, and Goodman (1995) stated that [Alpha] = .69 is acceptable by conventional standards. The finding for this study/vas within that parameter.

Participants

Usable surveys were returned by 108 counselors. Specifically, 29 LPCs from Connecticut (19%), 30 LMHPs from Nebraska (20%), 38 LPCCs from Ohio (30%), and 11 LMHCs from Florida (7%) provided responses. Of the 600 surveys sent, 72 (13 from Connecticut, 19 from Nebraska, 23 from Ohio, and 17 from Florida) were returned as undeliverable (12%). Another 2 surveys were returned blank ([is less than]1%) resulting in a 21% return rate. The causes for this low return rate, especially for Florida, were unclear. Follow-up efforts to identify the source of the problem were not fruitful. Although this was a lower than anticipated return rate, the findings from this research still merit examination for two reasons. First, this survey represents the first effort in the counseling profession to ask practitioners directly about their experience with managed care, a topic of significant concern to the profession. Its fundamental purpose is to encourage additional research. Second, the statistical analysis used in this study was limited to frequency distributions and rank ordering, so that the number of surveys received can be considered sufficient for this type of statistical treatment (Smith, 1999). The low return rate, particularly for Florida, suggests that caution should be used in generalizing these findings, however.

RESULTS

Demographics 

Respondents to this survey were predominately female (67.6%). The majority were between the ages of 45 and 60 (59.3%) with 10.2% over 60 years of age, 26.9% between the ages of 30 and 45, and 3.7% were under 30. The sample was predominantly European American (93%), with identical percentages (2.8% each) who were identified as African American and or Latino. One counselor identified as Asian American and another as Other. Most of the respondents held Master's degrees (77.8%), with half of the sample having post-Master's hours (50%). Nearly a quarter (22%) reported having doctorates.

The work settings of the participants varied. Forty seven percent indicated that they worked in a suburban setting, 38% in an urban setting, and 13% in a rural setting. Many were in private practice (42.6%) or agency practice (39.8%), with only 4.6% reporting employment in an HMO or hospital.

Counselor Involvement with Managed Care Organizations

Nearly three-quarters of the respondents (71%) reported that they have attempted to become managed care providers, and many of them (48%) indicated that as counselors they experienced difficulty in getting approved as providers. In spite of the difficulty, most have succeeded in this endeavor--60% of the respondents sample identified themselves as providers for at least one MCO.

When respondents were asked what percentage of their clients were insured by managed health care companies, 27% reported that more than 75% of their clients utilized managed care. Another 25% of the participants reported that between 26% and 74% of their clients utilized managed care, while 43.5% stated that less then 25% of their clients utilized managed care. These figures roughly parallel the percentage of mental health counselors in this study (60%) who are MCO providers.

Counselor Perception of Managed Care Impact

More than 90% of the sample reported that managed care has affected their practice in some way. On a Likert-type scale, slightly more than half the respondents (51.8%) identified its impact as more than moderate to strong, and 24.1% viewed it as moderate, but 9.3% denied any impact at all. When asked to characterize this impact as positive or negative, 60% of the participants reported that the effect of managed care on their practice was in some way negative, 11.1% said that the effect was somewhat positive, and 17.6% said the overall effect was neutral. (Because more than 90% of respondents indicated that managed care had had some level of impact on their practice, results from the entire sample were used in all subsequent analyses rather than the subset of the sample who self-identified as MCO providers.)

Much has been written in the professional literature about the effects of brief models of care in behavioral health plans on treatment quality and effectiveness (Glosoff, 1998) and about inaccurate diagnosis (Cooper & Gottlieb, 2000), so respondents were queried about both these issues. Five major effects on treatment were noted in this survey. First, a majority (60%) replied that they had changed or would change treatment plans based on managed care limitations. Second, almost half (46%) replied that they had terminated or would terminate with clients before they were ready because of these limits. Only 35.6% of respondents stated that they have never or would never terminate with a client because of managed care limits. Third, 44% of participants indicated that they had changed or would change a client's diagnosis in order to receive additional managed care reimbursement. Fourth, two thirds of the sample reported some level of negative impact on the counselor-client relationship. Thirty percent of respondents believed that managed care participation often compromised the client/counselor relationship, and another 37% believed that it had that effect at least occasionally. These findings are consistent with those of Kremer and Gesten (1998) who surveyed client perceptions. Finally, if an MCO denies reimbursement for care judged necessary, 55.6% of respondents indicated that they would reduce fees to continue service, and 27.8% would opt to see the client on a pro bono basis. Approximately one-quarter (27.8%) chose referral to another provider. Only 11% responded that they would terminate treatment without offering the client another option, even if they judged further treatment necessary. The remaining 26% were equally divided between changing the client's diagnosis in order to continue treatment from the MCO and utilizing other strategies, though none of the respondents specified these strategies.

Because managed care has affected the content, scope, and confidentiality of client records (Cooper & Gottlieb, 2000), respondents were queried about their approach to recordkeeping with MCO clients. We found that the length and detail of client records varied widely. A substantial percentage of participants (40.4%) reported that they occasionally would keep more detailed records for MCO clients, and 20.2% indicated they often do keep more detailed records. Approximately two thirds reported they never keep less detailed records for MCO clients.

Frequency of Ethical Dilemmas and Typical Counselor Response

When counselors were queried on a Likert-type scale about how often managed care requirements presented ethical dilemmas, 75% of the sample viewed managed care as presenting ethical challenges to some extent. The largest group of respondents (52.8%) reported that they occasionally experienced ethical dilemmas caused by managed care, but 12.1% reported that they experience these dilemmas more than occasionally, and 6.6% reported that they often experience ethical dilemmas. A little over one quarter of respondents (28.5%) denied any ethical dilemmas associated with managed care. These findings are consistent with psychologists' perceptions of the effect managed care has on ethical practice (Murphy et al., 1998).

Counselors were queried about the resources they consult to resolve ethical questions. When asked whether they consulted the professional codes of ethics, nearly one third (31%) of the participants reported that they consulted the ACA code. Most, however, did not find the codes to be a particularly useful resource. Only 4% of the respondents believed that the codes often provided answers to MCO issues, although 69% did believe that the codes occasionally provided answers. A small percentage of respondents (18.9%) reported consulting the professional literature to help them deal with ethical dilemmas presented by managed care. When given a list of other resources that could help with ethical dilemmas, 16% of the sample indicated that they would make a decision without consulting with anyone or referring to any documents. Further research will be needed to sort out whether the confidence of this group in their independent judgment is justified.

Types and Frequencies of Ethical Dilemmas

Counselors were presented with eight different ethical considerations related to managed care and asked to rank them in order of the most troubling to the least troubling. Confidentiality was most frequently listed as the most troubling issue under managed care (32.9%), followed by allocation of services (27%), referring to MCO restrictions on access to professionals.. Although quality of treatment was listed as number one by only 20.5% of the respondents, it was rated number two by 30.1% of the respondents, suggesting that the majority of participants believed that this issue is a prominent concern. Dual relationship issues were seen as the least troubling of the eight issues (40.8%), followed by informed consent, with 22.2% rating it number 7 and 12.5% rating it lowest.

When questioned about specific ethical issues they viewed as problematic in their dealings with managed care, more than one third of the sample (40.2%) believed that interactions with MCOs often compromised client confidentiality. Another 40.2% felt that the process occasionally compromised confidentiality. An additional 10.9% felt that the process rarely compromised confidentiality and only 8.7% of the respondents denied any impact of managed care on confidentiality. Participants were also asked their level of confidence in the confidentiality of the client information after it was released to the managed care companies. More than half (62.7%) stated that they were only occasionally confident that the information would remain confidential and another 31.9% of the counselors said that they were never confident that this information would remain confidential.

Two items explored the effect of managed care on informed consent. The first of these dealt with the frequency with which counselors explain to clients MCO restrictions on confidentiality and requirements for release of information. Over half of the respondents (58.2%) indicated that they always informed clients about information that the MCOs require for reimbursement. Another third of the sample (37.4%) occasionally explained these requirements. A small proportion (4.4%) stated that they rarely or never completed this aspect of informed consent. The second informed consent item explored the impact of MCO restrictions on confidentiality on clients. Specifically, the item asked whether they had experienced clients who declined to utilize managed care reimbursement after informed consent. Over a third of the responses (36.7%) showed no change in the use of the MCO, and 51.1% reported clients who rarely or occasionally declined. Only 12.2% responded that clients often decided against using managed care reimbursement based on disclosure requirements.

DISCUSSION

The majority of participants to this survey reported that managed mental health care negatively affects their work as professional counselors and presents ethical challenges to their clinical practice. Most believe that the quality of service provided to clients is compromised, though some saw this effect as moderate at best and approximately one tenth of the sample tended to view managed care as a benign or neutral influence. These findings are consistent with research conducted with psychologists (Murphy et al., 1998), psychiatrists (Keefe & Hall, 1999) and social workers (Davidson & Davidson, 1996). Nevertheless, the majority of the respondents continue to try to become managed mental health care providers, a somewhat difficult task for mental health counselors.

A disturbing number of respondents acknowledge actions or willingness to engage in actions that appear inconsistent with professional standards. Nearly half the sample (44%) either had already changed a diagnosis to gain MCO reimbursement or were willing to do so. If those changes resulted in an inaccurate statement of the client's problems, then they were contrary to both AMHCA and ACA codes of ethics. They also have legal repercussions and may constitute insurance fraud. Other potentially unethical practices were endorsed by the sample, including revising treatment plans to fit MCO protocols (60%), terminating counseling prematurely (44%), and failing to provide complete informed consent on consistent basis (36%). Their reluctance to offer comprehensive informed consent procedures may stem from fears about client reactions. These fears have some basis in fact. In a recent study, Pomerantz (2000) reported that when clients have full knowledge of clinicians' negative perceptions of managed care, they have significantly more negative attitudes about counseling and the benefits of counseling. Nevertheless, the ethical obligation to full disclosure (AMHCA, 2000, Principle 1.J; ACA, 1995 Sec. A.3.a.) is not erased by this effect on clients. In fact, the research by Pomerantz highlights how crucial full disclosure is and how betrayed some clients may feel if they learn about MCO practices after the fact or from someone other than their counselor. On a positive note over half of the respondents were willing to reduce their fees when reimbursement ended (56%) and more than a quarter of them were willing to offer pro bono services (28%), an indication of their counselors' commitment to promoting client welfare. Further research is needed to determine the extent to which professional counselors will change the therapeutic course of treatment in order to accommodate the requirements of managed care companies. What changes are acceptable and to what extent do counselors believe they are practicing ethically when making these changes? These are important questions awaiting future research.

Counselors viewed a number of ethical issues as problematic under managed mental health care, most notably the issue of client confidentiality. On the whole, respondents did not believe that the information obtained by the managed care companies would be kept confidential. On the other hand, clients believe that everything they say in the counseling relationship will be kept in confidence (Miller & Thelen, 1986). This belief strengthens the counselor-client relationship and gives the client an safe environment in which to disclose the most personal aspects of themselves (Welfel, 1998). Even when clients agree to the release of confidential information to third parties, counselors still have an ethical obligation to limit disclosure to parties that who will treat this information appropriately (AMHCA, 2000, Principle 3; ACA, 1995, Sec. B1.f.). A counselor's belief that information that is shared with the MCO will not be kept confidential makes even more compelling the need to limit disclosure to the MCO to the fullest extent possible. In addition, a majority of respondents acknowledged some increase in the detail included in client records for MCO clients, a change that adds to the risk that sensitive client information might be revealed to inappropriate persons.

Quality of treatment and allocation of services were two other issues that respondents viewed as serious ethical problems under managed care. The AMHCA Code of Ethics (2000, Principle 2.a., Principle 7) and the ACA Code of Ethics (1995, Section C.2.) stress counselors' obligations to practice within the scope of their competence and to offer their clients quality care. Research suggests that quality mental health care is difficult to realize under managed care due to monetary incentives to limit services that are available to clients (Austad, Ariel-Hunter, & Morgan, 1998). In addition, managed care often takes treatment decisions such as number of visits and appropriate treatment plans out of the hands of the mental health counselor (Glosoff et al., 1999).The results of this study suggest that counselors believe that client care is compromised when these types of treatment decisions are made by third parties.

A disappointing but not surprising result of this study was how few participants turned to the codes of ethics to help them resolve ethical questions. This finding is consistent with the findings of Austad et al. (1998), who reported that mental health professionals do not believe that ethics codes give enough guidance for practice. The intent of the codes is not to provide a blueprint for specific practice situations. Codes were never intended to act as a blueprint for practice, but rather to give a sense of the major ethical issues across the whole landscape of professional practice settings (Welfel, 1998). Nevertheless, all professionals are accountable for compliance with the codes and respondents did not appear to be taking full advantage of the direction that the codes do provide. Instead, the majority of professional counselors indicated that they rely on peers or supervisors to help them resolve ethical dilemmas or they kept their own counsel. Peer or supervisor consultation allows for dialogue about the problem, for description of the particular dimensions of the situation, and for emotional support, none of which can be found through reading the codes. However, the value of the feedback received from colleagues is dependent upon their knowledge of ethical standards and their commitment to compliance with them. A small but substantial percentage (16%) relied completely on their own judgment. Making a decision independently without consultation or reading is risky, as it deprives a professional from an objective feedback perspective about the quality of his or her reasoning. Finally, less than one fifth of the participants (18.9%) in this study took advantage of the rapidly expanding professional literature to help resolve ethical dilemmas (Appelbaum, 1993; Cooper & Gottlieb, 2000; Frager, 2000; Glosoff et al., 1999). This literature contains the wisdom of experienced professionals who have wrestled with similar questions and produced reasonable answers. A number of sources also address the prevention of ethical problems in managed care, a topic of obvious import for practitioners (e.g., Gilbelman, & Whiting, 1999; Haas & Cummings, 1991).

The participants' view that the codes of ethics were not particularly helpful in answering questions about the ethics of practice with managed care clients also suggests that professional associations may need to take a more active role in providing mental health counselors with better resources for coping with ethical dilemmas presented by managed care. Many options are possible, including a "frequently asked questions about managed care" page on the associations' websites, a published annotated bibliography on ethical and legal issues in managed care, or a consultation service with ethics committee members who specialize in mental health counseling. The dominance of managed care in the marketplace means that the ethical issues that participants in this survey identified are not likely to disappear soon. Consequently, active professional associations that are committed to supporting mental health counselors coping with these dilemmas may be well received.

This study has some several limitations The first is the low response rate (especially from Florida), which limits generalizability. It is not known if there was something specific about the survey that caused counselors in Florida not to respond, or if this is an indication of a characteristic about professional counselors in that state. In any event, the rate of return was not sufficient to allow the researchers to make comparisons among counselors in different states These comparisons may have been useful in understanding the influence of licensing patterns of professional practice in managed care. There is a need for future research using a national survey to determine if these findings reflect the perceptions and behaviors of professional counselors in general and to explore regional or licensing variations in response patterns A second limitation of the study is its reliance on self-report rather than experiment or observation of actual behavior. In addition to gathering data from professionals who have worked as MCO providers and directly confronted these issues, the survey included some counselors for whom the issues were largely hypothetical. For this subsample it is difficult to ascertain whether their actual behavior when confronted with those circumstances would match with their answers to this survey. Future research should discriminate more fully between MCO providers and other mental health counselors. Finally, this survey provides little information about the internal decision-making processes involved when mental health counselors are confronted with conflicts between the demands of managed care and the needs of their clients. Clearly, qualitative and quantitative research that explores the decision-making profess itself is needed. Armed with that information counselor educators and supervisors can better educate professionals to avoid actions that may put their licenses and professional standing at risk.

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Paula R. Danzinger, Ph.D., is an assistant professor of Counselor Education, Department of Special Education and Counseling, William Paterson University, Wayne, NJ. Email [e-mail]. Elizabeth Reynolds Welfel, Ph.D., is a professor of Counselor Education, Department of Counseling, Administration, Supervision and Adult Learning, Cleveland State University, OH. Email [e-mail]