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Managed care has become the dominant economic force in health care delivery and has challenged many of professional psychology's training concepts and cherished attitudes. Organized psychology has not kept pace with the rapid industrialization of health care during the past decade and has been overlooked as a participant in health economic decisions. A number of changes need to be made in professional education and training if psychology is to be a major player in the new health systems. Additionally, professional psychologists must reexamine some of their most generally accepted attitudes and beliefs if they are to survive. These are described with a number of recommendations for the survival of an embattled profession.The illiterate of the future are not those who cannot read or write, but those who cannot learn, unlearn and relearn.-Alan TofflerPsychotherapists have long been conditioned to believe that more is better, "self actualization" is the real goal of psychotherapy, and, consequently, the most prestigious practitioners are those who see a limited number of clients over a long period of time (Bloom, 1992). Managed care, with its emphasis on brief therapy, is changing all of this. A growing body of outcomes research demonstrates that efficient therapy can also be effective therapy (Bennett, 1994). For the past several years, it has been argued that most psychotherapists must receive retraining to become skillful in the efficient-effective therapies (Budman & Gurman, 1983, 1988. Over the past decade I have retrained literally hundreds of psychiatrists, psychologists, social workers, and counselors in a 130-hour module over a 2-week period and observed that for retraining to be successful, there must be significant changes in the practitioners' attitudes and belief systems. This "enabling attitude" has now only begun to receive the attention of those who are engaged in retraining practitioners (Bennett, 1994;Friedman & Fanger, 1991). Yet this point of view is now new. Balint (1957), in his monumental work, said,A further reason for the failure of traditional courses is that they have not taken into consideration the fact that the acquisition of psychotherapeutic skill does not consist only of learning something new: It inevitably also entails • • • a change in the doctor's personality, (p. 23) J. G. BENEDICT served as action editor for this article. NICHOLAS A. CUMMINGS received his PhD from Adelphi University in 1958. He is the founding chief executive officer (retired) of American Biodyne (now MedCo Behavioral Care Systems, a subsidiary of Merck). He is president of the Foundation for Behavioral Health and a former president of the American Psychological Association.

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This article reports the first Kaiser-Permanenle study comparing medical services utilized before and after shortand long-term psychotherapy. Findings indicate that persons in emotional distress were signgicantly higher users of medical facilities, that medical care utilization by individuals seen in Psychotherapy declined, and that lhis decline continued and remained constant during the 5 years afier termination of psychotherapy.

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There are two reasons why mental health, now more appropriately termed behavioral healthcare, is declining: (a) a lack of understanding among psychotherapists of healthcare economics, particularly the intricacies of medical cost offset, and (b) our failure as a profession to see the importance of behavioral interventions as an integral part of the healthcare system inasmuch as the nation pays for healthcare, not psychosocial care. This paper will briefly describe the rapid changes in the economics of healthcare during the past 75 years, including the post World War II enthusiastic espousal of psychotherapy by the American public which was followed by a precipitous decline as our outcomes research in behavioral care remained ignorant of financial outcomes, leaving it to the government and managed care to arbitrarily curtail escalating mental health costs. At the present time psychology is on the cusp of becoming part of the healthcare system through integrated behavioral/primary care, renewing the primacy of financial considerations such as return on investment (ROI) and medical cost offset, as well as an urgency that we avoid the mistakes that are emerging in some flawed implementations of integrated care.Keywords Healthcare economics Á Medical cost offset Á Integrated behavioral/primary care Very few people do anything creative after the age of 35. The reason is that very few people do anything creative before the age of 35.

Today, in 1992, when most psychotherapists are asked to identify the "creator" of modem psychotherapy, they think of Sigmund Freud. The setting of his work was private practice in Vienna, Austria. In the United States, the first psychology clinic was established at the University of Pennsylvania by Lightner Witmer in 1896 (Cattell, 1954). The employment setting was an academic one. Witmer's first case involved a child with an apparent academic problem (Brotemarkle, 1947), although one would infer from the initial report that the child may actually have been retarded.Over the course of the past 100 years, there have 'been many contributors to the development, evolution, and today's practice of psychotherapy, and they have been employed within a host of settings: private practice, universities, public psychiatric hospitals, child and family guidance centers, private psychotherapeutic centers, independent offices, schools, prisons, and the military. The sites themselves have influence over practice because the settings have provided differing patient populations.

Although this chapter uses the term managed care, it should be recognized that the term is a bit too widely used and covers several separate categories of financing arrangements. Actually, designed benefits, independent practice associations, preferred provider organizations, and health maintenance organizations are also forms of management, with greater or lesser intrusiveness into the procedures of treatment. 2Although we use the terms time-limited, brief treatment, and short-term therapy interchangeably, we hope it is recognized that these terms are not synonymous. Budman and Gurman (1988) suggested the term time-sensitive for their approach, and given our aversion to specific session limits. this is our term of choice.