ESTs, psychologists and third-party payers: A 'micro-physics of power'.

摘要

Division 12 (Clinical) of the American Psychological Association has begun promoting Empirically Supported Therapies (ESTs) which stipulate the use of specific approaches to therapy for specific DSM-IV diagnoses, despite the empirical evidence contradicting this conceptualization of treatment. EST proponents have conceded that the move has been made, in part, out of fears that third-party payers would otherwise dictate the terms of clinical practice for American psychologists. Canadian psychology, evidenced by recent policy decisions within the Canadian Psychological Association, has begun to follow the American lead in moving toward ESTs—despite a near lack of communication in either country between psychology and its payers as to how decisions regarding treatment are actually made. Given this situation, the current study involved open-ended interviews with five providers of psychological treatment, seven representatives of the insurance industry underwriting these services, and one government regulator of auto insurance in Ontario. One purpose of these interviews was to explore the nature of treatment decision-making, in light of ESTs, within a local, Canadian context. Results of a hermeneutical analysis of the interviews suggested there is a reciprocal process of influence between insurers and psychologists. Insurers learned about psychology through the information generated by psychology's own practices and actions, and tended to come to expect certain types of practice (CBT, or cognitive-behavioural therapy) based on that information. A valuing of cost, reduced treatment lengths and measurement of outcome in terms of observable behaviours on the part of insurers was also noted. Psychology appears to be using ‘scientistic’ discourse in the service of economic goals which may contribute to conflicts and antagonism in the relationship between psychologists and insurers. The results from this study are interpreted in light of the move toward ESTs; they are further situated within a Foucauldian framework, which suggests that the hegemony of ESTs may be understood as a reflection of the interplay of power and knowledge and the use of CBT as a contemporary “technology of power.”