Managing Managed Care: Habitus, Hysteresis and the End(s) of Psychotherapy

In this paper we examine how clinicians at acommunity mental health center are respondingto the beginnings of changes in the health caredelivery system, changes that are designatedunder the rubric of ``managed care.'' Wedescribe how clinicians' attitudes about goodmental health care are embodied in whatsociologist Pierre Bourdieu calls theirhabitus, i.e., their professional habits andsense of good practice. Viewed in this light,their moral outrage and sense of threat, aswell as their strategic attempts to resist orsubvert the dictates of managed care agencies,become a function of what Bourdieu terms thehysteresis effect. The paper is based onethnographic fieldwork conducted by a team ofresearchers at the mental health and substanceabuse service of a hospital-affiliated,storefront clinic which serves residents ofseveral neighborhoods in a large northeasterncity. Data consist primarily of observationsof meetings and interviews with staff members. We describe four aspects of the clinicians'professional habitus: a focus on cases asnarratives of character and relationship, animperative of authenticity, a distinctiveorientation towards time, and an ethic ofambiguity. We then chronicle practices thathave emerged in response to the limits on careimposed by managed care protocols, which areexperienced by clinicians as violating theintegrity of their work. These are discussedin relation to the concept of hysteresis.