Managing managed care: Habitus, hysteresis and the end(s) of psychotherapy

In this paper we examine how clinicians at a community mental health center are responding to the beginnings of changes in the health care delivery sy stem, changes that are designated under the rubric of ``managed care.'' We describe how clinicians' attitudes about good mental health care are embodi ed in what sociologist Pierre Bourdieu calls their habitus, i.e., their pro fessional habits and sense of good practice. Viewed in this light, their mo ral outrage and sense of threat, as well as their strategic attempts to res ist or subvert the dictates of managed care agencies, become a function of what Bourdieu terms the hysteresis effect. The paper is based on ethnograph ic fieldwork conducted by a team of researchers at the mental health and su bstance abuse service of a hospital-affiliated, storefront clinic which ser ves residents of several neighborhoods in a large northeastern city. Data c onsist primarily of observations of meetings and interviews with staff memb ers. We describe four aspects of the clinicians' professional habitus: a fo cus on cases as narratives of character and relationship, an imperative of authenticity, a distinctive orientation towards time, and an ethic of ambig uity. We then chronicle practices that have emerged in response to the limi ts on care imposed by managed care protocols, which are experienced by clin icians as violating the integrity of their work. These are discussed in rel ation to the concept of hysteresis.