treatment philosophies and strategies, many of which are conflicting and contradictory and which are recognized by insurers in varying degrees, is staggering.

In substance abuse treatment, counseling is traditionally provided by individuals who are in recovery from alcohol and drug abuse. State administrators and some national professional organizations are concerned that health plans may not view experiential counselors as essential practitioners by health plans and will not provide reimbursements for their services, despite their clinical and cost-effectiveness (NAADAC, 1996). Many states have a long history of supporting the social model programs or nonmedical programs in which these counselors predominate (Gerstein et al., 1994; IOM, 1990b).

A primary motivation for health care practitioners is to help their patients and clients to get better. Improvement can be measured in many ways, including a reduction in symptoms, the ability to return to work or school, improved quality of life, and improved relationships. Ideally, practitioners tailor treatment plans on the basis of a person 's needs and preferences, the availability of appropriate services, and their judgments about what will bring the best results. The realities of health care financing, however, also mean that treatment plans will be developed on the basis of what is paid for by the person 's insurance plan, whether it is a fee-for-service or managed care plan.

With managed care, treatment decisions are not only based on the private decisions of practitioners, clients or patients, and the clients' or patients' families. Managed behavioral health care companies in some cases approve a practitioner's treatment plans, so practitioners must disclose confidential information. Clinical protocols standardize treatment, and limitations can be imposed on the numbers and types of sessions, requiring approvals for additional sessions. Some companies emphasize medication management without counseling and psychotherapy, whereas others rely on nonphysician practitioners and use psychiatrists only when prescription medications or hospitalization are needed (Boyle and Callahan, 1993).

Arguably, the resistance to standardization of care is stronger in the behavioral health fields than anywhere else in the health care system. Treatment decisions are complicated by the great variability of conditions, and much remains to be learned about which treatments are most effective for which individuals at which time in the course of their treatment. Many clinicians resist the idea of