Professional counselors in school, campus, and mental health settings are facing increasing demands for accountability with respect to the cost and quality of their services. This article reviews dimensions of quality and ways of assessing these in counseling settings, with particular emphasis on the development of ongoing programs of quality improvement. Such programs are described as mechanisms for science-practice integration within counseling settings, providing decision support tools for triage, treatment planning, and the management of professional services.
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ounselors in college (Stone & Archer, 1990) and mental health (Johnsen, 1994) settings are facing increasing budgetary pressures at a time of rising demand for services. This has fueled an interest in brief (Steenbarger, 1992) and group (Steenbarger & Budman, 1996) counseling modalities that promise efficiencies in service delivery. It has also placed professional counselors under mounting pressure to justify their positions by demonstrating the value of their efforts. The most recent National Survey of Counseling Center Directors, for example, found that (a) over a quarter of all campuses were considering a downsizing of student affairs departments; (b) over half of counseling centers have increased their emphasis on short-term counseling; (c) over three quarters of counseling centers require evaluations of counseling services by clients; and (d) over 80% of counseling centers report an increase in clients with severe psychopathology (Gallagher, 1995). College counselors are thus being asked to do more with less-and to be able to document how well they are doing it.
Nowhere is this trend more evident than in mental health counseling. From 1988 to 1993, indemnity (nonmanaged) health insurance has dropped from almost 73% of the private market to 33%, as managed plans have expanded to cover over 120 million Americans (Weiss, 1995). All but several states have also applied for or received waivers from Medicaid regulations to allow for enrollment of public sector clientele in managed health plans (Monack, 1995), assuring that community mental health centers will be operating as part of integrated delivery systems for behavioral health care. This places mental health counselors under unprecedented pressure to deliver helping services in cost-effective ways, by keeping clients out of inpatient settings, offering services across a continuum of levels of care, and making maximum use of time-effective therapies (Budman & Steenbarger, in press).
Less appreciated, however, is the demand that managedcare organizations place on mental health counselors for the demonstration of the quality of their services. As purchasers of insurance become increasingly sophisticated, they seek information pertaining to the quality of health plans. This trend reached a milestone in 1993 with the accreditation of managed-care organizations by the National Committee for Quality Assurance (NCQA; Kenkel, 1995) and will be extended in 1997 with NCQA accreditation of managed behavioral health care organizations (National Committee for Quality Assurance, 1996). The latter is especially significant, as it requires providers of behavioral health care to be able to document the quality of their work in several areas, including client satisfaction, demonstration of clinical outcomes, and adherence to databased triage and care guidelines (National Committee for Quality Assurance, 1996). As a result, mental health coun-