Quick summary: check out www.scottmiller.com -With all the political talk about healthcare reform sometimes we can miss the idea of reforming the healthcare which is already in place. The current trend in psychotherapy is and has been (for about a decade) to find a ‘one size fits all’ ‘empirically based or evidence based intervention’ which can be standardized and implemented consistently by all mental health practitioners… sounds somewhat reasonable in theory especially if psychotherapy is to be looked at as a purely medical intervention. So what is the problem? Ironically scientific investigation has proven that the evidence-based trend is unhelpful (the trend will not improve therapeutic outcomes – note: outcomes were already very good before the trend)… and having worked within a mental health center I would suggest that the trend is horribly hurtful as it wastes an unthinkable amount of money, time, and emotional and physical energy. Whoever came up with this trend seemed to overlook all the science related to therapeutic outcomes, which show (and had shown even prior to the evidence based movement) that the technique and the theory used by the therapist is almost irrelevant to successful psychotherapy outcomes (some studies find no relevance others suggest theory and technique accounts for about 8% of outcome).Therapy will not advance if it is continued to be managed as such… fortunately there is exciting research about what does impact outcomes – feedback and adaptability. Would you prefer a therapist who used one way of helping everyone or a therapist who specifically catered their therapy to serve the specific and unique needs of each individual client? Is there one universal answer to the question, “how can I help you,” as it is related to therapy?
If you are a therapist – read Scott Miller’s writings (www.scottmiller.com) it is very good (he has a particularly good article in the ‘newyorker’).
Why is this important to the general public? – A huge percentage of therapists will not work for managed care companies, will not take insurance, and will not be a part of any bureaucratic network because of the tendency for such organizations to blindly follow misguided trends that do not help the client and do hurt the therapist.
- This makes it more expensive in many cases for people to access the benefits of therapy.
- This makes it more difficult to find specific therapists with specific specialties.
- Therapist cannot afford the emotional and economic detriments of spending 50% (while making 70% less income) of their time doing paperwork and attending mandated trainings that have thus far proven to be irrelevant to therapeutic outcomes.
- The mandated procedures and policies are often developed and implemented by people with no therapeutic experience.
- There are limmited options available to people who would benefit from therapy, but do not have a diagnosable condition.
Irony – people commonly seek therapy for troubles related to stress, depression, helplessness and anxiety. Trying to work within the current mental health system often produces those very symptoms within the therapist – which obviously does impact therapeutic outcomes.
This trend requires so much oversight that well over 50% of all money spent on mental health is going somewhere other than to the people that are actually offering the mental health interventions.
- Many if not most of the people offering the oversight of all the paperwork, authorizations, and ‘empirically based trainings’ that are irrelevant to outcomes actually have the credentials to offer mental health services.
- So by throwing away this useless trend we could theoretically increase the amount of people offering mental health services by 100% without any increase to the budget.
The other most significant problem with mental health services that are funded by insurance companies or by managed care companies is that they can currently only offer reactive interventions (imagine if the fire department was not allowed to respond to a fire until at least 4 houses in the neighborhood were already burning)… or interventions based on the medical model (you have an illness to be fixed or removed) as opposed to the wellness model (we can use your strengths to build new strengths while enhancing your relationships, your sense of purpose, your perception of your self, your sense of purpose and your general abilities etc.)
Psychotherapy is infinitely more effective if it is used pro-actively.
*example: it is more effective to offer marriage counseling than counseling for a child with depression resulting from a divorce.
- Unfortunately the only way to receive services from a managed care company or from an insurance company (there are a few exceptions) is for the therapist to give at least one person an individual diagnosis (clinical depression, schizophrenia, Bi-polar disorder and not – child–parent conflict or marital discord) which will effect their ability to access other benefits.
So what do we do?
Use what we know – therapeutic outcomes are already very good so the service is not in horrible need of some revolutionary trend.
Therapist function very well independently and there is already an immense amount of oversight involved in the process of becoming a therapist – perhaps people who spend 50 grand to earn less then 30 grand a year need less oversight then what is in place (I’ve never met a therapist who is in the trade to steal money from the government or from the insurance companies – a huge percentage of the paperwork is ironically to prove that a therapist is not wasting money, but that paperwork is inherently wasteful).
Get baselines and promote a culture of feedback – have the client qualitatively rate their progress and the effectiveness of the therapy – the therapist should adapt to meet the needs of the client.
Eliminate waste and harmful stress – private practice therapists have around 400% less paperwork and are able to offer the same outcomes.
Private practice therapist have supervisors for case consultation and have the same outcomes as people in mental health organizations who can have up to 6 or 7 tiers of upper management (why?).
- Again if we fixed this we could make therapy available to more people with the same budget. – Most of the managers are not offering direct services though they have the credentials to do so.
A therapists’ Hope, Empathy, ability to listen, ability to monitor his/her own internal reactions, ability to create hope, ability to interact without being judgmental, authenticity, ability to empower etc all effect therapeutic outcomes – If there is one ‘one size fit all’ idea that could be offered I would suggest this – healthy therapists are better at promoting healthy clients.
* if what is being asked of therapists is not helping client outcomes and is hurting a therapists ability to function optimally – then why are we not reforming this trend?