by Barry Duncan
Imagine a future in which the arbitrary distinction between mental and physical health has been obliterated; a future with a health care system so radically revamped that it addresses the needs of the whole person--medical, psychological and relational. In this system of integrated care, psychotherapists collaborate regularly with MDs, and clients are helped to feel that experiencing depression is no more a reflection on their character than is catching a flu. This new world will be convenient: People will be able to take care of nearly all their health needs under one roof--a medical superstore of services. It will be great for therapists, too, providing them with a seemingly inexhaustible stream of client referrals from the enormous pool of patients who, in earlier times (today), would have mistakenly identified their complaints as primarily physical.
Now, imagine a future in which every medical intervention in a patient's life is a matter of quasi-public record; in which therapy is tightly scripted and only a limited number of "approved" treatments are eligible for reimbursement. A future in which recalcitrant patients can be tracked and forced to undergo treatment, and in which therapists must serve as compliance cops for health management organizations and insurance companies. In this brave new world, integrated care actually means a more thoroughly medicalized health care system into which psychotherapy has been subsumed. Yes, therapists will work alongside medical doctors, but as junior partners, following treatment plans taken directly from authorized, standardized manuals.
These are not two different systems; rather, they are polarized descriptions of the same future, one that draws nearer every day. Make no mistake: A seismic change is coming to the American health care system. The age of integrated care is upon us, and psychotherapy may soon be incorporated in a way that will profoundly affect how and where it is practiced. But what will this new system really look like? How will therapists--and the therapeutic process--fit into it? What values will lie at its core? Although there is no question that a new system is coming, the nature and structure of this new system are still very much up for grabs. And this means that, for therapists, the future poses both tremendous opportunity and grave threat.
One version of the future--the one envisioned by such advocates of "reform" as the American Medical Association and the leading managed care companies--is of a seamless web of services that quickly identifies patients' true needs and efficiently delivers patients to the right professional for the correct treatment. The other vision--therapists' vision--has yet to be fully articulated, largely because most of us are still adjusting to the changes wrought by managed care and unaware of the implications of what's coming.
We have the opportunity now to present our vision, to argue for the holistic integration of medical and psychological services in a way that is true to the core principles of psychotherapy. We must resist the inevitable attempts to define therapy as, in essence, a treatment that gets dispensed by a professional to a patient and argue instead for therapy as a process of change that is entered into by client and therapist working together as allies. And it is critical to do so now, when psychotherapy is on the brink of another tectonic shift that could well discredit the majority of approaches therapists use today.
Carving In, Carving Out
To understand what lies ahead for the field of psychotherapy, we must first review some basic principles of health care economics. To state the matter in accountants' terms, mental health services have traditionally been "carved out"--handled and paid for separately from general health care costs and considered to be distinct from patients' medical needs. Most of us have grown accustomed to the idea that the point of entry for taking care of our medical needs is different from that of our mental health. Currently, 88 percent of the mental health cases are handled in this way. But experts such as noted psychologist Charles Kiesler--whose critical commentary on the accuracy of psychotherapy research and the expense of inpatient psychiatric care has been a springboard for policy discussions for more than 30 years, and who, in the mid-1980s, predicted that fledgling MCOs would soon dominate the American health care industry--see another sweeping change in the offing. Soon, they say, behavioral care, like most other medical specialties, will be "carved in"--that is, mental health services will be treated as an integral part of medical patient care and administered accordingly, with all the advantages and liabilities that entails. According to Kiesler, the changes to be ushered in by carve-ins will be "as dramatic as the computer revolution."
The reason for this coming change, of course, is the tremendous pressure on health care administrators to reduce spiraling costs, especially those that are racked up by patients who repeatedly seek medical treatment--often expensive specialty consultations--for complaints that are at least partly due to undiagnosed psychological issues. A typical scenario goes like this: A patient visits a physician or emergency room with a physical complaint, say neck pain. Doctors treat his physical symptoms, but don't refer him to a therapist, who might help him tackle the stress contributing to his symptoms. As a result, his neck pain flares regularly and he frequently seeks treatment from doctors. This pattern may repeat for years unless and until his behavioral problem is identified.
Over the last four decades, studies have repeatedly shown that as many as 60 to 70 percent of physician visits actually stem from psychological distress that finds somatic expression. Advocates of carving in behavioral care say it will not only save money, but will bring real advantages to therapists and patients alike. Imagine that before even meeting a client you could open a computer file and learn that her doctor put her on Prozac some years ago when her mother died of congestive heart failure. Curious about the mother's mental health history, you could click on the link to "familial predisposition" and find that the mother, too, had been treated for chronic depression. If such information were available to you in advance, argue advocates for carving in care, you'd obviously be better prepared to meet this person, and you'd have a deeper understanding of her situation.
And here's another apparent advantage of bringing together the medical and psychological disciplines: It becomes easier to provide care for people with disorders like chronic pain and insomnia that don't clearly fit into DSM categories; for people whose disorders are medical but clearly have psychological or relational components, such as irritable bowel syndrome and high blood pressure; and for people who fit into multiple categories, such as alcoholics with renal system problems.
The advantages of this new, collaborative system are evident in the case of a woman I'll call Kathy, a 23-year-old retail worker. Kathy was a client of family therapist Tom Mahan at the innovative Marillac Clinic in Grand Junction, Colorado--a model of how the integrated health care system of tomorrow can function at its best. She went to the clinic complaining of nausea, fatigue, feelings of helplessness and a constant burning in her chest. Kathy had seen six doctors in five years, and each one had told her she had no medical problem. Most recommended that she see a therapist, but she had rejected the idea that she had a "mental problem" and never followed this advice.
Then she visited the Marillac Clinic. She was seen first by a doctor, who conducted a sophisticated assessment of her biomedical, psychological, social and even spiritual life. At the end of the interview, the doctor told her that while she might have gastroesophageal reflux disease (GERD), psychosocial factors, such as high stress, relationship difficulties and perhaps depression, exacerbated her illness. He asked if Kathy would be willing to meet with "a behavioral care specialist" for some additional input and Kathy gave a tentative "maybe." So Mahan joined the interview and, in the course of an amiable chat, was able to demystify psychotherapy and explain the relevance of Kathy's emotional state to her physical complaints. By the end of the session, Kathy had agreed to meet with him to work on managing her "stress."
They met for three sessions. Kathy liked Mahan and felt she was finally making progress. While she responded positively to the treatment for GERD, which included medication and dietary changes, as well as to an antidepressant prescribed by the intake physician, she also began examining the psychosocial stressors in her life. Kathy talked about her dead-end job as a retail clerk, her frequent arguments with her boyfriend and her wish to move out of her parents' home. With Mahan's coaching and support, Kathy became more assertive in managing her own health: She learned more about GERD, formulated questions for her physicians and transformed from docile observer to active, informed consumer.
Her newfound confidence manifested itself in other areas of her life as well. She became more assertive in her relationship with her boyfriend and her family, as well as in her job. She moved away from home, started a walking regimen and finally got the wire-haired fox terrier she always wanted. In short, Kathy learned to speak up for herself and to act more decisively in her own interests. During a follow-up interview, she told Tom she was in better health and was paying more attention to her own needs. Kathy's new confidence also helped land her a more responsible position at work.
Integrated care was a godsend for Kathy. Aided by medical and behavioral professionals working in concert, she made changes in every facet of her life. Had Kathy not entered an integrated system, she might have continued to show up in the emergency room or the cardiologist's office, receiving costly, ineffective services. If she had encountered integrated health care from the beginning, she might have gotten the help she needed earlier and avoided the frustration of repeated but futile visits to doctors.
This is the beauty of an integrated system, its supporters say. Patients get a reliable diagnosis from a properly trained professional and no longer need to diagnose themselves. They get the medical and therapeutic care they need quickly and cost effectively. The system becomes more coherent--with mental health services easily available, but only through the primary care physician. The bottom line: Carve-ins--done right--increase collaboration, improve care and make psychotherapy more central to health care. And save insurance companies a lot of money.
The Nightmare of Integrated Care
So if carving in offers all this, why do many therapists fear it could undermine our relationship with clients, rob us of our creativity and challenge the fundamental values that underlie good psychotherapy? While the case of Kathy and the Marillac Clinic represents integrated care at its best, such success stories can lull us into underestimating the insidious and deeply ingrained mind-set of the traditional medical model--the idea that proper diagnosis plus prescriptive intervention equals effective treatment. What is obscured is the very real danger that in the name of "integration," psychotherapy will become ever more dominated by the assumptions of the medical model. At issue here is not the theoretical advantages of greater collaboration among health care professionals or bringing more of a therapeutic perspective to bear on medical conditions, but whether we will lose our bearings--and our autonomy--as a profession by becoming immersed in the powerful professional culture of biomedicine today.
To understand the potential danger of carving behavioral care into an integrated system, consider the case of a 15-year-old girl we'll call Carrie. Each morning, she would say goodbye to her mom and walk toward the bus stop near her home in one of the pleasantly named, planned communities that form the suburbs of a large southeastern city. But instead of getting on the bus, she'd walk to a friend's house, where she would spend the day, returning home just as the afternoon bus drove down the street. If not for the notices the school eventually mailed home, her family might never have learned what was going on.
Perplexed about her aversion to school, weary of her rebelliousness and her contentious attitude and frightened by her profound sadness, Carrie's mom took her to the family's HMO. A doctor there noted Carrie's depression, prescribed an antidepressant and recommended psychotherapy. During her visit the next week to the therapist to whom she had been referred, Carrie revealed that she'd been going into the kitchen late at night and making scratches on her arms and legs with a knife. The alarmed therapist admitted Carrie to the hospital. After three nights, she was diagnosed with depression and sent home with orders to take her meds, see the therapist regularly and come back to the hospital psychiatrist on a monthly basis.
In this case, the early referral for psychotherapy was no panacea. Carrie's therapist saw a collection of symptoms rather than a person and focused on alleviating those symptoms with the most efficient intervention at hand--medication. What happened next reflects the pitfalls of applying the medical model to complex interactional problems--when people don't respond to prescribed treatment, they are seen as "resistors" and, when in doubt, a hierarchical, medical system is likely to escalate its "treatments" in ways that compound, rather than resolve, problems.
Carrie didn't want to take the antidepressant prescribed--she said it "made her skin crawl." But in the face of the authority of the medical system, and at the insistence of her mother and the therapist, she took it anyway, and continued to feel bad and cut herself. Once, she even ran into traffic in an attempt to still the tumult inside her. Her friends ran after her, calmed her down and made sure she took her next dose of medication. But when her mother saw the scratches and the continued despair, she called the therapist and, in the next stage in the escalation of her treatment, Carrie again found herself in the hospital. At the hospital, the doctor diagnosed a Bipolar Disorder and added an anticonvulsant to her medication regimen.
But Carrie didn't want more medication--she hated the way she felt when she took the pills, and she wanted to "rule" her feelings without drugs. She just wished she didn't feel so sad. But the therapist and other health care professionals involved with her believed they knew the root of Carrie's problem--Bipolar Disorder--and were emphatic about the importance of the medication, reminding Carrie's mother that it was her legal responsibility to ensure that her daughter never missed a dose. Responding to the therapist's warning, Carrie's mom continued encouraging her daughter to take her pills and Carrie persisted in cutting herself to relieve her distress. All told, she was admitted three times to the hospital, was variously diagnosed with depression, Bipolar Disorder and Borderline Personality Disorder and was prescribed several antidepressants, lithium and an anticonvulsant.
Fortunately for her, Carrie's story doesn't end here, but let's pause to contemplate the mental health care she received in a system insidiously dominated by diagnostic thinking and a hierarchical treatment model. Even in an HMO in which therapists were closely involved early on in treatment, just as is proposed in the integrated care model of the future, Carrie was first required to be a patient; second, to see her problems as medical; and third, to listen and follow orders--her own capabilities and perspective on her problems were never enlisted in her treatment. No one ever really asked her what she wanted, or formed a personal connection with her.
Integrated care, in and of itself, does not provide safeguards that would prevent the kind of treatment Carrie received. In fact, the monolithic power of such a consolidated system, becoming, in effect, a court of last resort for health care, should alert us to its possible dangers. Of particular concern should be an element that its proponents consider a cornerstone of the health care of tomorrow--the integrated data base. With such a comprehensive, computerized record-keeping system of a patient's entire medical and psychiatric history, Carrie's treatment would permanently follow her, available to anyone with access to the system. Ten years from now, she might be unable to get insurance or join the military. And her history of suicide attempts and diagnoses of Bipolar and Borderline Personality disorders could easily affect her career prospects and even her personal relationships. Employers and colleges routinely question applicants about medical history. DSM disorders hardly qualify as preferred credentials on such applications, nor is a history of mental treatment usually included on a resume. In fact, background checks for any reason would take on ominous overtones in a system that would document "mental illness" as part of the medical record.
As it was, Carrie's treatment took an unexpected and fortuitous turn. Her truancy triggered involvement by juvenile authorities, who ordered her to receive treatment from a home-based therapist. Now outside the domain of the medical system, the focus of treatment shifted from Carrie's individual symptoms to understanding the fuller context of her life. The new therapist's first step was to include all Carrie's family members, not just her mother, in treatment. With their help, she began to develop a more complete picture of Carrie--that she was everyone's pet, and everyone's headache. The therapist learned about her karate class, about her love for the horses she cared for on the weekends and about her passion for Egyptian archaeology. The family began a home-schooling program and Carrie's mother took on responsibility for helping her daughter with her daily schoolwork. The therapist also learned, for the first time, that Carrie had been sexually abused by a friend's father.
After three months, and many intense family meetings, Carrie argued less, had stopped cutting herself and had decided to go back to school. At one point, after Carrie broke up with her boyfriend, the therapist worried that the scratching might go deeper and enlisted Carrie's family and friends in a 24-hour support network. They scheduled "check-in" points throughout the day, and Carrie and her family weathered the crisis. After six months of gradually less frequent visits with her therapist, Carrie experienced fewer periods of depression and returned to school.
In short, Carrie was finally helped by good old-fashioned therapy--the kind that entails listening to clients, meeting them in their own worlds and on their own terms and supporting them as they construct a life based on renewed confidence in their own capacities. But how would one translate this kind of treatment into medical terms? A health care system organized by traditional diagnostic thinking that addressed Carrie's symptoms had trouble grasping the larger context of her life.
Clearly, the initial involvement of a therapist in this case was no guarantee of the engagement of Carrie and her family that proved to be pivotal in the work with her. But it would be a mistake to simply write off the treatment Carrie initially received as simply bad therapy. In fact, it may closely resemble the kind of experience patients will receive within many integrated care systems. Why? Because this initial approach is far more consistent with the traditional medical-model thinking that permeates our health care system at all levels--match the right clinical method with the correct diagnosis.
And, in what is perhaps the most disturbing development that may determine the nature of "integrated" care in the future, the major professional associations have begun to position themselves as champions and adjudicators of a distinct set of "approved" interventions for targeted diagnostic groups that, in fact, ignore much of what we have learned makes therapy work in the first place. It is this fundamental misconception within the discipline itself about what constitutes effective psychotherapy that poses the gravest danger for our field.
The Myth of Evidence-Based Practice
In spite of the call to provide a bridge between therapeutic methods and scientific findings, the growing ascendancy of evidence-based practice may also be understood as the product of increasing competition among the mental health professions. Since the 1980s, the number of mental health practitioners has jumped by some 275 percent. Consumers can currently choose among psychiatrists, psychologists, social workers, counselors, marriage and family therapists, psychiatric nurses, pastoral counselors, addiction counselors and many others advertising their services under a variety of job titles and descriptions. In response, the various professional groups have felt an urgent need to document the scientific efficacy of their preferred approaches. In the early 1990s, members of the American Psychiatric Association (APA) decided that they should take the lead in determining the best treatments for the various diagnostic subgroups. So in 1993, the APA established the Steering Committee for Practice Guidelines to prepare guidelines designating specific treatments for specific disorders.
Beginning in 1993 with guidelines for Major Depression and Eating Disorders, the committee has produced guidelines for 10 disorders ranging from Bipolar Disorder to Alzheimer's Disease to Nicotine Dependence. Practice guidelines cover everything from treatment planning to psychiatric management and treatment selection for each of the disorders. More recent guidelines, issued since 1997, also include "practice parameters," ranging from "standards" (should be followed with few exceptions), to "guidelines" (exceptions are not rare, but require justification) to, finally, "options" (where there is no preference between choices). Yet, despite the committee's claim to strong empirical support for its recommendations and reliance on overwhelming clinical consensus, these guidelines have been criticized for treating open therapeutic questions about treatment effectiveness as though they have been definitively settled. For example, the guidelines for the treatment of depression are heavily skewed toward pharmacological intervention, despite the questionable evidence of the efficacy of drug therapy and the fact that studies show that psychotherapy with depressed people provides at least as much--and perhaps longer-lasting--symptom relief. However, the APA's imprimatur has given an aura of scientific legitimacy to what was primarily an agreement among psychiatrists about their preferred practices, with an emphasis on biological treatment.
The other APA, the American Psychological Association, was quick to follow psychiatry's lead, arguing that clients have a right to proven treatments. In 1993, a special APA task force, deriding psychiatry's approved treatment list as medically biased and unrepresentative of the clinical literature, set forth its conclusions about what constituted scientifically valid psychological treatments. Instead of clinical consensus and comprehensive guidelines, the task force concentrated its efforts on research demonstrations that a particular treatment has proven to be beneficial for clients in well-controlled studies. To be considered well established, a treatment must have demonstrated that its benefits exceed those of an alternative treatment or a placebo condition that controls for attention and expectancy. Additionally, this efficacy must be demonstrated by at least two independent research teams.
Since then, the task force has cited 71 empirically supported approaches for an ever-expanding list of disorders. Perhaps believing more is better, the list not only covers conditions like depression and anxiety, but also addresses marital discord, health problems and sexual dysfunction, to mention a few. While the psychiatry association's guidelines focus on a thorough delineation of psychiatric treatment for a few disorders, relying extensively on clinical consensus among experts, the psychology association's list emphasizes specific treatments with replicated empirical support.
There is a certain seductive appeal to the idea of having a specific psychological intervention for any given type of problem--the psychological equivalent of a pill for emotional distress. But, in fact, a closer look at the research literature on therapy clearly reveals that the whole idea of empirically supported treatments (ESTs) is critically flawed, especially as any kind of mandate for what should be done in therapy.
To start with, the criteria for the clinical procedures used to validate a treatment contain a fatal bias. Standard research design requires that the treatments being assessed not contain the inevitable improvisations of therapy as practiced in the real world. Instead, the approaches studied are all required to follow a script so that the "variable" presumably being examined--a precisely defined and structured form of treatment--can be strictly controlled. But while certain kinds of therapy can be scripted--cognitive-behavioral therapy (CBT) being the most prominent--most cannot. So it should come as no surprise that CBT and other behavioral approaches dominate the list of treatments that have received the imprimatur of the task force, amounting to about 80 percent of the list. Is this because these treatments are more effective? No, it is really because they are the easiest to duplicate and, therefore, have been the ones chosen to be researched. This privilege does not extend to some 250 other approaches around today.
Besides the issue of what determines whether a treatment is chosen for study in the first place, questions have also been raised about whether the specific methods associated with an EST really constitute its "active ingredient." One of the most provocative of the studies that raise doubts about this assumption was conducted by Louis Castonguay and Marvin Goldfried, two prominent cognitive-behaviorally oriented researchers who set out to compare the effects of the therapeutic alliance with the effectiveness of a highly structured cognitive approach with depression. Surprising to many who carry the banner for ESTs, their study concluded that the more emphasis a therapist placed on cognitive-behavioral techniques, the worse the treatment outcomes for clients. In their study of 30 depressed clients, Castonguay and Goldfried compared the impact of a treatment technique specific to cognitive therapy--the focus on correcting distorted cognitions--with two other, presumably, non-specific, treatment variables: the therapeutic alliance (agreement between therapist and client on treatment goals and methods) and the client's emotional involvement with the therapist. Results revealed that while the two so-called common variables were highly related to therapeutic progress, the technique unique to cognitive-behavioral therapy--eliminating negative emotions by changing distorted cognitions--was negatively related to successful outcome!
Although the American Psychological Association's intention in adopting ESTs was to demonstrate that psychiatrists had not cornered the market on empirically verifiable treatments, in effect, its task force has responded to the myth of the magic pill by propagating the myth of the magic method. In fact, the uncomfortable truth for advocates of these verified treatments is that there is no solid evidence demonstrating that specific treatment models have unique effects, or that any single therapeutic approach is superior to another. Of course, there have been studies that purport to show that a particular therapy is especially effective. CBT is an example of this. But studies have yet to show consistent differences in effectiveness among therapies developed to address a particular problem despite the Herculean efforts of legions of researchers to do just that.
The results of any attempt to rate the effectiveness of clinical methods--as opposed to the individual effectiveness of practitioners--is best summed up by the dodo bird in Alice's Adventures in Wonderland: "Everybody has won and all must have prizes." In 1936, Saul Rosenzweig invoked the dodo's words to describe the equivalent success of diverse psychotherapies. It has since been called the "dodo bird verdict" and has proven to be one of the most replicated findings in the psychotherapy literature--no approach can reliably make a greater claim to effectiveness than any other.
Perhaps the best publicized study to confirm this idea that all techniques are created equal is the landmark 1989 Treatment of Depression Collaborative Research Project, widely viewed as the most ambitious and methodologically sophisticated outcome study ever undertaken. This NIMH-funded project, which involved both psychiatrists and psychologists at multiple cites around the country, randomly assigned 250 depressed participants to four different treatments: Aaron Beck's cognitive therapy--an approach that seeks to reduce depressive symptoms by challenging irrational and distorted attitudes; Gerald Klerman and Myrna Weissman's interpersonal therapy--which focuses on developing more effective strategies for dealing with "here and now" interpersonal problems; treatment with antidepressant medication; and, finally, a placebo approach called "clinical management," which included a pill placebo plus support and encouragement. After all the effort that went into designing a study that represented the state-of-the-art in outcome research, the investigators were stunned by their own findings. Overall, the four treatments--including placebo--worked with about the same effectiveness.
Recent advancements in statistical methodology, particularly metanalytic studies, which allow researchers to comb through the vast clinical literature and draw conclusions from huge collections of data, lend even further credence to the dodo bird verdict. In psychotherapy researcher Bruce Wampold's comprehensive 1996 review of the therapy-outcome literature, some 277 studies conducted from 1970 to 1995 were analyzed--with particular attention given to the presumably more methodologically sophisticated research of recent years--to determine which therapeutic models have yielded the most robust results. This comprehensive review once again verified that no approach has reliably demonstrated superiority over any other. "Why," Wampold asks, "[do] researchers persist in attempts to find treatment differences, when they know that these effects are small?"
The Client as Partner
So, if empirically supported treatments aren't what makes psychotherapy beneficial to clients, what is? Even though Rosenzweig addressed this question 65 years ago, his conclusion still applies today. Writing in the American Journal of Orthopsychiatry, he argued that all approaches appear to be equally effective, so there must be some larger common factors in operation that overshadow any presumed differences between techniques. What are these factors? The answer isn't really a mystery. The real key to the success or failure of therapy, as Rosenzweig and many other therapists over the years have argued, is the resources a client brings into the room.
Why should it be a surprise that the very factors that were operating in a client's life before counseling also have a crucial effect on therapy? Clients who are, for example, persistent, open and optimistic, who, for that matter, have a supportive grandmother or are members of a religious community are more likely to make gains in therapy.
What else is important to therapeutic success? Researchers Alexandra Batchelor and Adam Horvath argue in their comprehensive 1999 review article that the client's perception of the therapeutic connection is the second most important ingredient of successful therapy, accounting for 30 percent of the outcome. In other words, therapy is much less about method than about the quality of the bond established between therapist and client. To many clinicians, this may seem obvious, but partisans of models and manuals too easily ignore this basic truth: The nature of a client's relationship with a therapist is more important than our cherished theoretical schools, our favorite techniques or our most worshiped gurus.
As we approach a far-reaching transformation in the way mental health services are delivered, it is more important than ever that we recognize that the very foundation of our work is the tailoring of our approaches to the unique needs and circumstances of each client. When you try to do therapy by a book, research tells us that things may not go according plan. For example, researcher Hans Strupp's classic studies, collectively known as the Vanderbilt II Psychotherapy Training Project, conducted in the early 1990s, demonstrated the dangers of overprogramming therapy. Strupp compared the work of therapists before and after they were trained with a manual on psychodynamic therapy. The results: Those who followed the manual were less approving and supportive of their clients, less optimistic and more authoritarian and defensive. Before health care systems organize themselves according to the recommendations of the APAs about what constitutes effective treatment, we need to heed such findings, as well as the previously mentioned study by Castonguay and Goldfried--practitioners of standardized therapy are in danger of developing better relationships with their treatment manuals than with their clients.
Nevertheless, within the medical world, the concept of empirically supported standardized treatments has tremendous appeal. Today, we may stand on the brink of a misguided system of "integrated care" in which manualized therapy will reduce clinicians to mere technicians. And, to make matters worse, integrated data bases will make it easier than ever for managed care organizations to keep track of whether our clients are adhering to the standardized regimens prescribed for them. Lists of approved treatments will give health care bureaucrats a potent weapon to use against those of us who don't order off the menu. This could even leave us in the ethically dubious position of enforcing compliance with treatments we don't endorse, and reporting our clients' lapses to the HMOs.
When our services are provided without a partnership with those receiving them, the client can easily become a cardboard cutout. Moreover, as the trend toward evidence-based practice picks up steam, therapists and clients uncomfortable with this market-driven standardization will find themselves under enormous pressure to conform. So before carved-in care becomes the only game in town, those of us who envision a different future for psychotherapy must step forward to make the case for therapeutic multiplicity.
No matter how invested we are in our own particular clinical methods, we first need to acknowledge that there are many ways to respect our clients' values and perceptions, many ways to be effective and many ways to maintain our clinical integrity. This isn't as easy as it sounds. We have all worked hard to establish our own distinct identity as therapists. We've invested heavily in our own methods. But if we do not unite behind methodological pluralism, we will be easy targets for medical-model ideologues, the proponents of empirically supported treatment and the bean counters of the HMOs.
Clinicians today must take stock of both the values that underlie our practices and our responsibility for professional accountability. Each of us must do his own soul searching about these issues. So what follows is not meant as a blueprint for how therapy should be practiced, just my own conclusions (along with my colleagues Scott Miller and Jacqueline Sparks) about how to extend to clients the same therapeutic freedom we must defend for ourselves and some alternative ideas about what the empirical literature can teach us regarding accountable practice.
Not long ago, I worked with Erica, a woman in her mid-thirties who came into therapy searching for an identity that she believed she had lost. All her life, Erica had wanted to be a police officer. As a teenager, she rode with state troopers, and as a young woman, she became the first female to graduate from the police academy.
Erica lived her dream as an officer for several years, until a car accident plunged her into a coma that lasted for two years. In a triumph of biomedicine, an experimental drug revived her, although she was left with some brain damage and a seizure disorder that made it impossible to work as a police officer. Without this identity she had devoted her life to achieving, she was no longer certain who she was.
How might a medical system of care address Erica's concerns? Although her quest for a new identity does not neatly fit into DSM categories or empirically supported treatments, there is a good possibility that Erica would be reduced to a collection of symptoms and interventions. She might well be diagnosed as depressed and prescribed cognitive-behavioral therapy and an SSRI, along with additional skills-training for deficits left by her brain injury. In the process, the fullness of Erica as a person could easily be lost and she could be reduced to a description of "illness."
My first contact with Erica, as with all my clients, was founded not in just giving lip service to being respectful of clients and collaborative with them, but in using the set of empirically supported findings that I have found most useful in making my therapy as effective as possible. In all the research literature, perhaps the most clinically relevant finding I've discovered is that client's improvement early in treatment is one of the best predictors of successful outcome. So, instead of regarding the first few therapy sessions as a "warm-up" period or a chance to try out the latest brief-therapy technique, I believe it is crucial to be accountable in the very first contact with clients. And given all we now know about the importance of the therapeutic alliance, I approach such initial sessions as a chance to discover how to make the best possible match between myself and my prospective client. Our burgeoning alliance is monitored by clients' session-by-session evaluations of their satisfaction with and progress in treatment. In other words, the guiding principle behind my work with clients is recognizing that all my decisions as a therapist must be guided by my clients' engagement in the treatment process, their view of the quality of the therapeutic relationship, their expectation for change and--the gold standard--their assessment of whether change occurs.
When Erica first called our clinic, she was given the opportunity to structure her therapy, including a choice about whether to meet with an individual therapist or a team. She chose to see me individually, and I first met with her outside the consultation room and told her that I wanted her perceptions to be the light that guided us through the coming process. At my request, she filled out a brief form about how she felt she was progressing individually and socially. Only then did we walk to the consulting room.
She then explained that she felt at a dead end in her life. Having recovered enough to go back to work of some kind, she could not even imagine a back-up dream now that her career in police work seemed over. To complicate matters, Erica was also wrestling with the idea of being "disabled," a word she despised. She recognized that she had some limitations and could not perform the strenuous duties she had once dispatched with ease. Still, the word stuck in her craw. As we explored her experience on the path to recovery, I found myself amazed by her courage, resilience and wisdom. Here was a woman who had it all and lost it--who defied others' expectations of what she could and could not do many times--early on, when she became the first female police office, later, when she unexpectedly came out of a coma, and now, once again. Despite her problems with seizures, vision and balance, she was fighting the expectations of her "disabled" label. She knew there was much more to her than any description of her disability could begin to capture. I knew it, too, as would anyone who spent any time getting to know her. I told Erica that one of the things I liked most about her was her refusal to accept her disability.
A few minutes before the end of our meeting, I asked Erica to fill out another short form, evaluating the progress of therapy to that point. Here, the key clinical information for me was that she felt that I took her problems and ideas seriously, and that she felt hopeful about her situation. Reflecting on how impressed I had been by her, I jokingly asked her if she had ever thought about pursuing a career as a motivational speaker. It was an offhand tribute to the power of her story, but, as I learned later, it struck a deep chord. As we discussed our meeting, Erica told me that she enjoyed the process we had begun--she liked telling her life story and fielding questions about her experiences. Just as the conversation was about to end, she declared that it had occurred to her that she might pursue a career teaching police officers.
That pronouncement was a key step in Erica's journey toward reclaiming her life. She did not end up as a training officer, but was able to reestablish her relationship with the work she loved by becoming a dispatcher. This satisfied Erica's itch for reconnecting with police work, which, for her, was a key to a meaningful life. It allowed her to move on and address other issues, such as her loneliness and her current living arrangements. Erica reported improvement on the outcome measure, and therapy ended a few sessions later.
I don't mention my experience with Erica as an example of a one-session therapeutic miracle, just the reverse. In fact, it is the ordinariness of this kind of interaction that addresses the core of what we have to offer as therapists--the forming of partnerships with clients that makes therapy effective and accountable. I offered Erica no irresistibly powerful interventions, just a relationship structured around her goals and values, that showcased her talents and fortitude. And my repeated requests of Erica to tell me whether the therapy was serving her needs involved a kind of accountability that is very different from the accountability that HMOs increasingly demand from therapists, and that we may expect even more of under integrated care. It stands in sharp contrast to a decision-making process predicated on psychiatric diagnoses, "approved" therapeutic modalities or treatment plans.
As is true of most therapeutic interventions, standardized treatments can be helpful with many clients. But we need a health care system that recognizes that many clients are unlikely to be helped by a medical model of treatment. And that means that if the emerging system of integrated care adopts evidence-based practice as its standard, they may not be helped at all. It is our responsibility as therapists to lift our voices and to advocate on behalf of our clients and our profession. We must make sure that the integrated care system is truly integrated and that it draws from the best of the vast range of approaches that therapists currently tailor to their clients' needs, not the limited number of techniques that are most easily studied. As we are about to enter the next stage in the evolution of our health care system, we need to draw from the accumulated wisdom in our field that teaches us that not all of our clients' struggles fit within diagnostic categories and that therapy can never be reduced to a set of prescribed interventions, no matter how "empirically" supported they may seem to be.
Barry Duncan is professor of family therapy and psychology in the Graduate School of Humanities and Social Sciences at Nova Southeastern University (NSU) and coauthor of 10 books, including The Heroic Client (Jossey-Bass, with Scott Miller) and the forthcoming Heroic Client, Heroic Agencies:
Partnerships for Change (NSU Press, with Jacqueline Sparks). He can be reached at: www.nova.edu/~blduncan. HASH(0xb895f6c) Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
Batchelor, Alexandra, and Adam Horvath. "The Therapeutic Relationship. In The Heart and Soul of Change: What Works in Therapy . Edited by Mark A. Hubble, Barry L. Duncan and Scott D. Miller. Washington: APA Press, 1999.
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Elkin, Irene, et al. "National Institute of Mental Health Treatment of Depression Collaborative Research Program: General Effectiveness of Treatments." Archives of General Psychiatry 46 (1989): 971-982.
Kiesler, Charles. "The Next Wave of Change for Psychology and Mental Health Services in the Health Care Revolution." American Psychologist 55 (2000): 481-487.
Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2000. APA Clinical Resources. Washington: American Psychiatric Association, 2000.
Rosenzweig, Saul. "Some Implicit Common Factors in Diverse Methods of Psychotherapy." American Journal of Orthopsychiatry 6 (1936): 412-415.
Strupp, Hans H., et al. "Effects of Training in Time-Limited Dynamic Psychotherapy: Changes in Therapist Behavior. Journal of Consulting and Clinical Psychology 61 (1993): 434-440.
Wampold, Bruce, et al. "A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, "All Must Have Prizes." Psychological Bulletin 122 (1997): 203-215.
by Richard Simon
Suddenly, sometime in the mid-1980s, as the managed care revolution raged around them, therapists emerged as if from a dream to find that terms like "heath care delivery systems," "covered lives" and "capitated health plans" had gone from being mind-numbing policyspeak to urgent pocketbook issues. As an entire profession nervously scanned the horizon, anyone at a national conference who had something vaguely credible to say about whether the Golden Age of Private Practice was truly coming to an end was able to attract a capacity crowd. Since that time, as the sense of imminent crisis has gradually subsided, most therapists have grown much less interested in such crystal-ball gazing. Many appear to have accepted the fact that they no longer live such sheltered lives and have adapted to the economic realities of the mental health field today. In fact, lots of clinicians talk confidently about having weathered the storm, freeing themselves from managed care and, in some cases, recasting their services as coaching or consulting so as to emancipate themselves entirely from the world of corporatized mental health care.
But is this just another example of therapists' notorious head-in-the-sand attitude toward the business of therapy? What does lie ahead for the more than half-million psychiatrists, psychologists, social workers, mental health counselors, marriage and family therapists and other professionals who continue to call what they offer the public "psychotherapy"?
Lacking the sense of urgency that accompanied the dawn of managed care, therapists today seem to have little interest in the cautious generalizations and policy jargon of health care industry analysts, while few of their clinical colleagues have emerged as leaders with a compelling grasp of the Big Picture of therapy practice in the 21st century. So when one hears a quote like "health care delivery in 20 years will bear as little resemblance to the managed care organizations of today as Henry Ford's Model T had to space technology," most informed observers can quickly identify the source--Nicholas Cummings, psychotherapy's most quotable soothsayer and, arguably, one of the prime architects of modern mental health practice.
For the last 40 years, Cummings has cast himself as both a friend to the ordinary practitioner and a visionary capable of seeing just around the curve to the next stage in the evolution of the health care marketplace. His contributions to the field are almost indistinguishable from the signal turning points in the delivery of therapy services over that period. The story of his career reveals much about the changing economics of mental health and the emergence of much of what we now take for granted about how therapy is practiced and the personal career options available to today's practitioners.
The Birth of Coverage for Psychotherapy
When Cummings started out as a young psychologist in the late 1950s, not a single health plan included psychotherapy. For the actuaries of the health insurance world, psychotherapy was simply too vague and ethereal to be taken seriously. But Sidney Garfield, cofounder of Kaiser Permanente, the nation's first HMO, had become increasingly aware of complaints from overworked physicians within the Kaiser system about the time spent dealing with "hypochondriacs"--patients who required attention for problems that had little to do with physical disease. Believing that psychotherapy might be the key to reducing the workloads of his physicians and realizing enormous cost savings, Garfield hired Cummings, who had recently resigned from the graduate faculty at Cornell University after only three weeks, unable to tolerate the bureaucratic snail's pace of academic life. Cummings's assignment was to investigate the impact of including psychotherapy as a benefit in the Kaiser plan.
Instead of viewing "hypochondria" as evidence of pathology, Cummings began by normalizing what he termed "somatization"--the predictable symptoms of the stress or underlying psychological issues that are part and parcel of any major medical condition. He designed a pilot project with 30,000 Kaiser subscribers, offering them--for the first time--the option of seeing a physician-referred psychotherapist for a $5 co-payment. By the end of his three-year study, Cummings concluded that as many as 60 percent of physician visits were based on somatized complaints and demonstrated that therapy could save medical and surgical dollars far beyond the money necessary to provide psychological services. Hence the term "medical cost offset," the economic rationale that fueled the growth of mental health coverage--and, ultimately, the mass impact of therapy on American culture--was born. As a direct result of Cummings's work, in 1963 Kaiser Permanente became the first health insurer to include psychotherapy as a regular benefit, with the rest of the insurance industry soon following suit.
Over the next two decades, Cummings became a member of a core group of insurgent psychologists within the American Psychological Association (APA), dubbed by their adversaries "the dirty dozen" (even though there were 14 of them) because of their penchant for unconventional guerrilla tactics in challenging the association's status quo. Along with his co-conspirators, Cummings set out to galvanize the staid, academically oriented APA into furthering the growth of psychology as an independent clinical practice. Cummings and his allies led the way in the battles for "freedom-of-choice" legislation in the '60s and '70s that opened the way for psychologists (and later social workers and other mental health professionals) to gain licensure and the right to be reimbursed alongside psychiatrists. Determined to offer an alternative to traditional academic clinical training, in 1969 Cummings also founded the California School of Professional Psychology, the first professional school of its kind, that offered doctoral-level clinical training emphasizing experiential learning, personal therapy as a requirement for trainees and a faculty of practicing clinicans rather than academics who, as Cummings puts it, "had never seen a patient in their lives."
By the mid-1980s, Cummings became convinced that the issue for therapists was no longer recognition and reimbursement, but a sea change in the fundamental economy of contemporary health care. His assessment: "The cottage industry which constituted a fractionated and disorganized non-system of health care was about to industrialize." He urged psychologists to become leaders in the inevitable movement toward a more coherent, cost-conscious approach to health care, rather than ceding the field to corporate interests. He argued that efficient, targeted treatment was not incompatible with effective clinical services and, by way of example, he founded American Biodyne, a model for the kind of practitioner-run national company he advocated that grew to serve 14.5 million enrollees in 39 states by the time he sold his interest in it in 1993.
Today, at 77, ever ebullient and able to get by with only three hours of sleep a night, he lectures widely and runs two foundations devoted to furthering the cause of quality mental health care--the Foundation for Behavioral Health and the Nicholas and Dorothy Cummings Foundation. And, as the following conversation reveals, one of his favorite pastimes still is foretelling the future of psychotherapy and the nation's health care system.
The Industrialization of Health Care
Psychotherapy Networker: Let's start with a typically provocative quote from a paper you wrote a few years ago--"The transition from managed care to the next phase in the industrialization of health care has already begun." Most therapists I know have struggled mightily to make their peace with managed care as it exists today, so what will we need to do to adjust to this next phase that you're talking about?
Cummings: Since the '80s, along with the enormous growth of managed care, we've seen all the managed care companies swallowed up into a few huge corporations. Today two companies--Magellan and ValueOptions--control 40 percent of the managed behavioral health care market. The 5 largest managed behavioral care companies control 50 percent of the market and the top 10 companies control 98 percent. But along with the mergers and the growth of these gigantic corporations, one problem has become clearer and clearer--these companies are now run by people who don't have a clue about how to deliver mental health services and, in the privacy of their own boardrooms, they're facing that fact. And so, even though they won't admit this publicly, they're surfeited with complaints and drowning in malpractice suits. So they're getting out of the behavioral care delivery business and beginning to reorganize themselves pretty much as third-party payers.
PN: So who will be stepping in to actually provide mental health care?
Cummings: The managed care companies are beginning to "outsource it--that's the word the industry uses for doing it out of house. For example, since the beginning of this year, Magellan, the largest managed behavioral care company with 60 million covered lives, has sold all the group practices it operated, most of them back to the providers themselves. They're now just administrators, completely out of the service delivery business. So the next great trend that we're starting to see is the emergence of large group practices run by providers who are taking over the delivery of health care. And the practices that are successful are those that have learned that if you concentrate on effective, efficient therapy, there's a bonanza to be made. They're out from under managed care--they now contract with managed care.
PN: And what will determine which of these groups will actually make it?
Cummings: Most of these groups start out saying, "Well, we're going to do better than the managed care companies did. We're going to make sure that the patient gets what the patient needs." Of course, they then find out that they're swimming in red ink because they haven't learned to differentiate between what gets the job done and what just feathers the nest of an individual practitioner. They're really two very different things. For the solo practitioner--the longer the thing takes and the less turnover there has to be, the better you do; plus you don't have to have as many referrals. But from an economic standpoint--and there's just no ignoring this--the opposite is true. The faster you get the job done, the more likely you are to make a profit. The point is to make therapy both effective and efficient.
Unfortunately, most practitioner groups don't have a clue how to do this, so the ones that are doing the best have finally admitted that they're economic illiterates and are beginning to bring in the right kind of managers to help them do it. So you've got an incredible paradox here--the managed behavioral care companies are outsourcing the clinical side and then the practitioners are outsourcing the management side. So you've got three levels of outsourcing here. Anyway, that trend is in full swing, and when a huge company like Magellan decides it no longer wants to be a deliverer of mental health services, you can begin to see where the industry is headed.
The Therapist Workplace of the Future
PN: Your other big prediction about the future of health care is that the majority of mental health services will be dispensed in medical primary care facilities, with therapists located right across the hall from physicians. So are the managed care giants proponents of this new kind of "integrated care"?
Cummings: Even though the managed care companies pay tremendous lip service to the integration of care, for the most part, they've done a miserable job of trying to bring it about. They are organized to provide "carve out" services, and how in the world to "carve in" is beyond them.
PN: But wait a minute. Aren't there tremendous economic incentives to reducing physician visits by "carving in" mental health services as part of primary care?
Cummings: That's true, and that's why they have tried to do it, but they have found out that they don't know how. Look, the success of the managed care industry has been tremendous. In 1993, the Congressional Budget Office predicted that by 1998 health care expenditures would reach $1.7 trillion. In fact, in the year 2000, health care costs had reached only $1.3 trillion. Managed care has saved the United States somewhere between $350 to $400 billion last year alone! Congress, literally, balanced the budget on what they saved on Medicare and Medicaid by farming out the services to managed care. So the managed care companies don't want to change. They don't want to do something they don't know how to do. And most of all, they don't want to disturb a huge profit center unless they absolutely have to. How can I explain this? I mean, it's like asking the members of the chauffeurs' union to suddenly all become airline pilots. You're either a pilot or you're a chauffeur. It takes a lot to stop physicians from doing what they are trained to do. A patient comes in week after week with the same symptoms and the physician will repeat the same "standard" test--electrocardiograms, blood tests, X-rays--trying to chase down some physical disease. And when one physician has had it, there are always more doctors with whom to start off the whole process again. And unless the patient mentions a psychological problem, most physicians have not been trained to think of referring to a mental health specialist.
But the important thing to remember about integrated care is that it's not enough just to change a few components in an otherwise traditional medical system. That's like adding a few drops of red paint to a 50-gallon can of white paint. You have to approach every primary care problem by including attention to the behavioral care issue as well. That's true integrated care.
PN: If there is so much resistance within traditional medicine and from managed care companies satisfied with their current profits, where is the impetus for change coming from?
Cummings: The real impetus for integrated care is coming from the employer. By now, they are familiar with the medical cost-offset literature that has consistently found that 60 to 70 percent of visits to physicians are made by people who have no organic disease, but whose primary problem is that they are somatizing stress. They know that there are billions and billions of dollars to save on the medical and surgical side, if those people could be treated by mental health professionals instead. So employers are starting to pressure the companies out there to change the way they deliver health care, which will have a huge impact on therapists.
PN: What about the people who are in private practice today? As I talk to therapists around the country, it seems that most of the experienced clinicians I know are able to be quite successful in private practice. Will this trend toward integrated care affect their livelihood?
Cummings: Back in 1996, I predicted that as the managed care companies continued to fail in delivering adequate and quality mental health services, consumers would be willing to pay out of pocket for private care that wasn't covered by insurance. But I also predicted that this "boutique market" would only last for a few years. It was a transient thing, a bubble, that was going to be very much subject to economic times--boutiques don't do well in recessions--and could never grow above five to eight percent of the market. I based that percentage on the fact that in every country that has universal health care, whether you're talking about Sweden or the United Kingdom, no more than five to eight percent of the population is willing to pay out of pocket for services that are insured. So the boutique market can be seductive, but it's a transient thing.
The success of the boutique market is inversely proportional to the number of people in it. The people who got into it first are doing very well. But if 30 or 40 or 50 percent of practitioners out there decide to go after the out-of-pocket, fee-for-service clientele, they're going to find that there's a very, very small clientele out there--too small to keep a large number of practitioners in practice.
Advice for Therapists
PN: Okay. If that is the big picture, what do you say to the individual practitioner who's trying to prepare for the contingencies of the future? As a therapist, how can I best shape my own destiny, rather than having the marketplace shape it for me?
Cummings: First, don't get sucked in by the bubble that we're seeing now because some private practitioners seem to be doing so well. Second, realize that psychotherapy is finally going to go where it should have gone from the very start--to be an integral part of general health care. So the most important thing you can do to prepare for the health care system of the future is to become proficient in health psychology--the application of behavioral and psychological techniques to medical conditions. There is no such thing as a physical illness without its behavioral dimension. For example, depression is an accompaniment of almost every chronic condition, and non-compliance with medical regimens is one of the costliest issues within our current health care system. Some conditions are especially notorious for non-compliance. The worst is hypertension, probably because with hypertension, patients often don't feel any serious discomfort. They just suddenly have a heart attack; there's no incentive to change their lifestyle. Hypertension, diabetes and asthma account for almost 30 percent of all the medical expenditures in the 25 to 55 age group, and it's mostly because of non-compliance and problems in handling stress. But to tease out the psychological component of patients' problems, therapists will need to know much more about the whole range of physical diseases.
PN: On a concrete level, how will therapists actually spend their time in the kind of health care system you envision?
Cummings: Most of their time will be spent leading time-limited, protocol-based, psychoeducational groups that have been shown to reduce medical costs and improve patients' functioning more than traditional medical treatment. One type of group might be called "disease management" groups--these are designed for people with the same medical condition: rheumatoid arthritis, asthma, diabetes--all of which are chronic, have no biomedical "cure" and are extremely frustrating conditions for traditionally trained primary care physicians, who don't really know what to do with these kind of patients once the diagnosis is made. And then there are "population-based" groups that address conditions that are not primarily medical--like Borderline Personality Disorder, depression, substance abuse, Panic Disorder--but which impinge drastically on the medical system.
PN: Is it groups like that you have in mind when you say at least 50 percent of the mental health services of the future will be psychoeducational?
Cummings: Correct. The future of health care will be based on increasing the self-efficacy of people in dealing with all the chronic conditions that modern medicine can arrest but not cure and providing psychological services in a much more effective and efficient way. With many medical problems, therapists in the future will be involved with helping people learn the specific things they can do to influence the state of their health, for example, monitoring their own blood sugar, their own exercise, their own stress level and so forth, getting them out of what Martin Seligman calls "learned helplessness." A major role for therapists in the future will be getting people out of taking the position of "I'm helpless. I may as well adjust to my illness."
PN: And with psychological problems, do you also believe that group interventions are more effective?
Cummings: That's what the research seems to be telling us. The differential between a group program for substance abuse and individual psychotherapy is so astronomical that nobody even argues about it anymore. But we are beginning to see the same thing with problems like depression, agoraphobia, panic and anxiety disorders.
PN: Many therapists believe that protocol-based treatment leaves out the most important elements that make therapy work. What do you see as the essence of an effective protocol?
Cummings: That it's research based. You construct a protocol and keep trying out and measuring your results. There is no such thing as a finished protocol--you're always reevaluating it and trying it out. But I think there are a few elements that we know are necessary ingredients, whether the protocol addresses a medical or a psychological condition. All protocols have an educational component. Patients learn very frankly, with no punches being pulled, what diabetes is or what borderline personality is or what Bipolar Disorder is. Every protocol teaches patients how to monitor and evaluate their own condition--diabetics learn to monitor their blood sugar, people with Borderline Personality Disorder learn how to monitor their mood and their sense of being blown like a leaf in the wind. Every protocol has a buddy system and a peer culture that the therapist can utilize. I cannot think of any psychological protocol in which exercise would not be an important component.
PN : With all of your confidence in protocol-based approaches, you've also written that two-thirds of the people within any of these population-based, group approaches are going to need individual attention at some point. Could you explain that?
Cummings: People are very diverse, even if they share a common condition. When someone hits a snag in a program, there should always be the option of seeing him or her individually as needed. But I believe that only 25 percent of the therapy of the future will be individual. Actually, that's 25 percent of the time allotted, and much less than 25 percent of the people being treated. Because if you have a practitioner who spends 25 percent of her time in individual therapy and 75 percent in time-limited group psychotherapy and psychoeducational disease and population-based models, 75 percent of the practitioner's time will yield more like 90 percent of the patients. But clearly practitioners of the future will have to learn how to do group psychotherapy in time-limited modules. They'll have to learn how to do individual therapy that's focused and targeted, not open ended. And therapists of the future will have to take business courses in graduate school, just as physicians are starting to do in medical school.
PN: What will they learn in the business course?
Cummings: How to balance a budget and maximize their time. Most therapists couldn't balance their checkbook. So they have no way of knowing that all the things they're doing are going to plunge them into the red when they have their quarterly accounting. They need to learn the kind of business discipline that says, "Wait a minute, what is the most effective and efficient treatment I can give this patient?" Most of all, therapists have to finally get over the belief that therapy should take as long as it takes, no matter the cost. We no longer live in a world that permits us to think that way.
Richard Simon, Ph.D., is the editor of the Psychotherapy Networker and author of One on One: Interviews With the Shapers of Family Therapy . Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
by Joshua Wolf Shenk
After he has awoken, from uneasy dreams, to find himself transformed in his bed into a giant insect, Gregor Samsa's first encounter with the world outside his bedroom comes in the form of his mother's voice. "Gregor," she says. "It's a quarter-to-seven. Hadn't you a train to catch?" When he opens his mouth to answer, Gregor hears a peculiar sound. The voice is "unmistakably his own" but has a "persistent horrible twittering squeak behind it like an undertone that left the words in their clear shape only for the first moment and then rose up reverberating round them to destroy their sense." And so, having at first thought that he would "explain everything," Gregor says only this: "Yes, yes, thank you Mother, I'm getting up now."
In The Metamorphosis, a story about alienation, the first rupture is one of language. Gregor Samsa cannot make himself known to the world. Just as his body has become unrecognizable, inexplicably Other, so has his voice. In this image--more clearly, even, than in Gregor's grotesque physical form--I feel the presence of the author. "I am constantly trying to communicate something incommunicable, to explain something inexplicable," Kafka wrote of himself. He was alienated from language, and even felt trapped by it. But words, metaphors, and stories were his only way out.
When I was a small child, about eight I think, I ripped apart my bedroom in a frenzy. I threw the pencil sharpener off my desk. I pulled the sheets and blankets off my bed and turned over the mattress. I pulled clothes out of their drawers, drawers out of the bureau. Eventually the bureau itself toppled. A few moments later, my mom stood in my doorway and said, with aplomb, "Looks like a tornado has been through here."
Five years later, I stood on the lawn of my father's house, just home from summer camp. My oldest brother drove up the dead-end street in his gray Fiat, and turned left into the short driveway. I ran over to see him. I recall, as I ran, feeling a false expansiveness. I wore a too-wide smile, like a clown scripted for a pratfall. As I began toward the car, my brother leaned over and rolled up the window on the Fiat's passenger side. Then he backed down the driveway and drove away.
When I was seventeen, I carried these and other fragments up the stairs of an old Victorian home in Cincinnati. As I sat in the waiting room of a psychiatry practice, I knew I was lonely, unhappy, even desperate. I did not know I was depressed. But that was the word that waited for me, a diagnosis that physicians since Hippocrates have been trying to elucidate and one that I would inherit.
The Hippocratic writers believed that gloom, abnegation, and misanthropy could be traced to excesses of black bile. Unlike the other three bodily humors (blood, phlegm, and yellow bile), black bile was never actually observed. Today, we know no such substance ever existed. Still, the Greek words--for black ( melan ) and bile ( khole )--dominated the language of inner states for more than two millennia.
In 1905, the influential American psychiatrist Adolf Meyer proposed that "melancholy" and "melancholia" be retired from the clinical vocabulary. He believed that the terms were used too broadly. They described "many dissimilar conditions" and also "implied a knowledge of something that we did not possess"--that is, the causal role of black bile. Meyer preferred the word depression. Other physicians followed him, as did medical texts and the lay culture.
In the hands of modern writers, "melancholy" has recently experienced a renaissance. In Darkness Visible, William Styron charges that Meyer "had a tin ear for the finer rhythms of English and therefore was unaware of the semantic damage he had inflicted by offering 'depression' as a descriptive noun for such a dreadful and raging disease." The word depression, Styron continues, has "slithered innocuously through the language like a slug, preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control."
It strikes me as telling that writers--for whom words are tools and imprecision deathly--knowingly use a term that is literally untrue; and that they use "depression," "melancholy," and other imperfect words interchangeably. These are two of many indications that the experience they describe has no true name. Styron, for instance, readily concedes the paradox that his memoir of melancholia is but a hazy shadow of something "indescribable." Most accounts of depression will have this sort of disclaimer. Others disclaim implicitly through dependence on metaphor and allusion.
Perhaps depression is simply hard to convey--even, as Styron says, "indescribable." But I'd like to suggest another possibility: That what we call "depression," like the mythical black bile, is a chimera. That it is cobbled together of so many different parts, causes, experiences, and affects as to render the word ineffectual and perhaps even noxious to a full, true narrative.
It is ironic, given the criticism directed at him, that Adolf Meyer seemed to have in mind the limits of single-word diagnoses when he proposed that depression replace melancholy. Meyer believed the former word, obviously inadequate, would force doctors to tailor their descriptions to individual cases. "Nobody would doubt that for medical purposes the term would have to be amplified so as to denote the kind of depression," Meyer wrote. (Italics added.) Perhaps Meyer even liked the insipid quality of "depression," believing it would announce (like a blank canvas or the blue screen on a film set) the absence of material to come.
If so, what transpired over the century can be counted among the great tragicomedies in the history of language: Somehow, we have come to believe that "depression" is the art, is the phantasm of special effects, is the evocative detail or phrase or story rather than a mere placeholder. The DSM-IV lists only a few qualifiers for "major depressive disorder." Psychiatrists and medical texts treat depression as a discrete entity, and assume it adheres to a particular course and treatment. Ads for drugs, herbal remedies, and nutritional supplements refer to depression as though it is a foreign invader, unrelated to the authentic self.
In lay culture, meanwhile, the word is often used with no context at all. A New York Times report on the rising suicide rate in Japan notes that the cause might be "depression," but does not offer even a single phrase to elaborate. In conversation, otherwise imaginative, articulate speakers toss around the words "depressive" and "depressed" as if they capture a person's essence. In his story "The Depressed Person," David Foster Wallace gives the eponymous character no other name, which I take as sardonic reflection on the way we drape over diverse sufferers a label that hides more than it reveals.
Perhaps, for many, staying hidden is part of the point. I think of Tipper Gore, who first spoke publicly of her depression in a front-page interview with USA Today. After her son recovered from a nearly fatal accident, Gore explained, she saw a social worker and was told she "had a clinical depression and one that I was going to have to have help to overcome."
She continued, "What I learned about it is your brain needs a certain amount of serotonin and when you run out of that, it's like running out of gas, it's like you're on empty. When you get to this point of being seriously depressed or what we call 'clinically depressed,' you just can't will your way out of that or pray your way out of that or pull yourself up by the boot straps out of that. You really have to go and get help, and I did. And I was treated for it successfully, I'm happy to report."
Gore did not describe in what way she felt depressed, nor how it affected her life only that she had a "clinical depression . . . and I was treated for it successfully." Her reticence might have been motivated by discretion, or a wish for privacy, and I do not begrudge her these. I appreciate her candor, insofar as many would choose to say nothing. Still, like so many public figures who have made similar confessions, she hinted at intimacy then quickly withdrew behind a wall. The word depression was that wall.
It is inevitable that we abbreviate and simplify. (It is apparent even in this essay that I see no way around the words "depression" and "melancholy.") But it is one thing to use shorthand while straining against the limits of language. It is quite another to mistake such brevities for the face of suffering. Each year, seventeen million Americans and one hundred million people worldwide experience clinical depression. What does this mean, exactly? Perhaps they all have deficits of serotonin, feel hopeless, ruminate on suicide. But why? What wrinkles crease their minds? How are they impaired? For how long--two weeks? a month each year? an entire life? And from where does this depression come?
Rather than acknowledge these variations and uncertainties, many react against them, taking comfort in language that raises the fewest questions, provokes the least fear of the unknown. Such is the case with the equation of emotional problems and mechanical failure. Phrases like "running out of gas," "neurotransmitter deficits," "biochemical malfunctions," and "biological brain disease" are terribly common, and are favored by well-intentioned activists who seek parity between emotional and somatic illnesses. Pharmaceutical companies also like machine imagery, since they manufacture the oils, coolants, and fuels that are supposed to make us run without knocks or stalls.
This language not only reflects, but constructs, our reality. When we funnel a sea of human experience into the linguistic equivalent of a laboratory beaker, when we discuss suffering in simple terms of broken and fixed, mad and sane, depressed and "treated successfully," we choke the long streams of breath needed to tell of a life in whole.
Just as we hear music through intervals, experience is often easiest to understand in terms of contrast. And so despair is often best expressed in terms of what has changed. "I used to relish crowds on the street, but now people repulse me." Or, "I used to wake up with a feeling of expectancy. Now I can only wrap the pillow around my head and pray for more sleep."
When I began psychotherapy late in high school, I had a clear and persistent sense that something was wrong with me, but no vocabulary with which to describe it. I could not draw on contrast because I didn't remember a time when I felt differently or better. I did not have seasons of happiness followed by epochs of misery, or fall off cliffs and climb back up among the daisies. I felt as I felt for as long as I could remember. I did not go to therapy to understand, or to get through, an episode. I needed to understand and get through my life.
Since my "condition" is so deeply rooted, much of my personality grew out of it and developed to cloak it. This made expressing myself even harder. I did well in school, stayed out of trouble, behaved like a son my parents could be proud of. I wrapped myself in a skin of normalcy and success but grew more hidden, from others and from myself. In high school, I wrote in a poem that I wished "to be a slug," to have an exterior that expressed what I felt. Like Gregor Samsa, I greatly desired to speak the whole truth. Instead, much of the time, I merely said, Thank you, thank you, I'm getting up now--going to school, going eventually to college and the bright future that everyone expected. But the present, which I tried so hard to dodge, could not be dodged.
In Seeing Voices, his book on the language of the deaf, Oliver Sacks notes that philosophers have long dreamed of "a primordial or original human language, in which everything has its true and natural name; a language so concrete, so particular, that it can catch the essence, the 'itness,' of everything; so spontaneous that it expresses all emotion directly; and so transparent that it is incapable of any evasion or deception. Such a language would be without (and indeed would have no need for) logic, grammar, metaphor, or abstractions--it would be a language not mediated, a symbolic expression of thought and feeling, but, almost magically, an im mediate one."
I hoped for such fluid, full, direct communication in therapy. I tried to express the relentless stream of criticism that I directed at myself and others, the way I felt split in two, the dull and sharp aches that moved around my body as though taunting me. I wished to plug a probe from my brain to the doctor's, so that he could see--without mediation--how I stood outside myself, watching and criticizing, and could never fully participate in a moment. How I felt bewildered, anguished, horrified.
Instead, I often found myself silent. When I spoke, it was with stumbles and stammers. Words-- unhappy, anxious, lonely --seemed plainly inadequate, as did modifiers: all the time, without relief. Ordinary phrases such as I feel bad or I am unhappy seemed pallid. Evocative metaphors-- My soul is like burnt skin, aching at any touch; I have the emotional equivalent of a dislocated limb --were garish. Though this language hinted at how bad I felt, it could not express what it felt like to be me.
I suppose the combination of words, body language, and silence did in some measure convey the message, because my first therapist was able to offer me a helpful phrase. "Is it," he asked, "as though you have a soundtrack of negative thoughts in your head--the volume rising or falling, but never going silent?" I pictured an old reel-to-reel tape machine, sitting alone on a table in an empty room. I lingered over the image, comforted especially by the acknowledgment that it never stopped. And I felt a spark of recognition, a kind of introduction to the meaning of my own experience.
The soundtrack image was an imperfect one, as I do not "hear voices" in the sense of hallucination; nor are the bad feelings that echo inside me always in words; nor can I always discern the difference between "self-criticism" and observation, between a gratuitous self-slap and a guide to truth.
But of several hundred afternoons in that Cincinnati office, this moment stands out--the offer and acceptance of a liberating, idiosyncratic metaphor, one that would need many revisions, but at least got me on the page. By contrast, I have no memory of hearing the word "depressed," which was how I was described at that time to my parents and to insurance companies.
In his exhaustive survey, Melancholia & Depression: From Hippocratic Times to Modern Times, the historian Stanley W. Jackson concludes that "no literal statement" can convey the experience. But he found that, over 2,500 years, two images recur most often: "being in a state of darkness and being weighed down." If we consider "melancholy" and "depression" as condensations of these images--as more than diagnoses--they retain enormous power. One of my earliest attempts at essay writing dwelled at length on an image of a dark room lit only by the space beneath the closed door. I did not make a habit of spending time in such rooms. The image of darkness imposed itself upon me, as it has for so many, as a symbol of distress.
And my dislike for the word "depression" does not mean that it has no application to my life. I am often "bowed down greatly" (from Psalm 38), feel weighed upon, feel myself on lower than level ground. Compared with others, it seems, I get less pleasure from what's pleasurable and have a harder time with what's hard. My sex drive is often muted (even without antidepressant medication, which exacerbates this problem). Work and activity that require some suspension of self-consciousness--like playing team sports--are difficult, bordering on impossible. I've tended toward activities in which self-criticism can be an asset, like writing. A tightness, an anxiety, a desperation usually grips me when I wake, relaxes its hold only occasionally through the day, and accompanies me when I lie down.
But, even as metaphors, these words are too thin to contain a life. For example, the times when I do pass from withdrawn to talkative are often quite unpleasant. Darkness aches, but light blinds.
At this point I encounter in the margins a note from my editor asking for further explanation of what is written above. And I shudder from the memory of moments like this: I am trying to explain myself and I encounter "Why?s" and "What do you mean?s" questions I fear can't be answered. I imagine the seams of this essay splitting, and the meaning and emotion I am struggling to convey here falling out like beans from a sack.
And so I remind myself: An imperfect word is sometimes better than silence, a pale metaphor better than suicide. Researchers and therapists want to understand problems in their broad dimensions; families and friends want to make sense of their afflicted loved ones; and, of course, those who suffer in isolation, starved for connection, mad with the sense that they will never be understood and never find relief, need to say something, even if it's wrong, or not wholly right.
Still, while we cannot be silent, or forsake the available word or metaphor for the perfect one that eludes us, we also cannot stop at those less-than-perfect words and metaphors. Insufficient or overused phrases--which resolve eventually into clicheÂ´s--lose their power to evoke a fresh, startling image. They stop tapping into the field of primal meaning that precedes language and to which, through language, we are forever trying to return. Worse, poor language can cripple the capacity to imagine. "A man may take to drink because he feels himself to be a failure," George Orwell writes, "and then fail all the more completely because he drinks."
The failure begins when words intended to codify or categorize, what Maurice Merleau-Ponty calls "empirical speech," actually disrupts or preempts "creative speech," or "that which frees the meaning captive in a thing." Every breath and word is an effort at translation and, at times, that effort can seem impossible. But poems, lyrics, stories can do an end run around the stubborn distance that separates us, helping us feel what it is to be alive. Words can create meaning, teach us our own thoughts, and perhaps even describe a life. But we have to plumb, with curiosity sustained over time, with toleration of uncertainty, the unsettling, elusive stories that make us who we are.
Letters form meaning from lines and curves. Words form meaning from letters. Metaphors form meaning from words. None of these units are large enough to encompass, to identify, to "diagnose" a person. If pressed, one could call Ahab "mad," or Bartleby "depressed." But to know these characters, you must read the story. To tell a life, you must tell a story.
Which is not by any means a straightforward task. Freud's idea of "repression" suggests that unconscious experience is like water pressed against a dam, that we need only remove the blockage and allow our memories to pour out. This is a dominant image of emotional healing in our culture. I think of it as the Hawkeye Pierce model of psychotherapy, after the last episode in M*A*S*H, in which Alan Alda's character has been confined in an asylum and is coaxed into retelling a traumatic episode. One by one, the authentic details emerge until he remembers the repressed memory of a small child's death. He cries. He is healed.
The psychoanalyst Donnel Stern, in his book Unformulated Experience, suggests another way of thinking about "repression." He uses the metaphor of the rock at the bottom of a lake, which requires great and sustained effort to recover. Perhaps our lives are many such rocks. Perhaps we have to raise the ones we can, imagine the rest and then, with these images and memories and emotions laid before us, find the patterns and shapes.
We are all natural storytellers. Even as we think we are just seeing a concrete image or hearing a distinct sound, we are in fact filling in gaps, putting material in context, constructing a narrative. That muted howl from the apartment next door--is it a woman crying, or a child laughing, or the laugh track from a television set? We make such choices at every moment, usually without conscious thought. We tell stories about other people, and we tell one big story about ourselves.
But sometimes, for some people, the story is torn. The essential sense of who we are, of what the world means, becomes lost. All the bits of life's evidence that must be sifted, digested, or passed over, instead fly like shrapnel. This happened to me a long time ago. In high school, when I first saw my name over small stories and articles, those words "Josh Shenk"--in ink against newsprint--struck me with dumb shock. I was thrilled and horrified at a small glimpse of what it meant to be real. It may seem strange that someone haunted by the inadequacy of words would become a writer, but I've often felt no other choice but to struggle and claw for what should be a simple birthright: to tell myself and others who I am.
Like everyone, I start with a handicap, which is that I don't know my own beginnings. Births and early infancy precede memory. Many later memories, which we should in theory have access to, are still as elusive as mist. So we become historians of our own lives, dependent on unreliable, reluctant sources. I can describe with precision the home I grew up in, its brown paint and simple brick, the gnarled limbs on the trees outside. But what did it feel like to live there? How did it form me?
I need to find these feelings, because the facts communicate so little. For instance, I was the youngest of three children and my parents divorced when I was seven. This is a story too common to be distinctive, but too important to be ignored--the slow leakage of affection and kindness from my parents' marriage, the grim entrance of resentment, confusion, and anger. The unspoken rules of the house forbade expressing these emotions, and this remained true after the divorce.
My brothers fled the home as best they could. I, the adoring younger brother, tried to follow them. But they had no interest in me, except as an occasional object of humiliation. I suppose I reminded them of what they hated in themselves: the vulnerable, longing, suffering son of their parents.
When I tried to let out my own feelings--tearing apart that room, for instance--my family pretended they were invisible. I learned to not speak how I felt, soon stopped knowing, and slowly but certainly developed a way of being--a sense of being split, an aching numbness, a cascade of critical voices--that would keep things that way. Some psychiatrists have described this as "depersonalization." It is a diagnosis listed in the DSM-IV in the category of dissociative disorders, along with post-traumatic stress and what used to be called multiple-personality disorder. Depersonalization, the manual says, is characterized by persistent or recurring feelings of "detachment or estrangement from one's self, a sensation of being an outside observer of one's mental process, one's body, or parts of one's body."
"Often," the manual continues, "individuals with Depersonalization Disorder may have difficulty describing their symptoms."
No diagnosis can tell my story. Still, depersonalization has the advantage of nicely announcing what is missing. To treat this "disorder" requires nothing less than removing the "de" to find the person--whatever is real beneath.
There is no drug for depersonalization, which leaves me adrift in an era where pharmaceuticals offer identity: If Ritalin or lithium or Xanax ease your symptoms, you can fit into the narrative of the corresponding disorder (attention deficit, bipolar, anxiety). If an anti-depressant helps, you can toss off the four letters preceding the hyphen and proudly affix to yourself the word that remains. I haven't been helped by medication. Many have. But I wonder if all of us are depleted by the way brand names, dosages, and combinations have eclipsed talk of agonies, fears, and dreams. Good stories must be reined in from chaos (the whole truth), which our imaginations are too feeble to comprehend. But good stories are never simple or precise. To shape and order our lives, without molding them into caricatures, is to hew a course between the poles of chaos and cliche--the course of authenticity.
This is a truncated memoir, an introduction to my own introduction to my story. I still need to imagine my life, to find my story by living it, following moments of emotional clarity through life's maze. I look for help in therapy, in relationships, and faith in its broadest sense--the faith of the gardener, the faith of the lover, the faith of the writer. The faith that I can experience what is real about the world, that I can hurt plainly, love ravenously, feel purely, and be strong enough to go on.
At the end of As You Like It, Shakespeare's famous "melancholy" character Jaques hears that a duke has "put on a religious life/ And thrown into neglect the pompous court." Jaques instantly declares, "To him will I/ Out of these convertites/ There is much matter to be heard and learn'd." It is a striking contrast to his earlier cynicism that "All the world's a stage/ And all the men and women merely players." It is the declaration of a character intent on finding some meaning.
But, in contrast to the smug assurance that passes for faith on the "700 Club," the truest faith reckons with uncertainty. It must account for the inevitable mystery, must survive the tension between the familiar and the shocking unknown (and the shocking unknowable). If one were forced to choose a single word to describe Jaques--who anguishes at the death of animals, wishes for love, longs for a fool's easy laughter--perhaps "melancholy" or "depressed" would be a good choice among poor options. Shakespeare chose "melancholy," but then had Jaques proclaim that he has neither the scholar's melancholy, nor the musician's, nor the courtier's, nor the soldier's, nor the lawyer's, nor the lady's, nor the lover's. Jaques has, he insists, "a melancholy of mine own, compounded of many simples, extracted from many objects." And off the stage he walks. Having hinted at his story, he goes to live it.
Joshua Wolf Shenk has contributed articles, essays and reviews to Harper's Magazine , The Nation , The Economist andÂ The New York Times . He is a past fellow in mental health journalism at the Carter Center. He lives in New York City and teaches writing at the New School University. His first book, The Melancholy of Abraham Lincoln , will be published in 2002 by Viking Press. Address c/o Psychotherapy Networker, 7705 13th Street, N.W. Washington, D.C. 20012; e-mail address: firstname.lastname@example.org. This essay first appeared in the recently published Unholy Ghost: Writers on Depression (William Morrow, an imprint of Harper Collins), edited by Nell Casey, and is reprinted by permission. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.