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.