When Seismic Change Becomes the Norm

The Therapist in the Real World

Magazine Issue
March/April 2016
A crumbling iceberg

One of the most significant changes in the role of a therapist during the past few decades has been a shift away from the tradition of serving as a dependable confidante over a lengthy period of time to that of a very temporary advisor. Some practitioners have even rebranded themselves as a “personal coach” or “personal consultant” in order to increase their “market share” and expand new opportunities. This might work fine for those described as the “worried well,” who require only assistance in their growth or development, but it leaves quite a number of people with more severe disorders or intractable problems without sufficient support. These are often individuals suffering from deep-rooted intrapsychic struggles, certain personality disorders, or chronic conditions that aren’t necessarily amenable to a “quick cure.”

It was during the Golden Era of our profession when insurance companies would subsidize treatments to the tune of 90 percent of whatever fees were reasonably charged, no questions asked. It was perfectly normal that therapy might last a year or longer with a focus not only on the presenting complaints, but also on underlying issues that might be brought into the conversation. While there were certainly abuses of this system, not to mention unnecessary client dependence, there were also far more opportunities not only to address current problems, but also to provide an ongoing forum for future growth.

What a luxury it would be these days to work with clients according to what we believe is actually in their best interests, not only to address what brought them into treatment, but also to help them develop the self-awareness, personal skills, and resilience to deal with other problems in the future. And while we’re reimagining bygone years, how lovely it would be to design therapeutic plans based on what’s actually best indicated, no matter how long that would take. Perhaps it’s better in some respects that we’re now held more accountable for our efficiency and outcomes, but there’s also a lot that’s been lost in this new climate.

Sprinkled liberally around most communities today are little clinics that offer the public medical services in the same spirit as department stores or chain restaurants. You can even find such operations squeezed into the corners of drug store chains that advertise “health screenings,” “medical consultations,” and “minute clinics.” Gone are the times when you had a personal physician, one who knew your family and history intimately. Some of us are old enough to actually remember doctors making house calls! Now you show up at one of these mini-medical centers (no appointment needed), take a number, and then take your chances that the doctor on duty is someone who knows something about what’s ailing you. Forget about anything resembling personal service: their job is to administer medicine cheaply and efficiently, not necessarily to deal with you as a human being.

I recently had the misfortune to visit one of these convenient clinics after sustaining multiple injuries in a bike accident. I could barely move and was experiencing excruciating pain in my back, shoulder, and side. “I wouldn’t worry,” the doctor told me as she was typing into the computer screen, rarely even bothering to make eye contact. Even more remarkable, during the whole “examination” she never once touched me.

“It’s probably just a severe muscle strain,” she said, glancing up from her typing for a moment. She sat on the other side of the examining room, entering data into my file, looking up only when I inadvertently screamed from a muscle spasm. She gave me prescriptions for a muscle relaxant and a painkiller, neither of which I could tolerate.

It turned out I had two broken ribs and a fractured scapula, neither of which was diagnosed because she was so rushed to attend to other patients who had been waiting in other examining rooms. I could forgive the doctor because she was operating as part of system that valued efficiency and cost-effectiveness rather than quality care—or even reasonably competent care. And I know I’m not alone in this acceptance of mediocrity.

The public is growing so used to this doc-in-the-box mentality that when it comes time to see a professional for some personal concern or emotional difficulty, people don’t even flinch at the prospect of choosing a random name from a published list of “approved providers.” One therapist is as good as another, they reason. The important thing to consider is: can I see this professional who is covered on my plan?

These are indeed the days of managed care, health maintenance organizations, employee assistance programs, and preferred provider networks. If the concept of private practice isn’t being systematically eroded, then it’s at least being altered to the point where therapists are working more hours, for less money, doing homogenized treatment for prescribed intervals. It’s not just the solo practitioner who’s losing autonomy; any community agency, organization, or mental health service has had to streamline the ways it operates.

If the trends continue, it appears that we may have even less autonomy in what we choose to do with our clients and how we prefer to do it. The emphasis continues to focus on doing therapy as briefly and efficiently as possible, dealing only with the original presenting complaint, and measuring outcomes as quantitatively as possible. In one instance, a friend of mine who worked on a psychiatric unit was appalled that benefits were cut off for one patient who was determined to have made “substantial progress” because now he reported there were only four poisonous snakes that he imagined were crawling around inside his belly instead of the 20 when he first entered treatment.

Although this situation may at times seem discouraging, there have also been some significant advances in making therapy more responsive and efficient, as well as more cost-effective. Some clients appreciate the greater convenience of being able to schedule sessions via alternative delivery systems (video, phone, etc.) and report that they can be even more honest and forthcoming than during face-to-face sessions. It remains to be seen whether research will support some of these testimonies.

One major problem seems to be the degree of competition rather than cooperation that now exists between members of the therapeutic community. The truth of the matter is that between social workers, psychologists, family therapists, counselors, pastoral care workers, psychiatric nurses, and psychiatrists, not to mention all the paraprofessional mental health workers operating without licenses and primary care physicians functioning outside of their specialties, there are too many of us in the marketplace. Whereas the prospects look most promising for masters-level counselors and therapists, there’s a far bleaker picture for more “expensive” doctoral-level practitioners. It’s now a matter of survival of the fittest—and those who adapt most smoothly to the changing landscape of professional practice. Economic and political realities have turned one profession against the other, and even within specialties practitioners undercut one another, outbid one another for contracts, and act as if we’re all fighting for a limited number of customers, which in a sense we are. This is especially ironic when we consider that the waiting lists at community mental health centers, veterans’ hospitals, and charitably funded agencies (NGOs) are staggering. Although there may be competition for affluent clients described as the “worried well,” there remain substantial numbers of economically disadvantaged and marginalized clients who desperately need help that isn’t available. Unfortunately, they can’t pay for services and the government continues to reduce funding for their mental health needs, leaving the poor and homeless without much support.

This situation has indeed caused considerable resentment and frustration, but it’s also had some constructive impact. The call for increased accountability has motivated us to improve our effectiveness. Clients are profiting from more efficient methods of symptom alleviation even if they’re sometimes being left out of opportunities to explore deeper issues of meaning in their lives. It’s also true that more and more middle-class working people are able to afford to seek our services than ever before.

Finally, it’s only reasonable that our profession is expected to ante up in the effort to control spiraling healthcare costs that have resulted from decades of abuse by some irresponsible individuals and organizations. In one such case, a social worker who worked within a private practice group would bring in large extended families, see them together, but then bill their insurance company for individual sessions, sometimes even 90 or 100 billing hours per week! In another case within the same agency, a psychologist would simultaneously schedule two or even three clients at the same time, just like doctors do. He’d then run back and forth between each interview room, giving clients assignments or tasks to complete while he’d alternate every few minutes between each of the sessions. Naturally, he’d then charge different insurance companies for the same hour, knowing that they wouldn’t compare their records to discover what he’d been doing. I’m certain that most of you can think of a few similar examples of your own in which unscrupulous colleagues have tried (and succeeded) in ripping off the system. It’s no wonder that strict controls have had to be implemented as a way to prevent such abuses and document more stringently the impact of our efforts.

Yet even with the pressure to become more accountable and work within a system that emphasizes efficiency over quality care, there are still practitioners who manage to provide excellent service within these parameters. When I returned to the same “doc in the box” for a follow-up visit to change my medication because the pain from my fall was intolerable, the new doctor shocked me when she pulled up a chair to face me. “So,” she said, “before we get into what brought you in to see me, tell me a little about yourself.”

I was so surprised at the attention I stammered for a minute, not sure where to begin. We spent the next few minutes chatting before she actually gave me a complete physical exam and accurately diagnosed the fractures, adjusting my treatment accordingly. When I left the appointment, I felt so much better, not only because of the way I’d been treated but also because I’d actually been heard.

Quicker. Swifter. Faster.

What was once learned in graduate school, and is still prevalent in some institutions, is a kind of therapy in which medium-term or even lengthy relationships are established in order to address intrapsychic conflicts, psychodynamic features, entrenched dysfunctional patterns, family patterns, existential themes, underlying issues, and other content that lends itself to prolonged, deep-level investigations of past experiences and current struggles. It’s certainly the case that medications or brief forms of therapy aren’t the best choice for everyone; there will always be a demand for inquisitive people who want to learn about themselves and the ways they relate to others. In our society, where people are increasingly feeling alienated, disenfranchised, and marginalized, there’s a desperate need to feel understood.

I remember some time ago devoting a year of professional development to upgrading my skills in the latest breakthroughs in brief therapy models. I couldn’t wait for opportunities to move my clients along a faster route toward deliverance. After all, I have long been far more attracted to dramatic confrontations than I have to more low-key interpretations—not because I believe they work better, but because they satisfy my own impatient need for progress.

I’d been working with one woman for some time, making modest progress, but certainly not by the standards of my more solution-focused colleagues. I felt like a dinosaur still resorting to the “primitive” ways of working I’d been practicing for years—listening carefully and compassionately, slowly building a solid alliance, exploring deep issues of freedom, personal responsibility, love, and breaking free of the past.Clearly it was time to get to the “bottom line.” My work with this client had been “dragging on” for months now, and I was feeling a little guilty that I wasn’t meeting the current standards of what’s expected. I interrupted my client on several occasions, especially proud of the deftness with which I introduced reframing, externalization, miracle questions, exception-seeking questions, deconstructions, paradoxical directives, and even an old-fashioned direct confrontation when I told her that I thought she might be needlessly stalling the pace of things in order to avoid facing the world on her own.

The tears that had been streaming down her face abruptly stopped. I could see anger in her eyes and in cords of muscle in her neck. “Kottler, what is your problem?” she asked none too politely. “In case you haven’t noticed, I have not felt that many men have ever listened to me in my life, not my boss, my father, my brothers, my ex-husband, or certainly my current husband, and not even my own son. I’m used to being interrupted. I’ve never been taken as seriously as I deserve. I had sincerely hoped that with you I might feel a little understanding. After all, I am paying you to listen to me. Is that clear?”

I nodded my head contritely, feeling ashamed.

“I wish you’d stop trying to fix me,” she continued the deserved scolding, “and just listen to me. I want you to understand what I’m experiencing. I want someone to finally understand who I am and what I want.”

She actually said all that. I, of course, immediately protected myself from this censure by telling myself that this “intervention” clearly worked—look at how assertive she had become, and all because of my technique of challenging her. While patting myself on the back, I also felt confusion settle over me. I realized that in my urgency to move more quickly, I’d focused more on technique than on the person in the room with me.

Prove It

There’s not only an imperative to move more quickly in our work, regardless of what the client wants or needs, much less what we believe is appropriate, but also a mandate that we must better assess the results of our efforts. And we damn well better be able to demonstrate that what we’re doing is consistent with what’s expected and considered normative by whoever is paying for it. It makes little difference whether solution-oriented therapy is appropriate for a given case or whether you even practice that sort of intervention; that’s what you’re ordered to do because its results can be easily measured.

Medical personnel and corporate executives who make up utilization review boards sometimes struggle to understand the work that we do because we can’t show them the offending tumors or body parts that we’ve excised from the patient’s body. They’re not even certain that things like depression and post-traumatic stress even exist in the real world, nor are they convinced that there’s anything we can really do to help these people.

On one level, it is absurd that we make people better by simply talking to them. This stands in contrast to the healing traditions in most of the world throughout history, traditions that are still practiced today among indigenous groups, in which those who are troubled almost never talk about what’s bothering them but instead are invited to participate in community-based rituals.

I once tried to explain to the head shaman of a village in the Kalahari Desert what I do for a living to help people and he just laughed at me. He wondered if talking about problems ever helps anyone.

If you think about it, that’s a really good question. It does sound rather ridiculous to a shaman describing what psychotherapy is all about. The healing traditions among many indigenous peoples have been refined over thousands of years. They almost never involve talk but rather various movements, spiritual incantations, and community involvement. Compared to all the rather dramatic and potent activities that are part of traditional healing, including the use of difficult trials, public confession, vision quests, fire walking, dance marathons, shaking movements, communication with the spirit world, our therapeutic conversations appear rather feeble. It’s no wonder I had such difficulty making a case that I was truly a competent healer. And it’s also not surprising that many within the medical establishment question our legitimacy.

Others are constantly looking over our shoulders, and they aren’t the sort of benevolent supervisors who seem to care much about client welfare, our continued professional development, or such matters as autonomy, confidentiality, and quality of service. Quite often, the person who approves our treatment and decides whether we’re allowed to continue seeing a client isn’t even trained in our profession. Such a case manager or utilization review worker may be a practical nurse, a general doctor, or even a company overseer who consults computer data and graphs but has never, ever even spoken to a person like our client.

Nevertheless, if we expect to continue doing business with the handful of organizations that will one day control all health care in this country, we must be able to document exactly what we did, what effects it had, and what results are likely if they should be kind enough to grant us another few sessions. This isn’t an unreasonable request if you’re talking about engineering or even traditional medicine. The problem for us, however, is that if we’re really honest, we’d have to admit that most of the time we don’t really know what it is that we said or did that had the greatest impact. Oh, we can make stuff up, and we do have our theories that we’re quite fond of. Nevertheless, when a client improves or gets worse, we delude ourselves that we think we know why. It’s always a humbling experience to follow up years later and invite clients to tell us what they found to be most helpful, often things that we don’t remember saying or doing, or even things completely unrelated to our treatment.

It boggles the mind to consider how rapidly much of what we once learned is quickly becoming obsolete. The types of presenting complaints that we were used to working with seem to have transformed themselves into new maladies. During Freud’s day there appeared to be a rash of hysteria, followed afterward by syphilis, “alien syndrome,” dissociative disorders, and more recently, an increased prevalence of eating disorders, post-traumatic stress, and newer or revised forms of mental illness added to the latest Diagnostic and Statistical Manual. Just as diagnostic entities have evolved, so have our treatment options.

Even among practitioners who identify strongly with a particular theoretical orientation, it’s difficult to ignore the innovations in technique and research that have been developed in the past decade. In fact, conceptual purity is now quite difficult to maintain in the face of new research and clinical improvements that are being made across a wide range of disciplines and schools of thought. We’re all becoming more alike, converging toward the center, as would be predicted in a profession that’s maturing into its second century of evolution.

Ultimately, there have been some huge seismic waves that have shaken our profession to its core, many of which present new challenges and a changing landscape that bears little resemblance to what may have once been expected. If we’re to survive professionally, much less flourish, we have to roll with these swells, making adjustments to augment our knowledge and skills. If there’s one thing about which we can be certain, it’s that the tsunami of change is relentless and ongoing.


This is an excerpt from The Therapist in the Real World: What You Never Learn in Graduate School (But Really Need to Know), © 2015 by Jeffrey A. Kottler, printed with permission of the publisher, W. W. Norton & Company, Inc.

Photo © Paul Souders/Getty Images

Jeffrey Kottler

Jeffrey A. Kottler, PhD, is a professor, psychologist, author, consultant, workshop leader, keynote speaker, and social justice advocate who has spent the past 40 years working, throughout the world to promote personal and professional development among professionals and marginalized groups.