You can’t cross the sea without having the courage to lose sight of the shore. — Norwegian Proverb
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We live in a time of pervasive uncertainty and imminent crisis. As we face a worldwide pandemic, imminent climate catastrophe, deepening political instability, overt inequality, and regular eruptions of mass violence, plenty of fuel for depression and anxiety exists everywhere you look. In a 2017 survey conducted by the American Psychiatric Association, nearly two-thirds of respondents reported being “extremely or somewhat anxious about health and safety for themselves and their families,” with greater than a third being “more anxious overall than last year.” For those in early adulthood, so-called millennials, the toll is even worse. This cohort, data show, is the most anxious generation in history.
Meanwhile, mental health systems around the world are underfunded, inadequately staffed, and strangled by bureaucratic red tape. This erosion of resources at the macro level has taken its toll on individual mental health practitioners. Research reveals rising levels of burnout, sick leave, and involuntary and voluntary attrition. In the United Kingdom, for example, a recent report found 2,000 mental health nurses, therapists, and psychiatrists quit every month. The result? As Denis Campbell of the Guardian reported in 2018, it’s nearly impossible to meet the “surge in patients seeking help for anxiety, depression, and other disorders.” A vicious cycle has set in. Dwindling funding and time tax the bandwidth of clinicians, pressing many to leave the workforce. The reduction of personnel leaves fewer and fewer available to meet demand, which then increases pressure on the remaining staff.
The current crises reveal cracks in the foundation of our mental health system that not only threaten the welfare of the citizenry, but also undermine the livelihood of service providers. In 1986, former APA president Nicholas Cummings issued an ominous warning: if therapists didn’t fight back, they were at serious risk of becoming “poorly paid and little respected employees of the giant health corporations.” He went on to predict what we’d do instead: submit to an already “outmoded health system”—one dominated by the medical model.
As is now painfully obvious, Cummings’s assessment turned out to be prophetic. Instead of offering innovative alternatives to the medical model, we blindly mimicked physicians. Presumably by diagnosing and applying the latest “evidence-based” treatments, efficiency and effectiveness would be assured. In the end, following in the footsteps of the medical model, we believed, would ensure our economic viability and competitiveness within the wider healthcare industry.
Nothing could be further from the truth.
By any standard, the constant parade of revised editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the frenzied effort to create a psychological formulary have miserably failed. As of 2019, the APA’s Division 12 (representing the interests of clinical psychologists), listed 80 “evidence-based” treatments for 27 of the 157 official DSM diagnoses. Professional organizations and government agencies throughout the world have adopted the same paradigm, going so far as to link payment and funding to the use of “officially” sanctioned approaches. And yet, while the number of methods believed remedial to specific disorders has proliferated, none has proven superior to any other bona fide psychotherapeutic approach or the outcomes of clinicians in practice. At the same time, the overall outcome of psychotherapy has not improved in more than 40 years.
How could this be? How could so much money and well-intentioned effort have so little impact? At first, the foregoing facts may strike many as implausible, if not false. After all, what therapist doesn’t believe they’re more effective than they were before their professional training and after years of clinical practice? Well, prepare yourself for more bad news. One searches in vain for any evidence that graduate school preparation, supervision, licensing, specialization, and participation in continuing education have any impact on therapeutic effectiveness. And the most sophisticated study of clinical experience to date—tracking the outcomes of practitioners up to 17 years—shows their effectiveness actually declines the more time they spend in practice.
Pick your metaphor. The wheels are coming off the bus. The train has jumped the tracks. We’re barking up the wrong tree or stuck on a cruise ship calling on all the wrong ports. The evidence is unequivocal. What we’re doing is neither working nor sustainable. Perhaps we’d do well to heed the counsel we often give our clients: reflect and change course.
While the challenge may seem daunting, thankfully, alternatives to traditional approaches to delivering mental health services are being designed and implemented around the world. Indeed, in one country, it’s happening on a national level. Decades of established order and accepted standards of care are being challenged and overturned, and importantly, better results are being delivered to a larger number of people.
From the Land of the Midnight Sun
Stange is a village of 20,000 located in the “breadbasket” of Norway. Over 300 square miles, its flat, rural landscape contrasts sharply with the jagged, snowcapped mountains and deep-water fjords most associate with the country. Situated in the town center is a drab, 1950s, red brick building. Its outward appearance provides no clues to the innovative, even revolutionary, work occurring within.
Stangehjelpa is the region’s public mental health agency. Pronounced, stong-ah yell-pa, the name literally means “the helping place.” The agency’s message is simple: call us or show up and we’ll help. No traditional intake. No formal assessment or diagnosis. No prescribed therapy protocols. No mountain of paperwork or time-consuming treatment plan. In fact, no imposition of any kind. Instead, people’s concerns are taken at face value, the start and end point of all services offered. Staff are encouraged and expected to do whatever it takes to bring about change—and they do, successfully. The data prove it.
Regarding the agency’s overall effectiveness, the outcomes of clients who’ve sought services are on par with results from the most tightly controlled, randomized trials—the “gold standard” represented by the very studies used to promote the adoption of diagnostically driven, “evidence-based” treatments. Further, there’s no waiting list. Call and you’ll be promptly seen. Once in, few drop out of treatment—half as many as found in similar settings around the world. And that small percentage of clients who absorb the lion’s share of time and resources in typical mental health agencies? The ones who stay on indefinitely, seemingly interminable, returning time and again without benefit? They don’t exist.
Also absent are the burnout and turnover rates characteristic of many mental health agencies. Jobs at Stangehjelpa are prized, with clinicians proudly asserting they’re working for the “A” team. The energy and focus is intense and electric. “This place is impossible,” one of the staff members says with a laugh, “and I can’t see myself ever wanting to work anyplace else.” Asked to explain her comments, she continues, “Although failing is understood and accepted, being ‘good enough’ isn’t. Here, I’m expected to deliver results all the time, with every client.”
Few limitations are placed on what staff can do to help clients. “You must succeed” is the prime directive, and all the structures seen in typical mental health agencies—individual supervision, case conferences, and discussions among clinicians over coffee—are focused on achieving that objective. At traditional treatment centers, nonprogressing cases can give rise to anxiety and exhaustion, but at Stangehjalpa they’re a cause for excitement and an opportunity for innovation. And innovate the staff do, drawing on ideas from not only psychotherapy, but also philosophy, literature, culture, alternative healing practices, simple common sense, and most importantly, the clients.
“I know all this sounds very 20,000 feet,” says agency director and psychologist Birgit Valla, “and not surprisingly, that’s the question I’m asked most frequently by administrators and practitioners who come for site visits, ‘What is it you do here?’” After a brief pause, she adds, “I really fumbled the answer to this question the first time I was asked. Now, I know exactly what to say: that is the wrong question. The correct one is, ‘How do we come to know what to do?’”
Without knowing it, Birgit and her team had intuited what Harvard professor Theodore Levitt first described in his 1960 article, “Marketing Myopia.” Published in the Harvard Business Review, it has become one of the most cited articles in the history of the journal. Levitt’s thesis: industries rise or fall based on how well they understand and attend to what consumers want.
Levitt provided numerous examples of how titans of the business world suffered crippling reversals of fortune when they succumbed to being “product-oriented instead of customer-oriented.” The old studio moguls of Hollywood, for instance, were caught completely off guard by the advent of television. Why? As Levitt informs us, they wrongly thought themselves to be in the movie rather than the entertainment business. A perfect example can be found in the bold assertion of famed director and studio executive Darryl F. Zanuck: “Television won’t be able to hold onto any market it captures after the first six months. People will soon get tired of staring at a plywood box every night.” Similarly, railroad executives, thinking they were in the train rather than the transportation business, failed to respond to consumers seeking faster, easier, more flexible, and individualized alternatives for getting from one place to the next. Consequently, the automobile, trucking, and airline industries flourished while the once dominant “iron horse” rusted away on the back lots of abandoned railroad yards.
Could it be that our field suffers from the very same myopia? Like other failed enterprises, our entire history shows we’ve been obsessed with what we do—the models that guide us—versus the outcome of what we’re doing. In stark terms, Levitt drew attention to the fate of those who focus on the means of production, rather than the delivery of customer satisfaction. “The illusion,” he wrote, is that success “is a matter of continued product innovation,” one that risks “defining an industry, or a product, or a cluster of know-how so narrowly as to guarantee its premature senescence.”
Or as Birgit notes, “Whenever people ask, ‘What is it you do at Stangehjalpa?’ I know what they’re looking for is some invariant process, a method, technique, or protocol they can copy and impose on whoever walks through the door. For anxiety do X, for depression do Y. And trauma? Get in line for the new, specialized training in Z.”
Clearly, the field has operated under the delusion it is in the therapy business. Birgit, channeling Levitt, will have none of it. “Our clients,” she insists, “don’t care a wit about psychotherapy. What they want is what they want. Our message, the organizing principle of everything we do, is ‘first, identify what the person wants, and then work backward to develop the means for achieving it, whatever they might be.’”
Asked if giving clients what they want—or think they want—is always the best approach to take, Birgit rolls her eyes. “I get this question all the time when I’m doing a training. Someone will say, ‘Well, what if a client wants to keep drinking. Is that okay?’ I always give the same answer, ‘No one has ever said this to me. Why would they? They don’t need any help with that. They’re already good at it. I then tell them, as a therapist committed to helping clients achieve what they want, you have to go one step further, making sure you’re not confusing what they want with how they hope to achieve it.” When asked for an example, she immediately responds, “Many people who end up in treatment as a result of their drinking want their families or some concerned other to stop complaining. That’s where we start.”
For those who believe the medical model is the gold standard for psychological care, first exposure to what goes at Stangehjalpa is often puzzling, if not deeply disconcerting. Observe one session, and you may see what amounts to traditional CBT or any other commonly applied method. Spend some time at the agency, and you quickly see few therapists are bound by an allegiance to any way of working. Outside the building, you could encounter a therapist teaching a client to ride a bike, and then peddling alongside through neighborhood streets. In other instances, what occurs would raise eyebrows even among the most open-minded of practitioners. Consider Kristin’s story.
“The psychotherapy I’d participated in had been okay,” Kristin relates. “What I really needed was trøst for my heart” (pronounced, tr-œu-st). In Norwegian, the word trøst is imbued with special significance, one readily understood by native speakers but challenging to translate into other languages. Consolation and solace come closest in English, but they miss something vital, a longing for certainty or assurance. The fact is, Kristin’s son Andreas had been murdered, along with 77 other people in a horrible act of violence, the largest mass shooting by a lone perpetrator in history.
When Birgit learned about the tragedy, she reached out. By this time, Kristin was no stranger to therapy. Public and government support had been tremendous—paid leave, access to psychologists, social workers, grief groups, and the sustained concern of the community. Still, it had made no difference for Kristin. “The grief, the loss,” she says, “hurts so much, it was too much for me to bear.” Emptiness and purposelessness had become constant companions, leading her to question whether life was worth living.
Looking back on it now, Birgit recalls, “Kristin made plain what she needed and what no therapist had delivered.” As both recognized, the cultural barriers to finding trøst were formidable. Indeed, even after the way forward through her grief emerged, Kristin told no one. She feared being the object of ridicule and scorn. Birgit’s role in strongly encouraging her to follow through, to do what she believed was right, says Kristin, “empowered me to reject the secular strictures of Norwegian society and find peace. It’s also why now I’m willing to speak openly about what helped.”
In the end, what made the difference for Kristin was as unconventional as it was potent. She spoke with her son! No, not in the form of a guided-imagery exercise. No, she didn’t write a therapeutic goodbye letter. Nor did she and Birgit engage in “empty-chair work.” Had Kristin been interested in working through her grief, any of the foregoing might have proven helpful. She was not. Rather, although many would view it as a failure to come to terms with her loss, she literally wanted to connect with her son. So Kristin spoke with Andreas through a person who claimed an ability to reach “beyond the veil” separating the living from the dead.
“He misses us, and we miss him terribly,” Kristin says. “But now I know he is doing well, and that’s enough for me.”
Simple but Not Easy
How does Stangehjalpa come to know what to do, unconventional or otherwise? What is it that keeps them on track, focused on achieving the best possible results? In a word, measurement. At each session, clients are asked about their progress and the quality of the relationship with their therapist. The practice, known in the literature as feedback-informed treatment, or FIT, involves the administration of two standardized measures at each visit: the Outcome and Session Rating Scales. If the results show the client is engaged and improving, therapists are encouraged to continue for as long as the client wishes. If not, they’re required to step in and take corrective action, including changing what’s being done (the approach), the setting or context in which it’s occurring (the venue or location), and with whom the client is working (the person providing care).
While many agencies around the world now routinely measure their outcomes, how the data are employed varies widely from one setting to the next. For some, it’s strictly administrative, just another way to satisfy statutory requirements for information on productivity and effectiveness. For others, those that research shows realize the most benefit, it’s an integral part of the clinical work. Clients complete the forms together with the therapist. Results are shared, openly discussed, and used to modify treatment in the absence of progress. Setting Stangehjalpa apart is what takes place after such efforts fail—in the particular, after staff have identified “at risk” therapies, initiated a change in course, and still are unsuccessful in facilitating progress.
“We literally practice creativity,” says Birgit. “It’s a tedious, frequently exasperating, trial-and-error undertaking. We come together as a group multiple times per week to address such cases. The point of the meetings is to knock us out of our rut, to make us aware of and able to escape any presuppositions possibly holding us back.” Asked for more detail, she continues, “Walk in the group room on any given day and you could see us reading poetry, watching videos, listening to music, telling stories, looking at art, using modes of communication other than words—like acting, drawing, or singing to describe the client and the therapist’s experience—even playing games. I know the process may strike some as mysterious, kooky, and for those who like manuals and protocols, as all so much mumbo jumbo. Truth is the specifics of what we do don’t really matter. It’s all about stimulating imaginativeness, inventiveness, and innovation, guided by and linked to helping clients get what they want.”
As effective as the meetings have proven for generating new and different ways for helping, what most often emerges is simple, even mundane, bearing little resemblance to traditional psychotherapy. For example, after weeks of unsuccessful therapy, a woman suffering from depression is sent to the beach to collect a rock. Over time, she ends up with a stack of stones, a collection she comes to regard as a “cairn on a mountain trail,” showing her a way forward. Another example is a boy, diagnosed with attention deficit and hyperactivity disorder, who’d been placed on a variety of medications. Despite this, and several courses of family work, he continued to struggle in school: fidgeting, speaking out of turn, struggling to stay on task, and falling behind his classmates. The turning point came when Mom, the boy, and clinical team agreed he wasn’t “mad,” not “bad,” just tired. They settle on several ways for helping him relax, unwind, and fall asleep naturally (e.g., massage), without the use of pharmaceuticals or treatment protocols.
“There’s really nothing magical to be found here,” Birgit observes. “Professional training and so-called standards make us stupid, blinding us, and placing limits on what we do. Think about it this way: they complicate something very basic, human—connecting and caring.”
Their results notwithstanding, the work of Birgit and her colleagues has not been without controversy. Eventually, they found themselves confronting another basic fact of human nature. As psychologist Sheldon Kopp long ago observed, “All solutions breed new problems.” Stangehjalpa had come to the attention of healthcare authorities and, to put it mildly, not all were pleased with their work and growing influence.
Enemy of the People
The two-page registered letter landed on Birgit’s desk without warning. It was from the county health commissioner’s office. The news was bad: a formal investigation of misconduct had been opened. In Norway, citizens are guaranteed by law certain entitlements and privileges with regard to their healthcare. One of these is the right to receive a bona fide diagnosis and approved methods of psychological or psychiatric treatment. Birgit stood accused. She was depriving clients of their due at Stangehjalpa, ignoring the covenant between the state and the people.
When the county commissioner’s office learned Birgit’s clinical responsibilities were limited to supervision, the investigation was quickly expanded to include everyone who saw clients at the agency. Along with other documentation, the investigators demanded client records. Birgit and her staff complied. What choice did they have? Besides, no one at the agency felt they had anything to hide. Indeed, they were proud of their results. The actual measured outcomes were indisputable. Still, it was impossible to escape the uncertainty and anxiety.
“Do you know the classic Norwegian play An Enemy of the People by Henrik Ibsen?” Birgit asks rhetorically. “The main character, Dr. Stockman, exposes an unpopular truth—the town baths are contaminated with a dangerous bacterium—and instead of trying to solve the problem, the community punishes him, eventually tearing his home apart.” Pausing to reflect, she continues, “Now, you might feel righteous indignation at the fate of this brave whistleblower. I certainly did. On the other hand, how could I not be worried? I’d put everyone and everything at risk. Even in the play, Ibsen suggests the protagonist may have gone too far.”
In fact, Birgit had appeared months before on NRK, the government-owned television station, part of the largest media organization in Norway, and repeated what she’d written in a widely read op-ed that described the work she and her colleagues were doing at Stangehjelpa. “We work on the basis of what the people who visit us define as their problem,” she said, “in collaboration with the individual . . . try[ing] to understand . . . what might be good solutions.” Her commentary did not stop there. She came out swinging, passionately critiquing the mental health system, reserving special contempt for the field’s reliance on psychiatric diagnoses. They were “useless,” she asserted, scientifically bankrupt, harmful to clients, and instrumental in creating barriers to efficient and effective care.
Birgit would have a long time to consider the wisdom of having been so outspoken. Turns out, the future of the agency she built and regarded with such pride would remain in doubt for an entire year. Throughout the wait, she remained optimistic, modeling confidence and hope for the staff, refusing to believe matters would take a turn for the worse. She was wrong.
The Verdict Is In
The day finally came when the official judgment from the local authorities arrived in Birgit’s inbox. In the preceding months, reams of paper and electronic documents were requested and submitted for review, followed by even more requests. Had others been with her, they would’ve noticed a slight tremor in her hands as she opened the email: Ruling in the Investigation of Stange Municipality / Stangehjelpa and Psychologist Birgit Valla.
Absent any of the formalities one would expect in professional correspondence—no salutation or introduction—it began with the verdict: Guilty of Breaching the Standards of Health Care Legislation.
In the next five pages, the violations were listed along with the specific steps authorities expected Birgit and the agency to take to meet the standard of care. Noncompliance would result in the termination of Birgit’s professional license and closure of Stangehjelpa. In all, the document was terse and officious, the tone critical, and even punitive. Lest there be any doubt, it made plain the ruling was final: no appeal permitted. And all demands had to be met within four months.
“Everyone was shocked,” Birgit remembers, “even my immediate boss, who’d been super supportive throughout.” The choice was clear: give in to the demands and ensure their continued existence or stand up for their beliefs and face losing their livelihoods and what they’d worked so hard to accomplish.
They chose to stand up.
Fortunately, the very same public statements that had incurred the wrath of the county health commission had attracted the interest of certain politicians in Parliament. Several had even come to see for themselves what was going on at Stangehjelpa, and for good reason. As in the United States and many other countries, the healthcare system in Norway was proving unsustainable. Billions of krona (the country’s currency) were being spent each year. Despite the massive investment, the mental health of the citizenry was not improving. In fact, the number of people on sick leave, and those receiving disability payments, owing to psychological problems, was continually increasing. This was especially so for young people. At the national level, it was clear that more of the same—additional expenditures for traditional programs and services—wasn’t the answer.
Within hours of receiving the judgment, Birgit reached out to one of the members of Parliament who’d come to Stangehjelpe for a site visit. He agreed to meet with her the following day in Oslo, the capital city. On hearing of the actions of local authorities, he voiced considerable dismay. In his estimation, it was bureaucracy at its worst, placing rules over results and valuing conformity over innovation. Before Birgit left, he promised to speak to the National Minister of Health on behalf of her embattled center.
Weeks passed as the countdown to closure proceeded. Nothing happened. Birgit and her leader frantically worked to recruit other allies, reaching out to anyone and everyone who might be of help. All were sympathetic, expressed their belief in Stangahjelpa’s philosophy and mission, hoped the agency would prevail, but ultimately provided little concrete help. “We had no idea,” Birgit sighs, “how this would end, and no plan B.”
Then, out of the blue, deliverance finally came on the eve of the deadline. Nothing was sent to Birgit, specifically. Rather, it came in the form of an official government document known as a rundskriv—a circular distributed to agencies throughout the country by the National Minister of Heath.
Embedded within layers of bureaucratic jargon and dense legalese was the permission Stangehjalpa needed to continue their way of working. “We were saved,” Birgit remembers. “Not only that, the minister’s intervention opened a door a sliver, providing wiggle room for agencies and practitioners throughout Norway to work differently, consider and implement new ways of conceptualizing and delivering mental health care.”
The results speak for themselves. Stangehjelpa’s example is being copied by other agencies. The first was in Øvre Eiker, a city two and a half hours south and west of Stange. Many others followed: Fredrikstad, Arendal, Kongsberg, and Oslo, serving 700,000 citizens! Word continues spreading, with Birgit teaching and providing guidance to mental health providers and clinic managers.
You Cannot Not Make a Choice
In his 2018 Networker article on the state of the therapy field, psychologist Bill Doherty explored what he considered a basic shift in the mindset of most clinicians. Not long ago, he noted, “The therapy profession seemed to be about something deeper. . . . We were prophets of a new wisdom tradition suited for the modern era.” He then reflected on how significantly the passion and promise of the field had changed. The prophets and practitioners, psychotherapy itself, he argued, had surrendered. As he put it, we “got into bed with” the medical model. Together with our clients, we’re living with the consequences of that decision.
Indeed, the failure to rise to our current challenges can be directly traced to the field’s capitulation to a way of thinking and working ill-suited to the real purpose of psychotherapy. That is, returning to Theodore Levitt, working hard to create pathways to the changes our clients want in their lives.
The example of Stangehjalpe demonstrates an alternative exists for making good on our promise to do whatever it takes to help the people we serve. In his piece, Doherty concludes, “Nobody can make transformation happen; we can only be open to it”—a position he asserts about what we can and cannot accomplish as psychotherapists, but can also be seen in how we’ve come to regard our power to effect change more broadly. To this day, Birgit sees matters quite differently. “Yes, openness is essential, but action is what counts.” Her example proves it.
Some might be tempted to call her naïve. After all, had that one politician, her sole ally in the otherwise nameless and faceless government bureaucracy, failed to follow through, none of what she and her colleagues had accomplished would matter, much less be remembered here. When Birgit is asked to reflect, knowing what she knows now, how she might have approached the task of changing the system, she’s unrepentantly adamant. “It’s easy to look back, second-guess yourself. For me, that’s just a recipe for inaction—no, more like paralysis. We have to face facts. No right time or right way exists. At some point, all of us have to draw a line in the sand and act.” She returns to the words of Dr. Stockman in Isben’s play, “Otherwise, ‘considerations of expediency turn morality and justice upside down.’”
As mental health professionals, we face a choice: limp along with the status quo or work to change it. One can understand how easy it is to feel overwhelmed and discouraged by the enormity of the task, challenges, and risks. Can we really jettison the DSM? Reject so called evidence-based treatment protocols? Stand up to payers and their scientifically bankrupt policies and procedures? And finally, place clients, their interests, and measured outcomes ahead of the shackles imposed on all of us by the medical model and the failed traditions of our profession?
With a wave of her hand, Birgit quickly brushes such concerns aside. “Do you know the song ‘Do the Right Thing’?” she asks with a laugh. “It’s from the musical Frozen II. As the mother of three kids, I’ve lost count of how many times I’ve seen it. Plus, living in Norway, with its months of winter and darkness, the popularity of a movie with that title is easy to understand. The lyrics have always stayed with me: ‘I’ve seen dark before / But not like this. . . . Can there be a day beyond this night? / Just do the next right thing. / Take a step, step again. / It is all I can do.’”
Suddenly serious, Birgit concludes, “No, things are not going to change overnight. But so what? Just take a step, step again, and do the next right thing.”
Scott D. Miller, PhD, is the founder of the International Center for Clinical Excellence, a consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioral health services. He’s the author of many books and articles. Contact: email@example.com.
Mark A. Hubble, PhD, is a national consultant and graduate of the postdoctoral fellowship in clinical psychology at the Menninger Clinic. He has coauthored and coedited eight books and is a senior advisor and founding member of the International Center for Clinical Excellence. Contact: firstname.lastname@example.org.
Birgit Valla is a psychologist and International Center for Clinical Excellence–certified FIT trainer and consultant. She is the author, with David S. Prescott, of Beyond Best Practice: How Mental Health Services Can be Better. Contact: Birgit.email@example.com.
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