Is The Field Of Psychotherapy In Crisis?
Natosha Monroe
In celebration of Dr. Irvin D. Yalom being our keynote speaker for this month’s ACA Conference, I’ve decided to highlight some of his wisdom in my next few blogs. More so than any college course I’ve completed, any lecture I’ve heard, any workshop I’ve attended, or any article I’ve read, lessons learned from Dr. Yalom’s The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients influenced my therapeutic interactions the most. I wouldn’t call myself an existentialist, but his words proved to be very useful in many different contexts. One lesson I learned came from reading and then pondering this concern of Dr. Yalom’s: “I worry about psychotherapy-about how it may be deformed by economic pressures and impoverished by radically abbreviated training programs.” Is this indeed occurring?
In the introduction to The Gift of Therapy, Dr. Yalom shares his feeling that “offering guidance and inspiration to the next generation of psychotherapists is exceedingly problematic today, because our field is in such crisis.” When I first read this as a fresh, inexperienced graduate student of professional counseling, I didn’t fully grasp the meaning behind his words and they sounded a bit dramatic. It wasn’t long before I entered a mental health care facility and saw that he was not being dramatic. Here is more insight into Dr. Yalom’s description of a growing “crisis” in our field:
Effects of Insurance and Health Care upon Our Professional Work
Dr. Yalom suggests: “An economically driven health-care system mandates a radical modification in psychological treatment, and psychotherapy is now obliged to be streamlined—that is, above all, inexpensive and, perforce, brief, superficial, and insubstantial.” OUCH! Has anyone else seen evidence of this being true? I have.
For example, let’s look at the U.S. military’s mental health care system. Well, a little bit anyway—this topic deserves another blog entirely! The military clearly favors treatment plans that are primarily pharmaceutical in nature. It is not uncommon at all for a Service Member to walk into a military facility or see a military mental health care officer and walk out—sometimes after only 10 minutes or so—with not just one prescription in hand but two or more. Just ask around. Why is this?
Is it statistically possible that an overwhelming majority of Troops who walk into most offices with a behavioral health concern (such as marital problems, nightmares, anger, stress) are in such severe shape they need multiple medications immediately and/or for years to follow? Should it concern us that so many Troops who are evacuated from overseas deployments happen to have been prescribed psycho-pharmaceutical medications –apparently the pills didn’t work so well, right? Is it acceptable for an individual to be told that his refusal to take an anti-anxiety pill is disobeying the orders of a military officer (I’ve unfortunately been told of this from more than one client)? Is it ethical for an individual to be given a diagnosis of PTSD without being told? Is it right for Service Members and their families to be denied the option of non-pharmaceutical mental health care, or not to be introduced to the idea that it exists? I think not.
Effects of Training Programs upon Students/Future Professionals
From whom and where will meaningful, thorough mental health care come? Dr. Yalom expresses, “I worry where the next generation of effective psychotherapists will be trained. Not in psychiatry…psychiatry is on the verge of abandoning the field of psychotherapy. Young psychiatrists are forced to specialize in psychopharmacology because third-party payers now reimburse for psychotherapy only if it is delivered by low-fee (in other words, minimally trained) practitioners. It seems certain that the…psychiatric clinicians [who are] skilled in both dynamic psychotherapy and pharmacological treatment [are] an endangered species.” And what about psychologists? “Unfortunately, clinical psychologists face the same market pressures, and most doctorate-granting schools of psychology are responding by teaching a therapy that is symptom-oriented, brief, and hence, reimbursable,” Dr. Yalom points out.
I hate to do so, but I have to admit it appears to me that many professionals in our field are mindless products of their education to the point of limited decision-making. By this I mean that many chose and developed their theoretical frameworks, approaches to therapy, and views of what therapy is based upon a reaction to what someone else taught them in school rather than what may have been concluded using their own minds, interactions, and sense. For example, a professor in my small master’s degree program was very active in Solution-Focused circles and even wrote books on this subject (as were the majority of the other professors). So, low and behold, the majority of everyone in my cohort—and those above and below us—chose to become, guess what? “Solution-focused counselors.”
Hmmm…so was it coincidental that so many people in my program loooooved Solution-Focused therapy and chose it over all other theoretical approaches? Perhaps. I mean, it is appealing to be able to wrap up a person’s issues in just a handful of sessions. It clearly is applicable to many scenarios—specifically those limited to a small number of sessions due to restraints of a school system or insurance policy, for example. And it appears to be more “logic-focused” than some others so is good for working with adolescents. I understand the appeal.
But what are the odds that out of everyone, only one practicum student chose Adlerian, only one chose psychoanalytic, and only two (including myself) chose a cognitive-behavioral approach during our practicum portion of the program? Let’s face it. Students were influenced by preferences of professors in the program. For better or worse, influence of educational training occurs. And if programs are, for whatever reasons, shifting toward teaching what will be most marketable, what will happen to other approaches to therapy? When I visited Peru last year, I found that every mental health professional I met supported a psychoanalytic approach due to—guess what again?—their educational programs. I also noticed the care they offered (while not supported financially as ours are in the U.S.) was much more individualized and thorough, by the way, than what I see most often here in the States.
Effects of Other Professions upon Psychotherapy
Amidst his noting the brewing trouble in psychologist and psychiatry professions, Dr. Yalom looks to other professions to be the deliverers of psychotherapy: “Nonetheless, I am confident that, in the future, a cohort of therapists coming from a variety of educational disciplines (psychology, counseling, social work, pastoral counseling, clinical philosophy) will continue to pursue rigorous postgraduate training and, even in the crush of HMO reality, will find patients desiring extensive growth and change willing to make an open-ended commitment to therapy.”
So are those professions—us, fellow counselors—living up to what Dr. Yalom’s predicted several years ago when he wrote that? Or has “the crush of HMO reality” crept into bed with us as well? How many licensed professional counselors, therapists, and social workers have given themselves fully over to screenings, testing, assessments, diagnoses, medications, and “treatment plans?” How “professional” and “therapeutic” are we when we intentionally leave out the vital portion of therapy that includes elements such as connection, respect, unconditional positive regard, positive rapport, and real conversation? Are we denying the full gift of therapy and instead regifting something crappy we’d not want for ourselves?
The military has admitted a need for more mental health care professionals, however no branch will recognize and allow counselors or therapists to serve and offer their services in the military. What the Army has done though, for example, is to “team up” with a university to pump out more master’s level social workers. I have met several over this past year who were at different phases of the Army social work program. I clearly cannot speak of all, but each that I met did not speak of the things Dr. Yalom speaks of in his books. There was no mention even of any theoretical framework. What I did hear them talk a lot about in the week I spent with them was condescension, diagnoses, medications, cookie-cutter “treatment plans,” and referring to all clients (different scenarios) as “patients.” I left that week in San Antonio saddened that this was a sample of the mental health officers that would soon be unleashed to work with our Troops. Better than nothing? Maybe…maybe not. I feel strongly about this concern because I have seen first-hand the lasting damage done to several Service Members (both psychologically and career-wise) by condescending, diagnosis- and pharmaceutical-focused military officers. I have seen similar in other environments as well.
This is just one example of how Dr. Yalom has made me think on a deeper level and evaluate what’s going on around me in the field of psychology. Over the years, the immense value of what I learned from his words have applied not only to my counseling experiences, but also to my international work, to research, to interactions with people in general, and most importantly to my work on myself. I say “most importantly” because I believe it is our realization of self and then our consistent growth that affects our “work” elsewhere in our lives. Dr. Yalom’s book is not meant just to provide advice so we may offer the gift of therapy to others—it is to be seen as a gift to us too, showing us the gift of the therapeutic process as well.
Did Yalom propose a valid concern? My answer is yes, but what do you think? Is psychotherapy in a state of crisis? Are health care and educational systems furthering the tendency for psychotherapy to be watered-down, abbreviated, streamlined, pill-focused…? If so, what can be done to retain the true and empowering gift of therapy so that we may offer it to the lives we touch through our work?
Natosha Monroe is a counselor and PhD candidate passionate about increasing Troop access to counseling services. Her blog contents are not representative of the Army or Department of Defense in any way.
Great post, Natosha. I learned a lot that I had suspicions of but have not read about regarding the military and the pressures of psychopharmacology. I agree with your suspicions that your classmates’ counseling approaches were greatly influenced by their professors. We all are! Its up to people like yourself to continually point these things out and get the rest of us to push ourselves outside the box a little more.
Lauren,
Thanks for your comments. I agree with you–about pushing ourselves to think outside the box and to “check ourselves.” I know I need to do this often!
I think those who work in an isolated manner (not seeking peer advice or review, not having frank discussions, not growing, etc) are in the most danger of becoming stagnant, out of touch, and narcissistic in their work. This is what I have concluded from the not-so-great mental health care workers I’ve come across.
Ready for a soap box?
With the military, the lack of accountability of the military behavioral health officers–especially once overseas–is an issue. (And please don’t get me wrong, I’ve also met some amazing BH officers, to include the psychiatrist and psychologist I worked under on my 2 deployments and others I’ve met over the years.) It’s just a different situation than other environments and not many “eyes” are upon what is truly going on and what kind of “care” our Troops are getting–again, especially while overseas. And the young Troops who are receiving the care often don’t know any better, they don’t know their treatment options, and they don’t know their patient rights as clearly as they should. Sure, a lot is written in the short stack of papers their required to look over and sign, but still.
And, unfortunately, in many cases military behavior health officers are promoted very quickly or given a high ranking position from the start. Also, many are paid an extra monthly stipend, are given money to complete their school/training, and/or they receive a large sign-on bonus (at one point $20,000 sign-on bonus, not sure about now). Therefor, this creates a perfect storm for a sense of privilege and entitlement, which we all know humans are sometimes drawn toward. Picture a struggling Social Worker, for example, who isn’t being paid much, can’t find a decent position, and isn’t respected much where he is working. He’s never joined the military before but now in his 50′s, he sees the bonus, extra pay each month, and the Army officer rank of Captain dangling in front of him. So he joins up. Might he enjoy this new power and position to the point of treating those “beneath” him in a certain manner? Sometimes yes, sometimes no. Again, doesn’t happen all the time of course–but I have seen it happen and it is very dangerous in our field. I’ve seen the damage to career (to include careers ended less than honorably) and psychological damage done to young Troops as a result of this.
This happens outside the military as well, I’m sure we’ve all seen mental health care professionals who were not treating clients ethically or respectfully. I’m sure we’ve seen someone’s negative thought patterns (mistrust of people caring, for instance) reinforced by the out-of-line actions of a mental health care worker. We need to speak up when this occurs. For the sake of our clients…and our profession.
Your blog rings like a flashback to
my earlier years. Although I chose
to serve children rather than adults
(hoped to jump the gun on poor treatment)
my passion & commitment couldn’t have
been greater. After 25 years in the field,
I can attest that a “quick fix-meds type
treatment” dominates. Patience is a thing
of the past. When the bill payor is not the
client, expedience often rules. Too often
I tried to work with students who were over
medicated and under supported. It is much
easier to treat the child than to teach the
the parent how to parent, and there are too
many folks telling parents that they have a
quick-fix pill or that the child is inherently
damaged. Hang in there and do your
loving work. I have left the field (not the work)
to work from a new approach. Continue to with love and
passion.
Great post Natosha!
I love Dr. Yalom and I am reading this book right now. I am only in my first year of my master program in mental health counseling and I am already worried and questioning where I am gonna fit when I graduate and enter the workforce.
I have a bachelor degree in Psychology from Brazil. It has been only 5 years I moved to the U.S.. Things here are very different. Because insurance coverage for psychotherapy in Brazil is really rare, most of professionals work independently and negotiate payments with the clients. The main disadvantage is that many people do not have access to psychotherapy services and counselors sometimes cannot make as much money. On the other hand, we do not have this “managed care” dictating our practices, which is priceless for the counselor who can be truth to what he or she wants to be and for the client who can receive high quality services.
I agree with you that our field is in crisis and that the future is scary. I can only hope that maybe through more scientific studies we can prove the inefficiency of medication without psychotherapy and hopefully things will turn around for the best.
Natosha -
Great post !! I read a book early in my graduate program that led me to ask the same questions. I urge you to investigate Peter Breggin’s book “Toxic Psychiatry”. This book gave me additional insight into the power and force of the change in traditional psychotherapy.
J
P,
Thank you SO MUCH for bringing in the perspective of counseling with children. WOW, this is a whole ‘nother level of unfortunate events
I’d like to comment on a few of your remarks:
1. “there are too many folks telling parents that they have a quick-fix pill or that the child is inherently damaged”
As a teacher in the public school system (while obtaining my counseling degree/starting my initial license hours I’ve yet to finish) I saw this as well. I was so saddened at my students who would refer to their mental health “label” as I like to call it to excuse their behavior or their “why I can’ts.” I was able to prove a few of their “I can’t because” beliefs, but clearly not all.
As you said, the issue is almost always the parent—not the child. And when the child returns to that environment daily, what are you to do? I have counseled the adults who were once the troubled children…we need more people such as yourself to keep providing the help they need.
2. “After 25 years in the field, I can attest that a “quick fix-meds type treatment” dominates.
Thank you for sharing your observation. I understand sometimes this is due to a client’s preference. When this is the case, so be it. I believe as Professional Counselors, however, it should remain our mission to stay the course and remain true to our profession–as Yalom points out, who else will?
I also find it unethical, having the knowledge that I do, to not advocate for the kind of “treatment” I personally believe is the most effective and empowering–counseling!
Nash
Andrea,
First of all, your intelligence and insight is clear. Thank you for sharing your perspective of comparing Brazil to here. This is of particular interest to me because I’m working toward my PhD in International Psychology! I’m in my final year/dissertation phase at The Chicago School of Professional Psychology (they have campuses in DC and in California as well as some online certification courses, etc.) You should check it out–we are very interested in collaborative, international perspectives on psychology and psychological services.
I have to say, congratulations on the start of your journey into the world of counseling! I would definitely recomment keeping Dr. Yalom’s book handy…and dog-eared…and highlighted…and tabbed…and perhaps buy an additional copy! This will be your guide, your reminder, at WHY you chose this profession and HOW to stay true to what people need—not just the treatment plans, not just the theoretical discussions, but the human connection that they likely have lacked at some place or they wouldn’t be in your office.
I encourage you to join me and others devoted to reminding people (especially Americans!) of the reality and importance of your last paragraph—psychotherapy is NECESSARY in addressing mental health care concerns, and it can’t ever be fully replaced by a pill.
Nash
Jack,
Thanks for reading my blog and thank you for suggesting this book. I immediately went to attempt to purchase it for my Kindle, but unfortunately it wasn’t offered as a Kindle book
I will search elsewhere. I’m sure it holds valuable insight that would help in more thoroughly understanding available treatment options.
N
Natosha,
This whole post had me on the edge of my seat with the unyielding desire to pump my fist in the air and go, “Yeah!”
Needless to say, I completely agree with you and have witnessed a lot of the same backwards thinking about psychotherapy in addictions treatment. There always seems to be a pill for every ill. I’m fortunate enough that the need for therapy is recognized and I’m encouraged to work with clients in a counseling relationship.
I also agree with your comments about social workers who have been trained to see clients as “patients”. It sends a shiver down my spine because that word alone invokes all attached meaning like diagnosis, sickness, etc. It just sets a client up for a pill or an excuse. They become reactive/passive in treatment as opposed to collaborating in a therapeutic relationship.
I could go on and on, but I just want to thank you for your post. It’s nice to know others out there think as I do about our profession. It gives me hope that Yalom’s fears will not come to fruition.
Jen
Jen,
Thank you for sharing your perspective from addictions counseling–this is an area I’ve never worked with exclusively but I can only imagine the implications of, as you mentioned, perscribing a pill for every ill.
On that note, I do recall “patients” in the mental health care facility where I worked for a while pointing out their displeasure at being given medications when they fully acknowledged they had addiction issues.
And just this morning, a co-worker told me about her friend who was raped at age 15 and has had ongoing troubles throughout her adult life in trusting men. She also has nightmares. I suggested she mention counseling to her friend to which she replied, “Oh, she’s in therapy and she’s on a sleeping pill and something else.”
After a little more discussion, she revealed that the friend is seeing a psychiatrist. I told her that most likely she’s NOT getting therapy then, only drugs. I also asked if she’s sleeping well and she said no. So I said, “Hmmm..sounds like the pill’s not working and the psychiatrist must suck if your friend still has so many issues.”
The public needs to be educated more about the differences in psych professions and what their options are with mental health care.
Natosha