ACA Blog

Natosha Monroe
Mar 01, 2012

Is The Field Of Psychotherapy In Crisis?

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.

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