The Affordable Care Act (ACA) hangs uncertainly over the environment. Increased regulation and consolidation of care is most likely the future and will create a different landscape for health care providers, particularly psychotherapists. California has already received millions of dollars from the US government to set up a health insurance exchange that will be the marketplace for individuals and small businesses to purchase health insurance. According to Katherine Nordal (1). The drive to reform health care delivery systems is well underway with hospitals and large medical specialty groups developing the blueprints for how services will be organized. January 2014 is the target date for implementation of the ACA.
Psychotherapists have been able to preserve a sanctuary for individual private practice over the last 20 years as medicine has shifted to larger group practices and many public sector therapists have had to implement cost-saving “evidenced-based” treatments. The structure and paradigm of psychotherapy is not likely to remain untouched by the ACA. The foundation of this paradigm has been the relational contract between therapist and client who have had the autonomy to collaborate on mutually determined treatment. This foundation has supported the development of diverse, multi-theoretical perspectives and treatment approaches allowing therapists to practice in two domains: 1) helping clients alleviate symptoms, and 2) helping clients grow emotionally. Emotional growth represents a higher order change that involves the transformation of deeply embedded belief systems about self and others and their accompanying behavioral patterns. This second order change takes time.
Three ideas dominate the discussion of the ACA, and will play a critical role in shaping healthcare: affordability, accountability, and integration of care. The incentive to contain costs will most likely lead to a change in the fee structure. Fee for service has contributed to the escalation of healthcare costs by reinforcing utilization. (1) Global payments, echoing the earlier notion of capitation, represents a cost-cutting model where fixed fees for patient care will be pre-set and health care providers will need to work within these budget constraints.
Accountability is the therapist’s Achilles heal. While privacy and confidentiality are the pillars of therapy, accountability has been regarded suspiciously. Therapists have been accountable to the client and to their theoretical orientation that establishes implicit parameters for the evaluation of change. The evaluation of psychotherapy progress is a sensitive, complex, intersubjective process. Yet when therapy is a covered benefit, the insurance company is contractually entitled to information. Therapists have resented this intrusion. Within the systems of care that will emerge, therapists will be held accountable for the effectiveness of their treatment. Evidence-based treatments and outcome measures will most likely be employed to determine what treatments can be provided, and to assess their effectiveness. This eventuality will not only affect the mental health of therapists but will also impact how therapy is practiced, taught and conceptualized.
Integration of care is the more complex and indeterminate part of the ACA and reflects how healthcare will be organized across the continuum of services from hospitals, specialty groups, primary care, and mental health services. Key words such as wellness, prevention, collaboration, and interprofessionalism sprinkle discussions about the ACA. Will psychotherapists become part of large primary care groups or will they maintain their geographical distance without sacrificing their autonomy?
The emphasis on integrated, cost-cutting systems of care threatens the autonomy of the individual provider and the paradigm that supports emotional growth and the time-stilled, non-linear paths this growth follows. These changes concern me since the value that psychotherapy offers to our culture is a place to care for the Psyche. As a psychoanalytically oriented psychotherapist, I fear these changes. I realize reluctantly that I will have to move outside my comfort zone to adapt to the future.
It is imperative for therapists to educate themselves about the ACA in order to understand how their practice will be affected and what new opportunities will emerge. With certain doors closing, other doors will open. What specialties will emerge as the result of therapists working with primary care? Not only will there be more individuals covered by insurance, but mental health services are considered an essential health benefit that will lead to greater utilization of these services.
It will also be important to work collaboratively with professional organizations to advocate for your profession. Change is often a top down process. The big power holders typically make the big decisions. The individual practitioner is not a power holder and will have no impact on the shape of changes set in motion by the ACA.
Bion (2) speaks about the creative process that is involved in learning from experience and change. Creativity involves the dismantling of old models of viewing the world in order to allow for the emergence of new ideas that often are regarded by the psyche as well as by the social group as threatening. Personal belief systems are containers that ground the individual in a familiar reality. Change involves rattling and breaking the container and the ability to tolerate disruption and anxiety. The capacity for transformation involves both the acceptance of the limitations of external reality, and the lessening of one’s omnipotence and one’s attachment to old belief systems.
1. Nordal, K.C., (2012) Healthcare Reform 2012: Implications for Professional Practice, The California Psychologist, Nov./Dec. 2012.
2. Bion, W. (1977) Seven Servants, Jason Aronson
Find out more about the effects of the ACA on psychotherapy practice in Health Care Reform: Preparing the Psychology Workforce by By Ronald H. Rozensky, Ph.D http://www.e-psychologist.org/index.iml?mdl=exam/show_article.mdl&Material_ID=119
Psychologists check Capitol Notes for updates on The ACA http://www.cpapsych.org/associations/13260/files/files/gov-affairs/capnotes/cn13-02.pdf
Check out the California Care website http://www.coveredca.com set up by the State of California for individuals and small businesses to purchase health insurance mandated by the ACA.
It is a challenging and unique aspect of our profession to have one’s professional identity so intimately linked with one’s personal self. The therapist’s identity is an amalgam of professional role that is intertwined with a personal sense of self. The professional and the personal dimensions of self are variables in a complex non-linear equation describing the therapist’s identity.
Becoming a therapist is not a simple process of acquiring skills and an increased efficiency in using these skills. It is a journey, whose curriculum is personal growth and whose learning curve is analogous to the learning curve of life. more »
A client says, “I come in week after week and complain about the same thing. Do you ever get tired of my complaining? Are we getting anywhere?”
These two questions are critical to the process of psychotherapy. Both questions are intertwined, linking and conflating assessment of psychotherapy progress with the client’s need for approval and the therapist’s concern about efficacy. The client wants to be a good client and the therapist wants to be a good therapist.
Most clients wonder what their therapist thinks of him or her, are fearful of the worst, and are afraid to ask. This is often the subtext of therapeutic conversations, wedded to the transference that relationally bridges core feelings of self-worth with perceptions of others. When brought to the surface, the conversations that ensue are often relieving, mobilizing, and liberating the client to speak more honestly.
Equally important is the question “are we getting anywhere.” This speaks to the broader issue of how to assess psychotherapy progress, and in this case, a long-term psychotherapy. It is also connected to the therapist’s self worth and ability to examine the possibility of ineffectiveness and failure as well as to examine theoretical assumptions that often have counter-transferential significance. If a therapist has to always be good, then the question, are we getting way is translated into am I good enough. If a therapist believes that every therapy is a long-term process, then a lull will more likely be seen as simply a pause.
Each therapy has its own rhythm, mood and tone that change over time. It is not unusual for the rhythm of therapy to ease into a lull where not much seems to be happening either in the client’s life or in therapy. It is not self-evident whether these periods represent a transitional phase, the flattened gradient of the working through process, or a sign that the therapy is nearing the end.
This skill set needed to assess psychotherapy progress should be an integral part of the psychotherapist’s toolbox. This navigational skill is more than a rating form. It enables the therapist to recognize the subtle signs of progress, the non-overt signs of a negative transference, the significance of lulls, and to have some sense of direction and focus that extends over time. The skill set becomes ever more complex within the trajectory of a long-term psychotherapy.
This skill set has become particularly relevant in our era of evidence-based treatment, where there is growing pressure for accountability and for this accountability to be measured. Long-term therapy by definition exceeds the time-limited framework of evidence-based treatment. While it is beyond the scope of this essay to critically examine the issues that evidence-based treatment raise, therapists have a responsibility to assess the extent of progress, the quality of the therapeutic relationship, and make a determination when therapy is not working.(1) If there is anything instructive about evidence-based treatment, it is the challenge to develop subjective, collaborative, and qualitative guidelines that are appropriate to the complexity of a long-term in-depth psychotherapy.
The slope of therapy inevitably levels out. The client might start sessions by saying I have nothing to talk about today or wonder about coming every week. The therapist might feel tired, bored, or distracted, and relieved when sessions end or the client cancels. These are crossroads in therapy that first and foremost need to be recognized as such. Therapeutic crossroads present opportunities for a thoughtful, mutual assessment of therapeutic progress.
Many therapies conveniently end at this point where both therapist and client unconsciously and or implicitly agree to not go further without exploring the deeper unexpressed feelings that have been tailing the therapy like a ghost. Conversely, there are therapies that just keep on going interminably fueled by habit and convenience. In these cases, the implicit contract, that the client keeps talking and the therapist keeps listening (and getting paid) is never questioned. It is comforting to work with a client who you like and who trusts and values you. For multiple reasons it is difficult to end these relationships.
In the blogs that follow I will explore case examples that illustrate an approach to assessing psychotherapy progress that is individualized, subjective and collaborative.
1 The Heart & Soul of Change: Delivering What works in Therapy. edited by Duncan, B.L., Miller, S.D., Wampold, B.E., & Hubble, M.A. 2010, Second Edition explores the findings from 6 decades of psychotherapy research, including a critiques of evidenced-based treatment.
As I dip into the sixth decade of my life with the growing consciousness of one who is aging, an awareness that frequently startles itself with the longing to be young, I feel the impossibility of summation or balance in my thinking, and a ground swell of questions and contradictory thoughts. This dilemma in contrast to the mid-life crisis of my 40’s is a somatically driven realization of a changing biology: a personal evolution pitching spirit/soul against soma, where the ultimate dialectics of Being wrestle their near final bout: body aches contend with ambition, desire dusted with new parameters, and a passing thought that this upheaval, this graying sturm and drang is adolescence revisited. Ah to be young again…but in an aging body: curse, blessing, and ironic twist of life?
The irony of this belated coming to age is irrepressible: after years of struggling to come of age, which often translates into fumbling efforts to realize one’s idealized version of self, one reaches a certain psychological summit. One might naively assume perspective comes from such a perch. Yet experience of having been young colludes with self-deception to sustain the internal perception of youth. This subjective baseline transports one through life’s stages, forever tempting one with illusory possibilities.
As I approached 60, I spent an inordinate amount of time wondering how people perceived me. Did I look old was the question I often asked as I sat down at a restaurant, or at a professional meeting. The puzzling counterpoint was represented by my internal self-image of a young man. I would look at people who appeared younger and see them as older. I knew the self that looked out represented a perennially young, distorted state of mind. Over time, I realized that my self-consciousness was an integral part of coming to terms with aging. I was slowly internalizing my age: I am 60 not 40, not 50, but 60. When I caught myself peering through my youth-tinged glasses, I performed this corrective.
Acceptance has never been an easy task, and yet never so compatible with development than at this stage of life. The aging process speaks through a language of aches and complaints that pose a series of unavoidable existential questions and create a gradient of difficulty that youth ill-prepares us for. Coming to terms with one’s age involves engagement with one’s aging body, the limits that it imposes, and reconciling this body with one’s mercurial psyche.
Acceptance is a process and not a singular event. Realizing that I am 60 solved one problem: I understood what I was not. This helped me to reel in my efforts to recreate youth and helped in adjusting my expectations about what I could and could not do. Closing the door on youth opened another door full of questions. What does 60 mean? What can I expect from 60? What is unique and emergent at this stage of life?
My enthusiasm rubs against cautiousness. My historic diet of apprehension feeds on it’s old self leaving me hungry for new, “age-appropriate” adventure, not for youthful recreations, but to discover what can only be realized at a certain point in one’s life when one understands there are diminished abilities and lost possibilities.
“Believe those who are seeking the truth, doubt those who find it.”
– Andre Gide
In The Heart and Soul of Psychotherapy: Delivering What Works, second edition, the author’s review decades of psychotherapy outcome research. The findings clearly affirm the value of psychotherapy. The research indicates that 80% of individuals who receive psychotherapy benefit in comparison to those who don’t. Beyond this reassuring data, the research challenges certain assumptions that many therapists hold as well as assumptions underlying evidence-supported therapy.
The research indicates that psychotherapy effectiveness is the result of common factors that different theoretical orientations share. The effectiveness of different therapeutic approaches is attributed to common factors that activate natural healing resources within the individual. The research does not support the specificity hypothesis that underlies evidence-supported therapy nor the idea that one therapeutic approach is better than another. No single approach is effective for all individuals and each particular approach needs to be tailored to the specific individual in distinction to the often over-generalized diagnostic category to achieve optimal results.
In examining the common factors that are associated with change, the research indicates that client variables are most strongly associated with psychological change. Client variables include factors such as motivation, degree of impairment, and the availability of both internal and external resources. The most important contribution that therapists make is their ability to form and sustain a collaborative therapeutic relationship tailored to the specific needs of individual clients. Somewhat sobering is the conclusion that therapeutic technique and placebo have comparable effects on promoting change and are of much less importance than either client variables or the therapeutic relationship.
Three interrelated research findings concerning the therapeutic relationship are noteworthy and have implications for increasing clinical effectiveness as well as for training.
- It is the client’s perception of the therapeutic relationship and not the therapist’s that is associated with positive therapeutic change.
- Therapists and clients perceptions are not always in agreement.
- Clients tend not to share their negative perceptions with therapists.
The therapeutic relationship is a complex, non-linear, intersubjective process that requires ongoing mutual feedback to optimize clinical effectiveness. Difficulty in this relationship is often imperceptible and not readily communicated. Appearances can be deceiving. When there is turbulence and conflict in therapy, it might signify progress. When therapy is moving smoothly, it might belie collusion and accommodation. Since there is a gradient of disagreement between therapist and client perceptions of the therapeutic relationship, the authors encourage clinicians to actively monitor the therapeutic relationship by eliciting feedback from their clients. Since clients typically don’t share negative feelings about therapy, therapists need to be sensitive to implicit, subtle signs that signal problems as well as to signs that conventionally signify progress. Since clients typically don’t share their negative feelings, therapists need to invite and re-invite them to share their feelings about therapy, both positive and negative. The research indicates that avoidance of these signs leads to negative therapeutic outcomes. Through my practice, I have learned that clients often communicate their dissatisfaction with their feet..
Therapeutic effectiveness derives neither from technique, nor from the elegance or sophistication of our theories. What differentiates effective from less effective therapists is their brilliance but their empathic ability to establish and sustain a therapeutic relationship. Statistics as well as theoretical reconstructions break down at the strange and unpredictable interface where two individuals come together and create what Bion called an “emotional storm.” Contending with this interpersonal storm that is characterized by ambiguity, mystery, and interpersonal disjunction is perhaps one of the greatest challenges of doing psychotherapy. The meaning gap between two individuals is a persistent, subtle and variable component of communication.
Effective therapists face this difficulty with empathy that simultaneously facilitates understanding of the client while enabling them to de-center from their perspective. Am I pushing too hard, am I missing something in the client’s narrative, does what I say make sense to you are questions to pose to clients. They exhibit a quality of humility that allows them to adjust their interventions to the needs of their clients. I have often thought with some clients I work like a CBT therapist might, with other likes an analyst, and others like a friend. The ability to hold lightly not only one’s theory but also one’s subjectivity, what Donna Orange has referred to as “theoretical fallabilism,” creates the space for client’s growth. This ability to de-center, to turn the activity of assertion into the passivity of reception and welcome the presence of the client is critical to therapeutic collaboration and subsequent changes within the client.