Sharon is 27 years old. She doesn't plan to be 28. She is lonely,
and hurting and desperate. Shes decided as a final attempt
to seek counseling; however, the few counselors covered by her insurance
company all have waiting lists. She also understands that her sessions
might be limited to as few as three sessions. The soonest she can
be seen is three weeks from now. She isn't sure how she will make
it through the day. She contacted a crisis line only to find that
the line had been disconnected.
Robert is 34. He is divorced with 3
children to support. After child support is taken from his check,
and rent and other essential living expenses are paid for, he only
has $21.00 a week left over. Therapy would cost him a minimum of
$50.00 per session. He has a $200.00 deductible, and once this is
met he will still be responsible for $25.00 a visit. Robert's anxiety
is growing by leaps and bounds. He hardly sleeps, has lost his appetite,
and has begun experiencing sharp pains in his chest. Twice last
week he has had to leave work early because he thought he was having
a heart attack. His doctor informed him that he was experiencing
panic attacks and suggested counseling. He has no idea how he can
afford it, however he feels as though he's running out of time faster
than he's running out of money.
Both of these individuals are feeling
out of control. Both seek counseling, yet it is unlikely that the
traditional once per week session offered indefinitely will be available
to them. While this is unfortunately the reality, there are other
realities as well: (1) they need help soon; (2) they are not alone;
there are many Americans in similar positions; and (3) we who live
in this "kinder, more gentle nation" have some responsibility
("the ability to respond") to offer assistance.
The days of close knit families and
communities that provided ready-made support for just about every
American are over for many of us. Instead, the average adult today
must often find his or her own way, constructing a safety net piece
by piece. Children are often required to fend for themselves as
their parents frantically struggle to keep the family intact, the
bills paid, and maintain the necessities. In this mobile and fast
moving society where we have grown dependent upon grocery stores,
electric companies, etc., we are required to develop a new kind
of self-reliance these days. Often we must deal with the complexities
of parenting, relationships and life crisis's without the loving
concern of family, mentors, and old friends nearby. More and more,
individuals who used to turn to built-in support systems now seek
the assistance of a stranger, a trained therapist during difficult
times. It sadly seems that while a growing number of people are
more amenable to utilizing such services; many individuals who are
in need of psychotherapy cannot afford it. Those who are in a position
to seek therapy all too often do so with the expectation that the
therapist will somehow administer a cure while the recipient remains
relatively passive. For some it's as if the therapist need only
to hear their prayer in order for the answers to be provided. Others
are prepared to work hard within the comfort of the therapist's
office and then resume their normal activities once the session
is concluded. Few recognize that healing requires as much and often
more effort outside of the therapist's domain. Most who utilize
the services of a psychotherapist are being forced to recognize
the limits of psychotherapy, as (ready or not) the number of sessions
available to those who rely on insurance to subsidize the cost are
often dramatically reduced.
It is commonly believed that therapy
occurs once per week. This is not necessarily so, and for some it
is not even financially possible. Therapy can provide significant
benefits without the old constraints of a 50-minute weekly session,
particularly when utilized in conjunction with other resources.
If the needs of individuals such as Sharon and Robert are to be
responded to whole heartedly: (1) we as therapists must offer alternatives
to the traditional psychotherapy format; (2) Robert and Sharon must
assume more responsibility than traditional psychotherapy clients
have in the past; and (3) a growing awareness must evolve within
our society regarding the necessity of mutual support while assuming
("taking upon oneself") more fully that which is required
of us to become more accountable ("liable to be called to account")
for our own health and well-being.
As usual, times are changing. One of
the changes that will be occurring more frequently due to the crisis
in health care costs is the alterations in medical benefits increasingly
overseen by managed care companies. In my own little corner of the
Universe, this is most dramatically represented by the wide spread
adoption of Brief Treatment methods. While the transition has created
a number of challenges, like all transformations that are spawned
by crisis, this shift also offers opportunities. We are clearly
not the only ones suffering the aches and pains brought on by the
transformation of the health care system. Our clients are sustaining
tremendous losses as well, and they should not be ignored. I have
tried to minimize my clients losses while ignoring the losses
of the population at large for the most part. I busily redesigned
my practice to some extent and repaired my lifeboat, so to speak,
in order to survive the incoming tide of managed care. The truth
of the matter is that my practice has grown as a result of my successful
attempts to figure out the politics and win the favor of managed
care companies. They really like me, and I am grateful. Perhaps
too grateful! I have heard of the frustration of clients who were
working with someone they cared about and trusted only to be informed
that the therapist was not covered by their new and "improved"
insurance policy. I have witnessed the anguish of a severely depressed
woman who's therapist informed her that weekly sessions would need
to be reduced to monthly in order to ensure that her sessions would
be covered by her insurance. I am aware of the many in need of services
being placed on lengthy waiting lists. I have tried for the most
part to not think about them too much. My own little lifeboat is
solid and sea worthy, and I have places to go, people to see. I
have tried until now to direct my energy elsewhere. Now I am forcing
myself to look and see. During this health care crisis, we as providers
are all preoccupied with saving our own practices and that is understandable;
however, the dust has begun to settle, and it is time that we examine
how we can individually and cooperatively create the most beneficial
environment to our clients. The good old days may be over but the
new ones hold great promise as well if we actively commit to exploring
the possibilities.
BRIEF TREATMENT
Brief Treatment from my view refers
to therapy which is conducted in as time-effective manner as possible
ranging from 1 to 20 sessions. The rapid rise of managed care not
only makes utilization of brief treatment methods desirable, but
necessary. As more and more providers of health care find their
referrals increasingly limited by managed care companies, we are
responding by attempting to adapt and adjust to the requirements
of managed care.
"The Provider," a newsletter
distributed to providers by MCC Behavioral Care, recently published
"Eight Characteristics of Therapy under Managed Care,"
based on the work of Michael Hoyt and Carol Austad. The eight characteristics
established by Hoyt and Austad were: (1) Specific problem solving;
(2) Rapid response and early intervention; (3) Clear definition
of patient and therapist responsibilities; (4) Time is used flexibly
and creatively; (5) Interdisciplinary cooperation; (6) Multiple
formats and modalities; (7) Intermittent treatment; and (8) A results
orientation.
Clearly, such therapy is not always
compatible with the traditional, open-ended psychotherapy that has
so often been the treatment of choice. However, considering that
the utilization of brief treatment methods is rapidly becoming a
requirement of managed care, therapists are attempting in increasing
numbers to respond to the demands this expanding trend involves.
We make these adjustments for the most part in order to continue
to serve our clients to the best of our abilities while also maintaining
reimbursability by insurance companies. From my perspective, this
is in some respects a time of reckoning (if we are able to put aside
our indignation long enough to acknowledge the purpose of medical
insurance in the first place)
Medical insurance was developed to
assist subscribers in seeking treatment for illness, not subsidize
explorations intended to facilitate growth or cover marital counseling.
For a number of years that is exactly what insurance companies have
found themselves doing all too often. Wide spread abuses of the
system have contributed significantly to our current dilemma of
our work policed by managed care.
Therapists being forced in some ways
to develop skills in brief treatment can be viewed as a positive
trend. Clients have a right to expect services to be performed in
a time-effective and cost-effective manner just as do insurance
companies. However, if we simply scramble to incorporate the slickest
brief treatment methods available in order to get the job done as
expediently as possible, we run the risk of offering, in many cases,
little more than a quick and all too often temporary fix.
HOLISTIC TREATMENT
Brief treatment expects much (as it
should) from both the therapist and the client, and it is here that
I believe holistic treatment emerges as a compatible ally. In addressing
holistic treatment as it relates to psychotherapy, I would like
to first examine how the advent of holistic treatment creates a
shift in roles and relationships. Traditional healthcare (the allopathic
approach) places responsibility for cure in the hands primarily
of the caregiver. The holistic approach returns it to its rightful
owner, the client. While the caregiver clearly must take an active
role in the resolution of the problem presented, clients are not
expected to passively accept the ministrations of the provider,
but must themselves work diligently to restore well being. The central
concept of the holistic approach, according to Richard Miles, (1978),
is that the individual is responsible for the development and maintenance
of his or her health and well being.
Miles contends that the holistic approach
does not focus on problems or symptoms but rather on clarity of
intention and the development and maintenance of well being and
self-responsibility. In this context, problems may be viewed as
important feedback messages to be dealt with on a conscious level
as part of the life process. A basic definition according to Miles,
of the holistic practitioner, is one who provides the client with
clear information about the processes of body, mind and spirit.
The client can then choose to follow with the provider's assistance,
a course of action that will offer more productive and healthy life
experiences. In choosing a particular course of action, the client
assumes ownership and thus places responsibility where it must reside--within
the individual.
In accepting the holistic model, one
acknowledges that everything effects our health and well being.
All aspects of ourselves including, physical, emotional, cognitive,
spiritual and environmental, play a role in the quality of our lives.
This first premise is easily accepted; however, when one moves on
to its implication that we must attend to all of these elements,
the challenge is then presented. Placing our lives in the hands
of experts to render solutions can seem far less daunting then the
work involved in prevention and self-care. For example, it seems
simpler to follow the latest fad diet to the letter than to address
the wide range of issues connected to unwanted weight gain. Further,
one is reinforced when the weight fades away with the use of such
a diet. All too often, however, satisfaction eventually is followed
by disillusionment later, when the pounds return or when some other
difficulty moves in to take their place.
Our practices are filled with individuals
who ask us in one form or another to take their pain away. We would
gladly oblige and often try. We even succeed from time to time.
The bottom line, however, as we all know, is that if our efforts
are to be sustainable over the long haul, our clients must learn
what is required of them to meet their own needs. They must also
possess the motivation to act upon this knowledge. In spite of impressive
techniques, modalities, and theories, there is no one magic bullet--no
one particular insight, behavior, drug, or technique that results
in lasting wellness. First of all, the very nature of life prevents
this; we are always confronted with change and new challenges. Second,
as stated earlier, and in line with systems theorists, we are all
made up of parts intermingling with other parts comprising various
systems that continually impact and are impacted by our environment.
Like the Mobile that John Bradshaw strikes during his presentation
aired by PBS on the family, when one of our components shift, the
others are also effected and respond. An argument here might be
made that if we then simply impact one element of the system, then
the others may also automatically benefit. While this is a distinct
possibility, it also implies that while we might fix a system or
person by adjusting one facet or problem, the entire system remains
highly vulnerable to a break down in another part of the system.
There is no avoiding this reality that we are all highly vulnerable,
and while I welcome information to the contrary, I must operate
within the context of this truth for now. Thus, in view of the fact
that we are comprised of parts that make up our whole, with each
segment being vulnerable to or positively impacted by the others,
would it not then make sense to respond to the needs of all components
to the best of our abilities?
Holistic treatment calls for the care
of all aspects of a client; brief treatment requires that we offer
services in as efficient, responsive, and timely manner as possible.
Both of these requirements (at a glance) may not seem readily compatible,
yet they still remain very clear obligations to me.
Tammie Byram Fowles, MSW, Ph.D. :
Dr. Fowles is a psychotherapist, author, consultant, and trainer
currently residing in Columbia, South Carolina. She received her
Masters Degree in Social Work from the University of Connecticut
and her Ph.D. in Counseling Psychology from Southwest University.
She is the author of "BirthQuake: A New Vision of Hope and
Healing," and "Finding the Forest: The Incorporation of
Holistic Treatment into a Brief Treatment Model with Survivors of
Trauma." She is currently working on her new book,
"Healing into Wholeness" Before moving to Columbia in
1995, she lived in Augusta, Maine and practiced in the nearby community
of Lewiston.
Dr. Fowles is available for consultation, training, and to conduct
"Healing into Wholeness" retreats as well as "Myth
and Meaning" workshops. She is willing to offer these programs
at no charge to non-profit service organizations. She can
be reached by e-mail ,
website or by calling 803-419-8256.
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