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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.
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