Below is a post on a therapist listserve by Dr. Barry Duncan. My profession is in some trouble due to our understandable human tendency in the last 40 years to ‘follow the money’. In health care, you get paid by diagnosing people. But is this really what you want when you go to a therapist? The answer probably won’t surprise people outside the profession because they are more likely to apply common sense than folks within my profession. This is a side story with the recent talk about health care reform, but there are lessons to be learned from mental health. The herd instinct has gotten to us, the urge to merge and lump everything together because it makes sense fianancially. Beware unforeseen consequences. We are in danger of creating a monoculture in health care, treating apples like oranges, and setting ourselves up for something like the Irish Potato Famine. If there had been more than one kind of potato in Ireland in the 1800’s , 1 million people wouldn’t have starved to death. Maybe I’m being drastic here. I ‘ll let Barry try and ’splain it.
I have been thinking about and writing about the medical model and its influence on psychotherapy for many years. It is an area of great importance and I also think there are some bright spots here. Therapists have been resisting these ideas for years, and alternative paradigms have been articulated. There was a “mentoring model” available to compete with the medical model in the forties. In addition, the humanistic perspective offered an alternative as did the systemic perspective as exemplified by the Mental Research Institute and later by solution focused and narrative or language based approaches. Unfortunately, the institutional support for these humanistic, systemic, and social constructionist perspectives was absent as the DSM rose to prominence and reimbursement dictated nearly everything. But there are alternatives that have brewing for many years. Psychotherapy, of course, is not a medical endeavor, it is a relational one. I have never had a therapist stand up in a workshop and challenge that statement. Yet, the medical model is the predominant description of what we do. Ironically, its assumptions and practices are not supported by the data (see Duncan & Miller, 2000; Duncan et al., 2004; Wampold, 2001, 2010). Instead, there is an empirically-based account of our services that offers a much better approximation, namely the common factors. For most of us that I encounter across the world, psychotherapy lies outside of the language of diagnosis, prescriptive treatment, and cure. Therapists describe the more interpersonal nature of the work and now the consumer’s perspective of therapeutic process, the benefit and fit of the services, is gaining steam. But the language we are taught is the language of the medical model. George Albee (2000) suggested that psychology made a Faustian deal with the medical model over fifty years ago. The deal was sealed, he asserted, at the famed Boulder conference in 1949, where psychology’s bible of training was developed with a fatal flaw: [The fatal flaw]…was the uncritical acceptance of the medical model, the organic explanation of mental disorders, with psychiatric hegemony, medical concepts, and language (Albee, 2000, p. 247). Later, in the 1970’s, with the passing of freedom of choice legislation guaranteeing parity with psychiatrists, psychologists (and later others) learned to collect from third-party payers using only a psychiatric diagnosis for reimbursement. Thereafter, drowning any possibilities for other psychosocial systems of understanding human challenges, the National Institute of Mental Health (NIMH), the leading source of research funding for psychotherapy, decided to apply the same methodology used in drug research to evaluate psychotherapy (Goldfried & Wolfe, 1996)—the randomized clinical trial requiring both diagnosis and manualized treatments. Diagnosis reached its pinnacle. Now both reimbursement and research funding depended on it. And the beat goes on: The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, enacted into law on October 3, 2008, will become effective on January 1, 2010. It ended health insurance benefits inequity between mental health/substance use “disorders” and medical/surgical benefits. While this may seem like a welcome boon, and it is in some respects, there is a downside: we are further drawn into the medical model and its description of our identity. Just like freedom of choice legislation forever enslaved us to reimbursement by diagnosis and medicalized the way we talked about our work, the recent parity bill promises further bondage to medical thinking and the DSM. Moreover, keep in mind that payers will still set fees, and pay us as little as they want. They will have to cover the costs associated with equal access somehow and you know reducing profit margins is not an option. In the context of parity, negotiating sessions based on benefit, or a fixed number of sessions, in return for better rates and relative autonomy would be moot. Parity does not address the outcome of the service. Collection of outcome data on a large scale could be very useful here. It could supply the impetus for reevaluating funding models and the medical model assumptions and practices used to justify services. As more and more evidence is collected, and becomes public, that shows the lack of relationship between diagnoses, ESTs, length of stay, and improvement, the real predictors of progress may come to light (like the alliance and early change). Once identified, practices improving outcomes could be implemented system wide, while those that are irrelevant eliminated. Consumers could be our allies here given the recovery movement’s stated dislike for the medical model (Bassman, 2007) as evidenced by the National Consensus Statement of Recovery. It is important to add that this is nothing wrong with the medical model and that people who think in those terms are not evil-doers! They, like us, want to be helpful to people. And embracing the medical model (diagosis is required in most settings) does allow services to be offerred to those in need. That is important also. That said, I do believe that we must recapture, as Dan suggests, the words “best practice” and “evidence based practice.” The APA Task Force’s EBP definition offers a great example. Evidence now includes the consideration of empirically supported treatments without privileging them, as well as the wide range of findings regarding the alliance, other common factors, and feedback. Moreover, the Task Force submitted: Clinical expertise also entails the monitoring of patient progress (and of changes in the patient’s circumstances — e.g., job loss, major illness) that may suggest the need to adjust the treatment (Lambert, Bergin, & Garfield, 2004a). If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate. (APA, 2006, p. 276-277) So, attaining feedback is an evidence based practice. In short, EBP now accommodates the common factors and includes client feedback as a necessary component. Finally, the Task Force said: The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential (Task Force, 2006, p. 280). Proponents from both sides of the common v. specific factors aisle recognized that outcome is not guaranteed regardless of evidentiary support of a given technique or the expertise of the therapist (Anker et al., 2009). Bruno, there is absolutely no empirical support for the assertions made by the presenters. Zero, nada, zip! And on average, people do change early in therapy, and it seems to be unequivocal at this point. It is true that some people take longer but importantly, it doesn’t take longer for them to start to change. It takes longer for them to plateau. A recent study of Baldwin and associates (2009) looked at over 4600 clients. A full 91% attended 12 or less sessions. The trajectories strongly supported the early change assumption. Moreover, they stratified the trajectories by number of sessions. Even then, for those folks staying over 20 sessions (perhaps the presumably described personality disorders), the change started immediately. The curve was flatter but started early nevertheless as demonstrated in other studies (Project Match; the Youth Cannabis Study, and the TDCRP). Finally, one needn’t pressure clients with early change to respect what the data say. It is merely a way to keep us focused on outcome and challenge our thinking when things are not changing. Neither do we need to pressure clients to stay in treatment for the belief that long term work is necessary for a given condition. My two cents.
Best, Barry
Stay away from my hot wife
October 1, 2009This article explains something that all guys know, talking to hot women makes you feel GRRRRREAT! They now have some science to back it up.
I also think this explains why men will often obsess about someone they will never have rather than be realistic and hook up with what is available, especially when they are younger or just going through a hard time. Just picturing that person may have similar effects to talking to them. That can get dangerous for certain impulsive types. But it may keep some people out of depression when ‘done in moderation’.
For those of us with a hot wife, feeling great is the norm
http://www.telegraph.co.uk/science/science-news/6243292/Meeting-pretty-women-makes-men-feel-good.html
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