The Heroic Client

A Revolutionary Way to Improve Effectiveness Through Client-Directed, Outcome-Informed Therapy

Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks

• Publisher: Jossey-Bass
• Year: 2011
• ISBN:
  9781118046623
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychotherapeutische Beratung

In this controversial book, psychologists Barry Duncan and Scott Miller, cofounders of the Institute for the Study of Therapeutic Change, challenge the traditional focus on diagnosis, "silver bullet" techniques, and magic pills, exposing them as empirically bankrupt practices that only diminish the role of clients and hasten therapy's extinction. Instead, they advocate for the long-ignored but most crucial factor in therapeutic success-the innate resources of the client. Based on extensive clinical research and case studies, The Heroic Client not only shows how to harness the client's powers of regeneration to make therapy effective, but also how to enlist the client as a partner to make therapy accountable. The Heroic Client inspires therapists to boldly rewrite the drama of therapy, recast clients in their rightful role as heroes and heroines of the therapeutic stage, and legitimize their services to third-party payers without the compromises of the medical model.

CHAPTER ONE

Therapy at the Crossroads

The Challenges of the Twenty-First Century

... every man his greatest, and, as it were, his own executioner.

—Sir Thomas Browne, Religio Medici

One day, the ancient fable by Aesop goes, the mighty oaks were complaining to the god Jupiter. “What good is it,” they asked him bitterly, “to have come to this Earth, struggled to survive through harsh winters and strong fall winds, only to end up under the woodcutter’s axe?” Jupiter would hear nothing of their complaints, however, and scolded them sternly. “Are you not responsible for your own misfortunes, as you yourselves provide the handles for those axes?” The sixth-century C.E. storyteller ends the tale with a moral: “It is the same for men: they absurdly reproach the gods for the misfortunes that they owe to no one but themselves” (Duriez, 1999, p. 1).

Though removed by some 2,600 years, the perilous situation of the oaks described in Aesop’s fable is not unlike that of the field of therapy today. Indeed, changes in virtually every aspect of the profession over the last ten years have left mental health practitioners with much to feel uncertain and unhappy about. Where once therapists were the complete and total masters of their domain, their power to make even the smallest of decisions regarding clinical practice has dwindled to nearly nothing. A recent survey found that a staggering 80 percent of practitioners felt they had lost complete control over aspects of “care and treatment they as clinicians should control” (e.g., type and length of treatment, and so on; Rabasca, 1999, p. 11, emphasis added).

Of course, the loss of control does not mean there has been a corresponding decrease in the workload of the average mental health professional. Rather, in place of the responsibility therapists used to have are a host of activities implemented under the guise of improving effectiveness and efficiency. For example, where in the past a simple, single-page HCFA 1500 form would suffice, clinicians must now contend with preauthorization, lengthy intake and diagnostic forms, extensive treatment plans, medication evaluations, and external case management to qualify for an ever decreasing amount of reimbursement and funding for a continually shrinking number of sessions and services. The paperwork and phone calls these activities require make it difficult to imagine how they could ever save time, money, or increase the effectiveness of the provided services.

As far as income is concerned, the reality is that the average practitioner has watched the bottom line drop by as much as 50 percent over the last ten years (Rabasca, 1999)! Berman (1998), for example, found that the net income of doctoral-level psychologists in solo practice after taxes averaged $24,000—a salary that hardly seems to merit an average investment of six years of postgraduate education and a minimum of $30,000 in tuition costs (Norcross, Hanych, & Terranova, 1996). On the public side of things, case managers and other bachelorlevel providers render more and more services, reducing the value and therefore salaries of master’s-trained mental health professionals.

Furthermore, several studies have found that the field has twice as many practitioners as are needed to meet current demand for services (Brown, Dreis, & Nace, 1999). Indeed, since the mid-1980s there has been a whopping 275 percent increase in the number of mental health professionals (Hubble, Duncan, & Miller, 1999a). Consumers can now choose among psychiatrists, psychologists, social workers, marriage and family therapists, clinical nurse specialists, professional counselors, pastoral counselors, alcohol and drug addiction counselors, and a host of other providers advertising virtually indistinguishable services under different job titles and descriptions (Hubble et al., 1999a). The reality is, as former American Psychological Association (APA) president Nicholas Cummings (1986, p. 426) predicted, that nonmedical helping professionals have become “poorly paid and little respected employees of giant health care corporations.”

In truth, those seeking mental health services have not fared any better than the professionals themselves. Consider a recent study that found that in spite of the dramatic increase in the number of practitioners between 1988 and 1998, actual mental health care benefits decreased by 54 percent during the same time period (Hay Group, 1999). This decrease, the research further shows, is not part of an across-the-board cut in general health care benefits. During the same period that outpatient mental health encounters fell by 10 percent, office visits to physicians increased by nearly a third. In addition, those seeking mental health services face a number of obstacles not present for health care in general (e.g., different limits, caps, deductions, etc.).

Moreover, most third-party payers now require the practitioner to provide information once deemed privileged and confidential before they will reimburse for mental health services (Johnson & Shaha, 1997; Sanchez & Turner, 2003). Unlike cost and numbers of visits, the impact of such obstacles is more difficult to assess. Nonetheless, in an exploratory study, Kremer and Gesten (1998) found that clients and potential clients showed less willingness to disclose when there was external oversight and reporting requirements than under standard confidentiality conditions.

Clearly, the future of mental health practice is uncertain. More troubling, however, like the mighty oaks in Aesop’s cautionary tale, the field itself may be providing the very handle—not the ax head, mind you, but the handle—that delivers the cutting blows to the profession.

THE FUTURE OF MENTAL HEALTH

The greatest enemy of the truth is not the lie—deliberate, contrived, and dishonest—but the myth—persistent, pervasive, and unrealistic.

—John F. Kennedy, Commencement Address,
Yale University

Imagine a future in which the arbitrary distinction between mental and physical health has been obliterated; a future with a health care system so radically revamped that it addresses the needs of the whole person—medical, psychological, and relational. In this system of integrated care, mental health professionals collaborate regularly with M.D.’s, and clients are helped to feel that experiencing depression is no more a reflection on their character than is catching the flu. This new world will be ultraconvenient: people will be able to take care of all their health needs under one roof—a medical superstore of services. Therapists will have a world of information at their fingertips, merely opening a computer file to learn the patient’s complete history of treatment, including familial predispositions, as well as compliance issues or other red flags.

Now imagine a future in which every medical, psychological, or relational intervention in a “patient’s” life is a matter of quasi-public record, part of an integrated database. Here, therapy is tightly scripted, and only a limited number of approved treatments are eligible for reimbursement. In this brave new world, integrated care actually means a more thoroughly medicalized health care system into which therapy has been subsumed. Yes, counselors will work alongside medical doctors but as junior partners, following treatment plans taken directly from authorized, standardized manuals. Mental health services will be dispensed like a medication, an intervention that a presiding physician orders at the first sign of “mental illness” detected during a routine visit or perusal of an integrated database.

These are not two different systems; rather, they are polarized descriptions of the same future, one that draws nearer every day. Noted psychologist Charles Kiesler (2000)—who in the mid-1980s predicted that fledgling managed care organizations would dominate the U.S. health care industry—predicts that mental health services will soon be integrated into medical patient care and administered accordingly. The reason for this coming change, of course, is the tremendous pressure on health care administrators to reduce spiraling costs. Many health care prognosticators believe that the cost-cutting measures of managed care have already realized all possible benefits and only a total reconfiguration will bring the critical savings required (Strosahl, 2001). Integrated care is a product of this realization.

And it is not hard to see their point. Over the last four decades, studies have repeatedly shown that as many as 60 to 70 percent of physician visits stem from psychological distress or are at least exacerbated by psychological or behavioral factors. In addition, those diagnosed with mental “disorders” have traditionally overutilized general medical care and have incurred the highest medical costs (Tomiak, Berthelot, & Mustard, 1998). Combine these well-known facts with the rather extensive evidence that the delivery of psychological services offsets the cost of medical care (Sanchez & Turner, 2003)—and voilà, integrated care is the greatest thing since sliced bread. Cummings (2000) suggested that a mere 10 percent reduction in medical and surgical care resulting from behavioral care intervention would exceed the entire mental health care insurance budget! Bottom line: according to its supporters, integrated care increases collaboration, improves care, and makes psychotherapy more central to health care—and of course, saves insurance companies and public funders a ton of money.

What the proposed advantages obscure is the inevitability that, in the name of integration, psychotherapy will become ever more dominated by the assumptions and practices of the medical model; that much like an overpowered civilization in the sci-fi adventure Star Trek, we will be assimilated into the medical Borg. The mental health professional of the coming integrated care era, Kiesler (2000) predicts, will be a specialist in treating specific disorders with highly standardized, scientifically proven interventions. At issue here are not the advantages of greater collaboration with health care professionals or of bringing a psychological or systemic perspective to bear on medical conditions. Rather, at issue is whether we will lose our autonomy as a profession by becoming immersed in the powerful culture of biomedicine, breaking the already tenuous connection to our nonmedical, relational identity.

The resulting influx of potential mental health clients into the primary care setting will further promote the conceptualization of mental “disorders” as biologically based and increase current trends toward medication solutions. Indeed, a recent large national survey of primary care physicians revealed that antidepressants were the treatment of choice for depression 72 percent of the time, compared to only 38 percent for mental health referrals (Williams et al., 1999). This is a disturbing trend, especially given what is known about the relative merits of antidepressants (see Chapter Six). Parenthetically, physicians typically diagnose depression in a thirteen-minute visit in which they discuss with patients an average of six problems (Schappert, 1994).

In this nightmarish vision of the future, the woodcutter in the Aesop fable has already cut us down into fireplace-sized pieces, hauled us off, and neatly stacked us for consumption in the fires of the medical model of integrated care. And what is so bad about the medical model? Nothing when it is applied to medical conditions and nothing as one among many options to address the concerns that clients bring to our doorsteps. But as a privileged or mandated practice in mental health, it is a myth, “persistent, pervasive, and unrealistic.” The medical model works with the following equation:

PROPER DIAGNOSIS + PRESCRIPTIVE
INTERVENTION =
EFFECTIVE TREATMENT

Or

TARGETED DIAGNOSTIC GROUPS + EVIDENCE-BASED
TREATMENTS = SYMPTOM REDUCTION

Consider the left side of the first equation: proper diagnosis and prescriptive intervention. A cursory review of professional publications and training offerings strongly suggests that the medical model of mental health already rules, that integrated care will only add icing to a cake of foregone conclusions. For example, of all the continuing education workshops to appear in a recent ad for the American Healthcare Institute (2003)—one of the nation’s largest sponsors of training for therapists—nearly 90 percent were organized around a psychiatric diagnosis. Of these, 70 percent taught specific treatments for specific disorders as defined in the DSM-IV (American Psychiatric Association, 1994). As another example, consider that nearly two-thirds of the articles appearing in the prestigious Journal of Consulting and Clinical Psychology during 2002 were organized around a psychiatric diagnosis, and more than a quarter reported on specific treatments for specific DSM disorders. In fact, funding for studies not related to a specific DSM diagnosis dropped nearly 200 percent from the late 1980s to 1990 (Wolfe, 1993), and the trend continues. The bottom line: the medical model of mental health prevails and is so much a part of professional discourse that we do not notice its insidious influence.

Further, on a national level, mental health professional organizations, drug manufacturers, and hospital corporations design and support campaigns aimed at informing the public about the nature of psychiatric illness and benefits of professional treatment. National Anxiety and Depression Awareness Day is a good example. Advertising on radio, on TV, and in print lay out the signs and symptoms of these two “common colds” of mental health and then tell people where they can go to be evaluated and speak with a professional. At least one study found that more than 50 percent of those who are screened end up in some form of treatment—a considerable return on the investment of a single day (APA, 1998a)! In truth, diagnosis and psychopathology are now part of the American vernacular. Almost everyone knows, thanks to the Zoloft television ad and that cute happy face guy, that depression is a serious medical condition caused by an imbalance of chemicals in the brain.

Concurrently, evidence-based practice has become the buzz word du jour. They represent those treatments that have been shown, through randomized clinical trials, to be efficacious over placebo or no treatment (or in psychiatry’s case, via research review and clinical consensus). Hardly a day goes by without some publication crossing therapists’ desks announcing the latest in evidence-based fashion. Consider the opening line in a recent guide to evidence-based practices: “Good clinicians understand that medical care must be based on the skillful use of scientifically valid and evidence-based information” (McGuire, 2002, p. i). Such pronouncements are not only a part of the everyday information barrage but also have become institutionalized in training programs and licensing boards. For example, APA’s executive director for education, Cynthia Belar, asserts: “Health professionals must learn evidence-based practice. Although APA accreditation criteria require this in training, psychologists must also develop the capability to deliver evidence-based care throughout their careers” (Belar, 2003, p. 38). Such statements imply that you will be left at the station if you don’t jump on board the evidence-based train. They play on our desires to be good clinicians as well as on our fears about surviving financially in an era that promises that insurance or public funds will reimburse only such treatments.

Among physicians, the concept of evidence-based practice has tremendous appeal. For example, an editorial in the New England Journal of Medicine advised physicians to refer patients to therapists proficient at manualized cognitive-behavioral therapy (Scott, 2000), the crown prince of psychology, for chronic depression. The integrated care system will only increase evidence-based treatment because primary care doctors will be the ultimate gatekeepers. Physicians, of course, are not at fault here. Unfortunately, we have not educated the health care system that success depends far less on the type of treatment provided than on the strengths and resources that the client brings and the quality of the alliance the client forms with the therapist.

The development of evidence-based therapies has in fact become a growth industry, paralleling the growth of therapies in general. Since the mid-1960s, the number of talk therapy approaches has mushroomed from 60 to more than 250 at last count (Hubble et al., 1999a). Similarly, since the birth of evidence-based treatments in the early 1990s, these have expanded to well over 100, depending on whose “evidence” from which professional organization you include. Ironically, the effectiveness of psychotherapy has not improved one scintilla, not one percentage point, despite this exponential growth of new treatment technologies and the purported advantages of the so-called scientifically validated approaches. In truth, therapy is no more effective now than it was in the 1960s.

Trying to adjust to yet another fad, mental health agencies and individual professionals spend thousands of dollars on workshops, conferences, and books to learn designer diagnostics and brand-name miracles purportedly based on empirical science. Stepping back, we see that this process differs little from the rush to be brief when managed care first appeared or the stampede to learn about the infamous borderline personality disorder when it first frightened the mental health scene. Unfortunately, similar to all the prior claims of the latest and greatest approaches, the promised advantages always seem just out of reach for most of us, even with those models that supposedly have scientific, valid, and evidence-based information. Why won’t the powerful evidence-based sword slay the dragon of misery of the client in my office now? Why doesn’t the state-mandated empirically supported treatment work in our agency as its proponents insist?

At this point, one might reasonably wonder what could possibly be wrong with the medical model applied to mental health. What’s so bad, for example, about a day of psychoeducation aimed at informing people about the nature of mental illness and helping them overcome the stigma and natural resistance to treatment? For that matter, what’s wrong with diagnosis and an emphasis on pathology? After all, people don’t go to therapy when they are doing well! Doesn’t it just make sense that to help a person, the therapist must first figure out what’s wrong with that person? And isn’t interes...