Barry L. Duncan

Scott D. Miller

Jacqueline A. Sparks

The Heroic ClientA Revolutionary Way to Improve Effectiveness ThroughClient-Directed, Outcome-InformedTherapy

Revised Edition

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By the Same Authors

Heroic Clients, Heroic Agencies: Partners for Change, BarryDuncan, Jacqueline Sparks

The Heart and Soul of Change: What Works in Therapy, MarkHubble, Barry Duncan, Scott Miller

Escape from Babel: Toward a Unifying Language forPsychotherapy, Scott Miller, Barry Duncan, Mark Hubble

Psychotherapy with “Impossible” Cases: The Efficient Treat-ment of Therapy Veterans, Barry Duncan, Mark Hubble,Scott Miller

Brief Intervention for School Problems: Collaborating forPractical Solutions, John Murphy, Barry Duncan

Handbook of Solution-Focused Brief Therapy: Theory,Research, and Practice, Scott Miller, Mark Hubble, BarryDuncan

Changing the Rules: A Client-Directed Approach to Therapy,Barry Duncan, Andrew Solovey, Greg Rusk

Working with the Problem Drinker: A Solution-FocusedApproach, Insoo Berg, Scott Miller

Self-Help

Staying on Top and Keeping the Sand Out of Your Pants, ScottMiller, Mark Hubble, Seth Houdeshell

“Let’s Face It, Men Are &$$%\¢$”: What Women Can DoAbout It, Joseph Rock, Barry Duncan

The Miracle Method: A Radically New Approach to ProblemDrinking, Scott Miller, Insoo Berg

Overcoming Relationship Impasses: Ways to Initiate ChangeWhen Your Partner Won’t Help, Barry Duncan, Joseph Rock

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The Heroic Client

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Barry L. Duncan

Scott D. Miller

Jacqueline A. Sparks

The Heroic ClientA Revolutionary Way to Improve Effectiveness ThroughClient-Directed, Outcome-InformedTherapy

Revised Edition

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Copyright © 2004 by John Wiley & Sons, Inc. All rights reserved.

Published by Jossey-BassA Wiley Imprint989 Market Street, San Francisco, CA 94103-1741 www.josseybass.com

No part of this publication may be reproduced, stored in a retrieval system, or transmit-ted in any form or by any means, electronic, mechanical, photocopying, recording, scan-ning, or otherwise, except as permitted under Section 107 or 108 of the 1976 UnitedStates Copyright Act, without either the prior written permission of the Publisher, orauthorization through payment of the appropriate per-copy fee to the Copyright Clear-ance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-

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Jossey-Bass also publishes its books in a variety of electronic formats. Some content thatappears in print may not be available in electronic books.

Excerpts from “The psychology of mental illness: The consumers/survivors/ex-mentalpatients’ perspective” by Ronald Bassman from Psychotherapy Bulletin, 34(1), Winter1999, 14–16. Reprinted with permission of Psychotherapy Bulletin.

Figure 4.1 from American Psychologist, 41(2), 1986, 159–164, copyright © 1986 by the American Psychological Association. Reprinted with permission.

Library of Congress Cataloging-in-Publication Data

Duncan, Barry L.The heroic client : a revolutionary way to improve effectiveness through client-directed,

outcome-informed therapy / Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks.—Rev. ed.

p. cm.“First edition.”Includes bibliographical references and index.

ISBN 0-7879-7240-1 (alk. paper)1. Client-centered psychotherapy. I. Miller, Scott D. II. Sparks,

Jacqueline. III. Title.RC481.D86 2004616.89�14—dc22 2003018314

Printed in the United States of AmericaREVISED EDITION

PB Printing 10 9 8 7 6 5 4 3 2 1

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8700, or on the Web at www.copyright.com. Requests to the Publisher for permission

http://www.josseybass.comhttp://www.copyright.com

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Contents

Foreword to the Revised Edition ixBruce E. Wampold

Foreword to the First Edition xiiLarry E. Beutler

Preface xvii

1 Therapy at the Crossroads 1

2 The Myth of the Medical Model 21

3 Becoming Client Directed 49

4 Becoming Outcome Informed 81with Lynn Johnson, Jeb Brown, and Morten Anker

5 The Client’s Theory of Change 119with Susanne Coleman, Lisa Kelledy, and Steven Kopp

6 The Myth of the Magic Pill 147with Grace Jackson, Roger P. Greenberg,and Karen Kinchin

7 Planet Mental Health 178

Epilogue: A Tale of Two Therapies 201

Appendixes

I A First-Person Account of Mental Health Services 213Ronald Bassman

II Consumer/Survivor/Ex-Patient Resource Information 217Ronald Bassman

III Five Questions About Psychotherapy 219

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IV Outcome Rating Scale and Session Rating Scale; 221Experimental Versions for Children

References 229

About the Authors 249

Name Index 254

Subject Index 261

CONTENTS

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Foreword to the Revised Edition

Every society, historical or contemporary, has a culturally embeddedset of healing practices. These practices are so ingrained into people’sthinking that they go unquestioned. Receiving acupuncture as part ofChinese care would not be astonishing to a Chinese person living inthe culture. To an ancient Greek, the acupuncture ritual would be allwrong: the idea of chi would be foreign, but temple rituals based onmythical gods would be comfortable and accepted. Simply, we do notquestion the predominant healing models of our culture.

The predominant healing practice in our culture is modern medi-cine. We may question a particular diagnosis or procedure, but mostWesterners unquestioningly accept the basic premise that disease iscaused by some physiochemical abnormality that can be correctedthrough the administration of medicine or physical procedure. In themost simple example, bacteria causes pneumonia; antibiotics killthe bacteria; and the pneumonia is cured. Sufficient evidence existsthat bacteria are real (we can see them with a microscope) and thatantibiotics are effective. Modern medicine has a distinct distaste forhealing practices that have “strange” explanations (that is, involveprocesses not verifiable by scientific means) such as those involvinganimal magnetism (the basis of Mesmer’s treatments), chi, spirits, andso forth, whether or not the healing practices are effective.

Barry Duncan, Scott Miller, and Jacqueline Sparks have cogentlyexamined the research on psychotherapy and concluded that the med-ical model does not apply to this healing practice (see Chapter Two).This conclusion is controversial, not because it is not supported by theresearch but because it challenges the predominant cultural under-standing. There is convincing evidence that psychotherapy does notact specifically on disorders in the way in which medicine is purportedto work. It is not the cognitive interventions in cognitive therapy thatmake it effective; more likely, the benefits are due to the explanationgiven to the clients; the rituals consistent with that explanation, which

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remoralize the client; the relationship between the therapist and theclient; the skill of the therapist; the healing context; the client’s expec-tation and hope; and so forth. Indeed, as Duncan, Miller, and Sparksexplain, all psychotherapies competently administered are equallyeffective. People benefit from psychotherapy in ways that are not eas-ily explained by a medical model. It is not surprising, therefore, thatpharmacological treatments are not particularly effective and maywork primarily through means other than the specific effects on thebrain. Chapter Six (coauthored with Grace Jackson, Roger P.Greenberg, and Karen Kinchin) is a stunning indictment of drug treat-ments for most conditions that we label as mental disorders.

It is important to note, as Duncan, Miller, and Sparks have, that themedical model permeates the treatment of clients. Television is satu-rated with advertisements for medicines for physical ailments (e.g.,allergies, constipation, diarrhea, heartburn, chemotherapy-inducednausea) as well as mental disorders (e.g., depression and anxiety). Psy-chotropic medications are among the most widely sold drugs in theUnited States. However, the helping professions have shared in apply-ing the medical model to assisting clients, partly from the pressures ofmanaged care, partly from competition from biological psychiatry,and partly from our reverence of science and the medical model. Wediagnose clients; we formulate treatment plans; we administer diag-nostics (e.g., personality tests); we maintain medical charts; and wethink of ourselves as the agents of change. Our leaders in academiaare busy developing empirically supported treatments so as to estab-lish our treatment authority. Duncan, Miller, and Sparks have cogentlyand refreshingly presented an alternative: client-directed andoutcome-informed therapy.

The Heroic Client is not simply an humanistic tilting at the medical-model windmill. Duncan, Miller, and Sparks’s contribution may bethought of as proposing a scientific alternative to the medical model.One of the distinguishing features of modern medicine is that it hasresulted in treatments that are demonstrably effective. Over the his-tory of the world, the effectiveness of thousands of healing practicesadopted by various cultures has not been established. Although it isnot clear whether or not such practices have been beneficial, thereis no doubt that some have been harmful (see Duncan, Miller, andSparks’s description of the iatrogenic effects of George Washington’sphysicians’ treatments of his respiratory disorder in Chapter One).

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Foreword to the Revised Edition XI

Psychotherapy has been scientifically established as a remarkably effec-tive practice, more effective than many accepted medical treatments.Duncan, Miller, and Sparks take a further and vital step down theempirical road by demonstrating the usefulness of monitoring clientprogress. Monitoring client outcomes is such an obviously importantactivity that knowing it has not been standard practice since the incep-tion of talk cures boggles the mind. We have for decades attempted,albeit unsuccessfully, to identify the characteristics of successfultherapists—Duncan, Miller, and Sparks propose the eminently rea-sonable solution that we evaluate the effectiveness of therapy basedon the outcome and not on the adherence of the therapist to a treat-ment protocol, an expectation of a supervisor, or other implicit aspectsof the therapy.

The final recommendation of The Heroic Client is to listen to theclient to guide the therapy. The notion of client-directed therapy hitsindeed at a central tenet of the medical model, which always proposesan external explanation for a disorder, located in scientific under-standing. Client-directed therapy requires that we therapists give upour notion of “expertness,” a proposition that is difficult to assimilateafter the years of training we have endured in order to achieve our sta-tus. I suspect that many clients present to us because of the perceivedexpertness as well. However, Duncan, Miller, and Sparks make a con-vincing case that the humility required to become a client-directedtherapist is worth the effort because of the benefit that clients willexperience by participating in a healing practice that recognizes theirwisdom and respects their understanding of themselves.

Duncan, Miller, and Sparks have it exactly right, to my mind, byfocusing on effectiveness as well as respect. They have shown thecourage to break free of the shackles of the medical model withoutsacrificing the values (and value) of science and evidence. It is not onlythe clients who are heroic—Duncan, Miller, and Sparks are heroic, asare the therapists who resist the temptation to conform to a medicalmodel and thus assist clients in effective and respectful ways.

BRUCE E. WAMPOLDUniversity of Wisconsin-Madison

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Foreword to the First Edition

Name a psychiatric condition, and it is likely that a document fromone or another mental health agency or interest group maintains thatthis condition is “seriously underdiagnosed and unrecognized” in soci-ety. Often, it is asserted that it is underdiagnosed because it is malig-nantly asymptomatic (without symptoms), but if the truth wereknown, we are told, it would be revealed that this condition hasreached epidemic proportions. And of course, all of these conditionsrequire the services of an expert clinician, a magic pill, and months oreven years of expensive treatment.

Factually, it is quite uncertain that the clusters of symptoms thatwe bind together under discrete diagnostic labels really represent dis-crete conditions or disease processes at all, and even more uncertainthat even highly trained clinicians can identify them reliably or treatthem discriminately when they are recognized. Diagnostic descriptorsare proliferating at a much faster rate than the accumulation of sup-portive research or the expansion and growth of new symptoms, withevery new edition of the Diagnostic and Statistical Manual of MentalDisorders adding new diseases to our vocabulary. The accumulationof these diseases, some might add, are more responsive to the vote ofthe American Psychiatric Association than to the findings from theresearch laboratory. Applications of democracy to eradicating disease,as done in psychiatry, should certainly be tried by those who treat can-cer and heart disease.

In view of this, one has to wonder why and how both diagnosesand treatment approaches have proliferated so widely, there now beingmore than 400 of each. As one inspects the peculiarly strong correla-tion between the number of new diagnoses and the number of pro-fessionals being trained to treat these disorders, he or she may secretlywonder, which came first—the diseases or the healers? Conventionalwisdom portrays a struggling mental health system that is overrun byan ever expanding epidemic, straining under the press of emerging

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disorders—a system whose scientists are uncovering, daily, new sick-nesses and problems, and whose weak efforts to amass an army tofight these diseases is inadequate to stem the tide.

But there is another view, one that suggests that new diseases havebeen manufactured in order to feed a social system that prefers tothink of “diseases” needing treatment than of choices that imply per-sonal responsibility and vulnerability. This latter view suggests thatthe expanding diagnostic system was created in order to support theneeds of a growing array of mental health professionals and a bur-geoning pharmaceutical industry—make it into a disease and youimply that it requires an expert, a pill, and a specialized treatment tofix it.

The evidence for this alternative perspective is compelling, as BarryDuncan and Scott Miller document. For example, in spite of an expo-nential increase in the number of new and novel theories of change,psychopathology, and treatment, it remains that even skilled profes-sionals cannot agree on when a given condition is present. Even if theydo agree, moreover, they assign different treatments. And finally, thetreatments they assign, while different in assumed mechanism andform—both chemical and psychological—are nonspecific. That is,they produce similar effects, and most of the effects take place earlyin treatment. It seems that every new practitioner develops his or herown theory of how behavior develops and changes, which often is nomore than a rationale for why his or her special skills are needed. Theevidence available indicates that factors that are incidental to most ofthese theories account for most of the benefits of the treatments. Mostof the factors that help people are inherent to the patient and involvehis or her resources, expectancies, and faith. What change is notaccounted for by these qualities of the person who seeks treatment islargely accounted for by how well the therapist can relate to thepatient. Indeed, in this day of trying to identify empirically supportedtreatments, the treatment that has earned the strongest research sup-port is any specific one in which therapist and client/patient collabo-rate, the therapist is supportive and caring, and both or all participantsshare a perspective of where they are going. A therapy that capitalizeson creating this type of environment is what is advocated anddescribed by Duncan and Miller in espousing “client-directed, out-come informed” therapy.

Considering contemporary literature about the contributors toeffective amelioration of problems in living and personal discomfort,

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one would be hard pressed to imagine that client-directed therapywould be ill advised for anyone. It is an approach that respects thepatient and stimulates collaboration toward patient-initiated goals.And it addresses the area about which we know the most regardinghow to maximize the effects of psychotherapeutic efforts, the thera-peutic relationship. It acknowledges the importance of patient prepa-ration, of session-by-session evaluation, of early change events, andof monitoring and correcting the quality of the therapeutic alliance.

Duncan and Miller and I agree about the problems of diagnosis,the fallacy of the magic pill, the importance of early change, and thevalue of working through the treatment relationship to construct atreatment plan. At this juncture, however, we also have some diver-gent views. The snag is in the question of whether improvementbeyond the relationship can be achieved by the use of specific tech-niques in any way that will allow pretreatment and presession plan-ning. Duncan and Miller argue that specific procedures applied on thebasis of group algorithms add little to treatment benefit and that anyimplementation of specific procedures should be decided in responseto immediate feedback from patients about the relationship, theirexpectations, their wants, and their progress. They critique those likeme who advocate adding to the relationship enhancement processesa prescriptive or preplanned intervention, tailored to patient qualities.Duncan and Miller fear, with some justification, that such preplan-ning places too much faith in the skill of the therapist and introducesa status rift into the relationship. I, on the other hand, fear thatpatients may, just as therapists clearly do, come to reify beliefs and the-ories to their disadvantage. There are instances, I believe, such as thatof Stacey (Chapter Five) in which working from only the patient’stheory tacitly reinforces the tendency to assume that one’s memories,especially those induced by treatment, are accurate representations ofreal events from the past, and freezes our views of what is real. I believethat a therapist’s responsibility is partially to provide a check againstreification of memories and cementing of constructed theories thatare or may be damaging to people and relationships in the long run.

But the differences in our views represent hypotheses that are inneed of further test. Science will eventually reveal the path to follow.But whatever we ultimately determine the effect to be of specificpsychotherapeutic interventions based on diagnosed disorders, I amconvinced that we will continue to find that they are of lesser impor-tance than those things whose objectives are to enhance and facilitate

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the quality of the relationship between client and clinician. Thisrelationship is enhanced when the therapist is able to move within thepatient’s view and world. It is these things that this book addressesmost completely and thoroughly. It is the descriptions of how to treata “patient” as an equal, how to facilitate the quality of the relationship,and how to establish collaboration and cooperation that are the mostvaluable and enduring facts. And in this, one cannot go wrong by fol-lowing Duncan and Miller’s lead. But more, you can do much that willbe good and helpful.

LARRY E. BEUTLERUniversity of California, Santa Barbara

Right Running Heads Are the Chapter Title XV

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To

The memory of Lee Duncan—

Who taught Barry about Heroism

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Preface

About twenty-four years ago, I (Barry Duncan) began my mentalhealth career at a state hospital. I experienced firsthand the facial gri-maces and tongue wagging that characterize the neurological damage(tardive dyskinesia) caused by antipsychotics and sadly realized thatthese young adults would be forever branded as grotesquely different,as “mental patients.” I witnessed the dehumanization of peoplereduced to drooling, shuffling zombies, spoken to like children andtreated like cattle. I barely kept my head above water as hopelessnessflooded the halls of the hospital, drowning staff and clients alike in anocean of lost causes.

Shortly thereafter, I began working in a residential treatment cen-ter for troubled adolescents. So “disturbed” were these kids that everyone “required” at least two psychotropic medications and a minimumof two diagnoses. One time when the psychiatrist was on vacation andthe center director was unable to cover him, a sixteen-year-old, Ann,was admitted to the center. I was assigned her case and saw her everyday in individual therapy as well as in the groups I conducted. Annwas like many of the kids, abused in all ways imaginable, drop-kickedfrom one foster home to another, with periodic suicide attempts andtrips to hospitals and runaway shelters. In spite of all that, Ann was apure delight—creative, funny, and hopeful for a future far differentthan her childhood. The therapy went great: we hit it off famously,and Ann settled in and started attending high school for the first timein several months.

Three weeks later, the psychiatrist returned and prescribed an anti-depressant and lithium for Ann. She adamantly opposed taking themedication—she said she had been down that path already. Buther voice went unheard. More accurately, she had no voice at all in herown treatment. I protested to the psychiatrist, citing evidence of howwell she was doing, but to no avail. I was only a mental health grunt

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xviii PREFACE

and a student to boot. I argued that forcing meds on Ann could beharmful, but he did not listen. And it was.

Ann became a different person—sullen, hostile, and combative. Shesoon ran away and went on a three-day binge of alcohol and drugs. Acarload of men picked her up while she was hitchhiking and endedthe ride with a gang rape. Adding insult to injury, Ann was forcefullyinjected with an antipsychotic when the police brought her back tothe center. When Ann described this experience, she saw the horroron my face and reassured me that she had suffered far worse indig-nities than being forcefully tranquilized. It was little solace for eitherof us.

When Ann persisted in her ardent protests against the medication,I encouraged her to talk to the center director. Rather than listening,however, the director admonished me for putting ideas into Ann’shead and told me to drop it. Instead, I spent days researching the lit-erature. What I found surprised me. In contrast to what most clientswere told, little was known about how psychotropic drugs actuallyworked. Drugs like cocaine, for example, blocked the reuptake of thebrain chemicals believed critical to depression in exactly the same wayas antidepressants but did not have any so-called therapeutic effect.Furthermore, although increases in these supposedly critical neuro-transmitters were present within hours of the first dose, they did notresult in any therapeutic benefit for four to six weeks! Moreover, therewas no empirical support for prescribing these drugs to children—letalone multiple drugs.

Finally, I was shocked to find that the very helpfulness of medica-tion was suspect. I discovered a 1974 review (Morris & Beck, 1974) ofninety-one studies that showed antidepressants to be no more effec-tive than a sugar pill in one-third of the published reports. This find-ing is particularly noteworthy because the studies eliminatedparticipants who showed rapid improvement to the fake pill (calledplacebo responders). Furthermore, because research with negativeresults is less likely to be published, this review likely underestimatedthe extent of the placebo response rate.

Simply put, I had unexpectedly discovered that the emperor hadno clothes. What did I get when I challenged the psychiatrist withthese facts? Fired. Ann survived as usual, resisting when she could, andunfortunately viewed this experience as just another cog in her wheelof abuse from her “helpers.” I left demoralized but determined neverto be in the dark again, complicit by virtue of ignorance. Later, Ann

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wrote me and thanked me for supporting her resistance. Ann’sresilience gave me hope.

These many years later, the same practices that diminished andexcluded Ann, as well as dictated her options, still thrive. This bookseeks to undermine those practices that oppress clients and providetherapists with the information necessary to question the mentalhealth status quo. Consequently, this book is decidedly political. Wecritically examine and slaughter the sacred cows of the medical modelas it applies to the human dilemmas clients and therapists routinelyface.

But that is not enough. Therapists have whined about the mentalhealth system for many years. More important, we also suggest analternative that we believe fits therapist’s values more and releases ther-apists and clients alike from practices in which they do not believe. Atthe core of our proposal is the heroic client. This book recasts thedrama of therapy and places clients in their rightful role as heroes andheroines of the therapeutic stage.

We argue that attending to clients’ centrality to change by moni-toring the client’s view of progress and fit dramatically improves effec-tiveness and makes psychotherapy accountable to both consumers andpayers. We call this approach “client directed and outcome informed.”

We, however, are not laying the cornerstone of a new model or con-cocting a tag line for selling a new and improved brand of therapy.Any therapy can be client directed and outcome informed; the onlyrequirement is that ongoing client perceptions about the fit andprogress of therapy direct options and provide the ultimate litmus testfor success. Consequently, we dictate no fixed techniques, no certain-ties or invariant patterns in therapeutic process, and offer no insight-ful explanations for the concerns that bring folks to therapy. We arecertain that you have “been there, done that.” Instead, we suggest prin-ciples that therapists of any orientation can consider to enhance thosefactors identified by research to account for successful outcome—butonly the client can determine the benefit of any particular application.Therefore, we suggest a way that therapists of any theoretical prefer-ence can elicit clients’ “real-time” feedback about the benefit of theservices received to inform and modify their work—not only toimprove effectiveness but also to form an identity separate from themedical model.

In this revision of The Heroic Client, we intended at first to changeonly two chapters substantially to reflect the evolution of our thinking

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and simply update the others. But as Jacqueline Sparks, our newthird author, commented, once you repaint one room in the house,suddenly all the rooms look in need of a coat of paint. Consequently,readers familiar with the first edition will notice many changes in addi-tion to updated references. The new version is decidedly more userfriendly, replete with several more client examples to illustrate ourpoints. This edition offers a more practical discussion of the most rad-ical of our ideas: partnering with clients to change the way mentalhealth services are delivered and funded. We lay out the details ofbecoming outcome informed to encourage not only more insurrec-tion against those practices that marginalize clients but also to provideenough foundation for readers to begin an outcome project in theirsettings. Those desiring to implement these ideas can find support atour listserv, http://www.heroicagencies.org. We have also expanded ourarguments about evidence-based treatments and psychotropic med-ication to enable the informed therapist to thoughtfully consider thecontroversies at hand.

Finally, we changed the subtitle to “A Revolutionary Way toImprove Effectiveness.” These are strong words. We mean “revolu-tionary way” to reflect two themes central to this book. One is our rev-olutionary desire to overthrow mental health practices that do notpromote a partnership with clients in all decisions that affect their wellbeing. The second theme is the revolutionary improvements thatrecent research about outcome feedback has demonstrated—usingclient-based outcome feedback increases effectiveness by an incredi-ble 65 percent in real clinical settings. Such results, when taken in com-bination with the field’s obvious failure to discover and systematizetherapeutic process in a manner that reliably improves success, haveled us to conclude that the best hope for improving effectiveness willbe found in outcome management.

QAny project of this kind reflects contributions by many, and to themwe are deeply grateful. We remain indebted to our clients, who con-tinue to teach us to do good work by depending on them. Several peo-ple deserve special mention. In addition to the influences mentionedin our previous publications, we would like to acknowledge the inspi-ration provided by therapists and leaders around the world whoimplement the ideas described in this book in the places that reallymatter, in the day-to-day world with clients in distress—Wenche

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BrunnLien, Dave Claud, Daniil Danilopoulos, Morten Hammer, MarySusan Haynes, Tove and Andy Huggins, Bill Plum, Geir Skauli, DaveStadler, Anne-Grethe Tuseth, and Jim Walt to mention just a few—and whose willingness to challenge the status of the emperor’s fash-ions provide models for us all to emulate. We are grateful to RitaBenasutti, Joan Katz, Sara Klug, and Joe Rock for their feedback andongoing support; and to the heroicagencies listserv, too many namesto mention, for continued lively conversation and the inspiration totry to make a difference. Finally, we feel especially indebted to AlanRinzler, executive editor at Jossey-Bass, for recognizing our passionsand encouraging them to become manifest.

BARRY L. DUNCANSCOTT D. MILLER

JACQUELINE A. SPARKS

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C H A P T E R O N E

Therapy at the CrossroadsThe Challenges of the Twenty-First

Century

. . . every man his greatest, and, as it were, his ownexecutioner.

—Sir Thomas Browne, Religio Medici

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

Though removed by some 2,600 years, the perilous situation of theoaks described in Aesop’s fable is not unlike that of the field of ther-apy today. Indeed, changes in virtually every aspect of the professionover the last ten years have left mental health practitioners with muchto feel uncertain and unhappy about. Where once therapists were thecomplete and total masters of their domain, their power to make eventhe smallest of decisions regarding clinical practice has dwindledto nearly nothing. A recent survey found that a staggering 80 percentof practitioners felt they had lost complete control over aspects of

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“care and treatment they as clinicians should control” (e.g., type andlength of treatment, and so on; Rabasca, 1999, p. 11, emphasis added).

Of course, the loss of control does not mean there has been a cor-responding decrease in the workload of the average mental health pro-fessional. Rather, in place of the responsibility therapists used to haveare a host of activities implemented under the guise of improvingeffectiveness and efficiency. For example, where in the past a simple,single-page HCFA 1500 form would suffice, clinicians must now con-tend with preauthorization, lengthy intake and diagnostic forms,extensive treatment plans, medication evaluations, and external casemanagement to qualify for an ever decreasing amount of reimburse-ment and funding for a continually shrinking number of sessions andservices. The paperwork and phone calls these activities require makeit difficult to imagine how they could ever save time, money, orincrease the effectiveness of the provided services.

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

Furthermore, several studies have found that the field has twiceas many practitioners as are needed to meet current demand forservices (Brown, Dreis, & Nace, 1999). Indeed, since the mid-1980sthere has been a whopping 275 percent increase in the number ofmental health professionals (Hubble, Duncan, & Miller, 1999a). Con-sumers can now choose among psychiatrists, psychologists, socialworkers, marriage and family therapists, clinical nurse specialists, pro-fessional counselors, pastoral counselors, alcohol and drug addictioncounselors, and a host of other providers advertising virtuallyindistinguishable services under different job titles and descriptions(Hubble et al., 1999a). The reality is, as former American Psy-chological Association (APA) president Nicholas Cummings (1986,p. 426) predicted, that nonmedical helping professionals have become“poorly paid and little respected employees of giant health carecorporations.”

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

Moreover, most third-party payers now require the practitioner toprovide information once deemed privileged and confidential beforethey will reimburse for mental health services (Johnson & Shaha,1997; Sanchez & Turner, 2003). Unlike cost and numbers of visits, theimpact of such obstacles is more difficult to assess. Nonetheless, in anexploratory study, Kremer and Gesten (1998) found that clients andpotential clients showed less willingness to disclose when there wasexternal oversight and reporting requirements than under standardconfidentiality conditions.

Clearly, the future of mental health practice is uncertain. Moretroubling, 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 theprofession.

THE FUTURE OF MENTAL HEALTHThe 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 mentaland physical health has been obliterated; a future with a health caresystem so radically revamped that it addresses the needs of the wholeperson—medical, psychological, and relational. In this system of inte-grated care, mental health professionals collaborate regularly withM.D.’s, and clients are helped to feel that experiencing depression is

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no more a reflection on their character than is catching the flu. Thisnew world will be ultraconvenient: people will be able to take care ofall their health needs under one roof—a medical superstore of ser-vices. Therapists will have a world of information at their fingertips,merely opening a computer file to learn the patient’s complete historyof treatment, including familial predispositions, as well as complianceissues or other red flags.

Now imagine a future in which every medical, psychological, orrelational intervention in a “patient’s” life is a matter of quasi-publicrecord, part of an integrated database. Here, therapy is tightly scripted,and only a limited number of approved treatments are eligible forreimbursement. In this brave new world, integrated care actuallymeans a more thoroughly medicalized health care system into whichtherapy has been subsumed. Yes, counselors will work alongside med-ical doctors but as junior partners, following treatment plans takendirectly from authorized, standardized manuals. Mental health ser-vices will be dispensed like a medication, an intervention that a pre-siding physician orders at the first sign of “mental illness” detectedduring a routine visit or perusal of an integrated database.

These are not two different systems; rather, they are polarizeddescriptions of the same future, one that draws nearer every day.Noted psychologist Charles Kiesler (2000)—who in the mid-1980spredicted that fledgling managed care organizations would dominatethe U.S. health care industry—predicts that mental health services willsoon be integrated into medical patient care and administered accord-ingly. The reason for this coming change, of course, is the tremendouspressure on health care administrators to reduce spiraling costs. Manyhealth care prognosticators believe that the cost-cutting measures ofmanaged care have already realized all possible benefits and only atotal 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 ofphysician visits stem from psychological distress or are at least exac-erbated by psychological or behavioral factors. In addition, those diag-nosed with mental “disorders” have traditionally overutilized generalmedical care and have incurred the highest medical costs (Tomiak,Berthelot, & Mustard, 1998). Combine these well-known facts withthe rather extensive evidence that the delivery of psychological ser-vices offsets the cost of medical care (Sanchez & Turner, 2003)—and

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voilà, integrated care is the greatest thing since sliced bread. Cum-mings (2000) suggested that a mere 10 percent reduction in medicaland surgical care resulting from behavioral care intervention wouldexceed 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 healthcare—and of course, saves insurance companies and public funders aton of money.

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

The resulting influx of potential mental health clients into the pri-mary care setting will further promote the conceptualization of men-tal “disorders” as biologically based and increase current trends towardmedication solutions. Indeed, a recent large national survey of pri-mary care physicians revealed that antidepressants were the treatmentof choice for depression 72 percent of the time, compared to only38 percent for mental health referrals (Williams et al., 1999). This is adisturbing trend, especially given what is known about the relativemerits of antidepressants (see Chapter Six). Parenthetically, physicianstypically diagnose depression in a thirteen-minute visit in which theydiscuss with patients an average of six problems (Schappert, 1994).

In this nightmarish vision of the future, the woodcutter in theAesop fable has already cut us down into fireplace-sized pieces, hauledus off, and neatly stacked us for consumption in the fires of the med-ical model of integrated care. And what is so bad about the medicalmodel? Nothing when it is applied to medical conditions and noth-ing as one among many options to address the concerns that clientsbring to our doorsteps. But as a privileged or mandated practice in

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