National Board for Certified
Phyllis Watts, Ph.D.
Psychology and managed care are engaged in a conversation. It is a national conversation and an incredible one. The discussion, conversation, argument is not only about economics or the industrialization of health care. It is, at its deepest level, a conversation about soul--a fight for the soul of our profession. And, I believe that unless we can come to see that, we will miss the essence of what is happening and our deeper role in this unfolding drama.
For me the conversation is about values. It is a conversation about nothing less than how we conceptualize life. In this conversation, we as psychotherapists are the ones who must carry an understanding of the sacredness of the therapeutic process, of the therapeutic relationship, of the soul, and of the essence of our work. It is not the job of managed care, nor that of our clients.
Yet, when I look around, I do not see us claiming what is ours to claim. This, I think, is due to our fear and anguish and our highly individualistic natures. Perhaps most important it is due to our forgetting the values and yearnings that brought us to the profession. Fear is being used to get us to comply rather than to reflect, analyze, and organize a coherent response. For me the question is not, "What will managed care pay for?"; but, "What is our role, our responsibility to our clients, our profession, ourselves and our society?" We are not just "providers," we are psychotherapists. The function we serve in this culture is essential.
The archetypal or collective power of our role for our culture is enormous. If we forget this, just tell a stranger what we do and watch the response. Often it is one of fear mixed with wonder, because the role itself carries the huge mystery and compelling curiosity of moving into the deeper realms of life, for which I see a true hunger in our culture. There is a yearning for connection with self, with others and with life that the values of our material world don't fulfill. For me, a central part of our task is to facilitate a movement for our clients toward wholeness and the fullness of whom one is, whatever the capacity of the client, whatever our theoretical orientation. With managed care, it is a task we are less and less able to accomplish.
Evolution of managed care
During the late seventies there was a huge push in our field to be able to receive third party reimbursement. We wanted parity with psychiatry. But, in order to have parity we had to become more indentured to the DSM as the conceptual frame from which we would operate. We had to accept it as the map of the territory of psychological functioning. People who consulted us had to be "patients" and we had to "treat" them. Because of the path we took, we came to be viewed by the general public as part of the medical establishment.
There were pluses to using the DSM as the map; namely a burgeoning of our field and an increase in access to psychotherapy. There were also many minuses in that it entrenched the stigmatization of psychotherapy as being sought only for mental illness. And, it devalued it as something one would pay for oneself. And why would you, if it means that you are mentally ill, if that is the map? It was not about cultivating the value of working on oneself, but about weakness, dysfunction, pathology. Also, it narrowed for us the map that we were using to chart the territory of human well being and human suffering, until we would forget . . . and begin to think that the DSM wasn't just a map, but in fact the territory itself. We have a nine hundred page book that describes for us "mental illness." But we do not have one mutually agreed upon sentence that describes mental health. Why do we as therapists not notice this? Abraham Maslow was reputed to have once said that there were really only three important questions in psychology; namely, what is the healthy individual, what is the healthy society, and how do we get there as soon as possible?
The issue isn't just the economic market or the industrialization of health care, but values. People in our culture have always tried to find the money to pay for what they valued. Though, what is mostly valued in our culture is image rather than substance. If we were driven to acquire self development, interpersonal development and community development in the way we are driven to acquire material development, what a different society this would be.
Psychology's values, managed care's values . . . an unholy alliance
The values of managed care fundamentally differ from those of psychology. We are being encouraged to develop our primary relationship with the managed care company rather than the client. From their perspective, the relationship between therapist and client is tangential. Yet, the most prevalent, consistent finding in outcome research is the importance of the relationship, irrespective of theoretical orientation.
For me, the world view of managed care is essentially a fundamentalist one. There is an extreme demand for conformity on the part of the therapist and regimentation in working with clients. There is a strong focus on pseudo-science and the language of science to legitimize their reimbursement policies. Managed care views the person as a machine and uses industrial, technological metaphor rather than organic process metaphor to define what we do. We are "providers," essentially technicians, who are being required to dispense "units of treatment" to "patients" in the proper "dosage." But, we are not machines. We are living organisms. And we have internal lives that have meaning and that guide and shape our external lives . . . whether or not we acknowledge it. What's more, I am not a "provider". The whole notion of "generic-izing" our profession--renaming us, truly devalues who we are and what we do. I am a psychologist and I practice the art, craft, and science of psychology through psychotherapy, organizational consulting, teaching and writing. Managed care is asking us to turn therapy into manufactured white bread. It all looks the same, it all tastes the same, there is little texture, substance, aroma and nourishment. It doesn't fill the soul.
Language, and who controls it, is the central defining issue in the battle with managed care because of what is happening historically at this juncture. Currently western culture is at the cusp between two eras. For the last several decades we have been leaving the modern era and moving into postmodernism. There are profound and complex implications for this vast cultural shift (too numerous to name here), but the most central for therapists is the change in the cultural view of the importance of language. In the modern era, language was seen to merely describe reality, if used "objectively." In the postmodern era, language is seen to create reality and there is no such thing as pure objectivity. New theories are emerging that reflect this change in eras. In the more behavioral domain there is "solution oriented" and "narrative" therapy and in the psychodynamic domain there is the "inter-subjective" approach.
It is this pivotal shift that is central for us to understand in our struggle with managed care. We are not being asked to merely fill out a form, but to enter their reality, and to act as though our reality and our values don't exist. We must use their language, their standards, their way of conceptualizing in order to "relate" to them. In the postmodern era, who controls language controls reality. In fact, in this new era, it's all about competing realities and different voices vying for dominance in the cultural milieu. So, it is extraordinarily dangerous to give up our voice. Yet that is the crux of what is happening to all of us.
So how do we invigorate the soul of our profession? First we must remember our roots and shift to a broader paradigm of psychological functioning. This is essential. Then understand that it is through the replication of ideas . . . how things are defined, described and repeated . . . that attitudes, opinions and values change. Our market isn't managed care--it is the general public. But how we are positioned in the minds of the general public is problematic. Psychology must come to people in a much more direct, personal and non-stigmatized way. At a cultural level we must work to develop the value of psychological understanding and awareness. This is done through workshops, articles and lectures on issues outside of "mental illness." It is done through developing public relations campaigns that let people get to know us in human ways. It is done through using research to shape public policy in regard to its impact on psychological well being. It is done through writing, faxing, e-mailing and phoning media representatives when we see our profession or the value of psychological awareness being denigrated or misrepresented and when we see it valued. It is done through developing a creative matrix at local, regional and national levels out of which we stimulate ideas, actions and support. It is done through not losing heart.
I truly love psychology. But I believe we have lost our way and are in danger of losing much more if we forget to remember our roots, to know our responsibility and for each of us to find where we stand . . . then to have the courage to act from that stance.
Earlier versions of this article were published in 'The National Psychologist' and 'California Psychologist.'
Phyllis Watts, Ph.D., has practiced psychology for the past two decades through psychotherapy, organizational consulting, lecturing, teaching, writing and her own self work. Throughout this time she has had and continues to have a fee for service practice. Her interests encompass the role of the feminine realm of experience in our culture, the relationship between psychotherapy and spirituality, the psychological impact of the postmodern era and dance as the embodiment of soul. She is the president of Wild Swan Resources.
You may write her at 3010 "I" Street, Suite 1, Sacramento, CA 95816.
Phone: 916-447-7463, fax: 916-421-6919, e-mail: firstname.lastname@example.org.
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