The
Incorporation of Holistic Treatment into a Brief Treatment
Framework
By Tammie Byram
Fowles, MSW, Ph.D.
 Sharon
is 27 years old. She doesn't plan to be 28. She is lonely, and
hurting and desperate. She’s decided as a final attempt to seek
counseling; however, the few counselors covered by her insurance
company all have waiting lists. She also understands that her
sessions might be limited to as few as three sessions. The soonest
she can be seen is three weeks from now. She isn't sure how she will
make it through the day. She contacted a crisis line only to find
that the line had been disconnected.
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.
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