© 2016 Gary E. Bloom
- Guide Blurb
- How to Read This Book
- Marriage and Family Therapists
- Mental Health Counselors (Professional Counselors)
- Social Workers
- Counseling Professions Summary
- Credentials — Grad School
- Credentials — License and Practicum Laws
- Game of Thorns (MHS pt 1)
- Economics 101 — MHS (pt 2)
- Systems Theory (MHS pt 3)
- Continuing Education (MHS pt 4)
- Records and Privacy — (MHS pt 5)
- Counseling (finally!)
- How to Have a Career
- Appendix — Evidenced Based Practice
- Appendix — Counselors and Integrity
- Appendix — How to suck as a counselor — ignore that person in front of you
- Appendix — The psychotherapy of Doc Martin, by Dr. Rachel Timoney
- Appendix — Jailhouse Rock, a brief intervention
- Appendix — How to Work With Schizophrenics
- Appendix — Playing the Black Card
- Appendix — Psychotherapy as car reviews
- Author Blurb
I wrote A Personal Guide to Working in the Mental Health Field to help those considering counseling and psychotherapy as a profession and for those early in their clinical career who might like help with a career direction. I call it a personal guide because I make no attempt to pretend that I’m a dispassionate observer.
I had a long, varied career, which started at age 18. Before I earned a bachelor’s degree, I had worked with autistic children, drug-using teens and young adults, and with severely-disturbed patients in a locked mental health unit. Following attaining my license in marriage and family therapy, first in California, then in Washington State, I worked in residential treatment for schizophrenics, emergency services, outpatient clinics, an HMO, and private practice. I have also taught a few grad-school classes and dabbled in supervision. In my later years, I have moved my focus to having strong opinions.
While shorter than the average non-fiction book, I think this guide is a great value. Let me give you an example: The section on records and privacy, a mere thousand words, represents about $750 in trainings, an additional 40 or so hours in independent research, and several trial-and-error solutions on my part. That it will take you only five minutes to read is not a bug, it’s a feature (especially, if you take advantage of the resources listed on my web site). There are many other examples in the guide that represent similar effort on my part — a lot of time-consuming research so you don’t have to..
I would like to thank my friend and colleague, Denise Hie, MA, LMFT, who inspired me to write this guide and has provided many critiques. And I wish to thank my wife, Joan McGinnis, MSW, LICSW. A comprehensive account of her support would double the size of the Guide. However, neither should be held responsible for guilt by association. The opinions in the Guide are mine and mine alone. Even under severe duress, no one else would admit to these opinions.
How to Read This Book
It’s in English, so left to right.
In the 60s and 70s, my father had the largest counseling practice in the San Fernando Valley. Note that, when he started out, the largest practice in the Valley might have been three clients. At the time, the good news was, as the 17th licensed psychologist in California, he had little competition. The bad news was there were few customers seeking help for emotional, marital, or family issues. As a pioneer, he had to help invent a little known professional service that would capture the attention of those in need.
During World War II, psychiatrists were pressed into service as physicians; clinical psychologists took over the responsibility to treat soldiers’ emotional problems, primarily PTSD (then known as shell-shock). But their role in the armed forces aside, hardly anyone knew what a clinical psychologist did.
Following the war, and a move from Chicago to Los Angeles, my father spent years marketing his practice, educating people on how his work could make their lives better. Eventually, it paid off, as he developed a full-time practice.
As my father’s practice expanded, my life didn’t change much. Though we moved from living with relatives to moderately large homes (by that era’s standards), there wasn’t any upgrade in family cars, let alone cars for teenage boys that would elevate my status with high school girls. What I gleaned from my father’s success were some false premises about a career in the counseling business. This is what my father’s practice looked like to a kid: step 1, you train to be a therapist; step 2, you go to your office daily to serve your large clientele; step 3, you send invoices at the end of each month; step 4, deposit checks, paid by grateful clients; step 5, enjoy the steady income and professional respect.
Though I grew up in the household of a pioneering psychotherapist, what I missed was the part about building a practice. And what I couldn’t anticipate is that only the first step would remain relatively fixed. My intended profession would evolve into something entirely different from my father’s experience: marketing a counseling practice became less like giving an educational talk in a library and more like trying to be heard above the din in a football stadium. While I didn’t have to invent the profession, I had to compete vigorously in the bizarre bazaar1 of pioneering counseling practices, and many of those practices were wrapped in packaging that was better than the product.
The most unprepared change for me was that, while in my father’s time, clients came armed with problems and insecurities, in my era, clients came armed with problems, insecurities, and insurance forms. I was prepared and confident dealing with the first two, not so with the third. While as an MFT, I initially cheered the professional recognition that insurance coverage meant, with its accompanying boon to private practice, I wasn’t a proponent of the medical model that insurance coverage brought to marriage and family therapy.
Don’t chase a mirage
When you’re young, you don’t understand how quickly change comes, or that what you saw was a mirage. Part of my attraction to becoming a counselor was the rarity of practitioners, but when I was in college, budding clinicians had become as rare as Beatles fans (if you’re a millennial, read that as rare as Taylor Swift fans). By far, the most popular major at my undergraduate school2 was psychology. The territory I considered my birthright turned out to be public property.
While much has changed since I became a counselor, what hasn’t is that I see budding counselors going into a field that’s very different from what they envision. Your motivation for joining the profession may stem from a counselor helping you through a difficult transition; or because you’re regarded as a good listener; or you’ve been lauded for your parenting advice; or you have contended successfully with a serious emotional or substance abuse problem of your own. Unfortunately, one or more of those gratifying personal experiences does not mean you know what you’re in for as a future clinician. If the counselor you saw was in private practice and had a nice fancy office, you may have gotten the wrong idea. The mental health profession is much like professional baseball, where you have a minority of players who do really well, and many who never get past the minor league system. To make good in either, combine talent, hard work, and a bit of luck.
A couple of issues to note before we get started. First, this guide is designed to be read through or as a reference. Hence, you will encounter occasional redundant information (and I’m afraid, even occasional redundant jokes). Second, some readers may view my criticism of psychiatry and the pharmaceutical industry as over the top; I think I used restraint. The influence of psychiatry on the mental health system is akin to the toxic influence of oil spills on marine life. You may disagree with me and write your own book. Third, I use the terms counselor, and psychotherapist, interchangeably. I consider the disagreements over the meanings of these terms a religious battle. In this quarrel, I’m agnostic. Finally, the tone of this guide may seem cynical, but that’s not my intention. My intention is to give prospective counselors a realistic window into what lies ahead in the field. While my criticisms are not there for fun, for the benefit of the reader, I try to have fun with how I make them.
Marriage and Family Therapists
In my early post-college years (the 70s), the most common precursor for the break-up of the marriage of one of my friends or acquaintances was that one or both members of the couple entered individual psychotherapy. “Personal growth” rather than stable relationships was all the rage in that era, especially for those on the path to practice marriage and family therapy.3 Left in the wake of the personal-growth fad was the refuse dump of starter marriages, with the accompanying new trend of shared child custody.4 What about the children? They were compensated with the same number of bedrooms as they had (biological) parents and could practice playing one parent against another, a skill that would become useful later in life when they got competing job offers from the New York Yankees and the Boston Red Sox.
When psychoanalysis5 dominated the definition of psychotherapy, psychotherapists believed that the path to mend rifts between members of a couple was to have them, separate from their partners, sit or lay on a couch and talk about their memories of childhood. Starting in the 40s, a few psychoanalysts recognized that, while psychoanalysis for a member of a couple might be the royal road to a comfortable income for themselves, it wasn’t usually the answer to heal marital problems.
Because these disenchanted analysts had no formal training in marriage and family counseling — there wasn’t any to be had — they had to make it up as they went along. First order of business in those days was to get all affected parties in the same room for sessions. Second order of business — well, there wasn’t any second order, because as I said, they had to make it up as they went along. Leaving the psychoanalytic model behind, the pioneers had only their confidence, charisma, hunches, and the knowledge that the old way didn’t translate to success in marriage and family counseling.
Fortunately, for both therapists and their clientele, ideas from systems theory, cybernetics, and hypnosis surfaced as a theoretical foundation for how families work not-so-well, and how to help them work better.
In 1964, California became the first state6 to issue a license to practice as a Marriage, Family, and Child Counselor. With California law as a model, the remaining 49 states followed. Around the same time, a doctorate degree7 became the necessary credential to get licensed as a psychologist. As a result, the marriage counseling license became the go-to credential for masters-level clinicians.
Ridiculous as it seems in retrospect, there weren’t any graduate programs to support marriage and family counseling as a profession. Clinicians8 qualified academically for the marriage and family therapy license (MFT) with a masters in either counseling or psychology. Far from the implied expertise or interest in couple and family counseling, most early MFT licensees focused on individual counseling — commonly, employing psychodynamic (Freudian), Rogerian, or other individual-oriented approaches. The MFT license preceded a practical path to training as an MFT, and a generation of licensed MFTs was that in name only.
Beginning in the late 70s, first in California, graduate programs in marriage and family therapy began to spring up. Infused with a pioneering generation that studied how to understand and work with family systems, marriage and family therapy became an approach and profession in its own right.
In sum, three generations of MFTs had distinct experiences: The first were mostly psychoanalysts who pioneered a new approach to help with emotional concerns that originated in one’s family. The second were largely motivated by a shorter-term educational investment in earning a license to practice: they were apt to identify themselves as psychotherapists, rather than as marriage and family counselors. And, finally, came clinicians who were both motivated to be, and trained to be, MFTs.
Mental Health Counselors (Professional Counselors)
“It’s the same thing, only different.”
The profession of mental health counseling came out of the soup of vocational counseling, school counseling, and other loosely identified helping professions, but now has little to do with those specializations. The first state license for mental health counselors (MHC) was issued in 1976, a dozen years after that of the initial marriage and family therapy (MFT) license. It was not until 2009 that the MHC license became available in all 50 states, the District of Columbia, and Puerto Rico.
I have my doubts there would have been a MFT license if licensing of MHCs9 came first. As I stated previously, the first generation of licensed MFTs (in California) were motivated not by creating a new profession, but by being able to qualify for a license to practice psychotherapy with a masters degree. If the MHC license came first, I believe that marriage and family counseling would be a theoretical foundation, like Jungian Analysis, or Person-Centered therapy, rather than a separate professional license. As it is, there’s little to separate masters-level counseling professions (which also include MFTs and social workers) at the licensing level. They all have the same clinical privileges and responsibilities. All masters-level clinicians in most states10 can treat mental illnesses as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) and qualify for health insurance reimbursement11. All have the same responsibilities for record-keeping and the same client/therapist confidentiality privilege. They are so similar at the licensing level that an integration, as it has been done in Nebraska,12 may eventually become the norm.
At the clinical level, there are different emphases:13 The theoretical foundation of MFT educational programs emphasizes systems thinking. The focus of treatment14 in MFT programs is couple and family therapy or individual counseling that focuses on relationships. In contrast, mental health counseling programs are similar to those masters programs in psychology developed in the 50s and 60s, which emphasized diagnosis, testing, abnormal psychology, and the medical model. Treatment emphasizes insight-oriented individual therapy, and group therapy. In short, those wanting to become MFTs tend to think in terms of issues between (and among) people, while mental health counselors tend to think in terms of issues within an individual — typically, psychodynamic issues.
MHCs share another aspect with MFTs and social workers in that they act as junior psychiatrists within the mental health system. As stated previously, medical insurance reimbursement requires a DSM diagnosis, which uses the medical model, which puts psychiatry at the top of the mental health food chain. To some extent, insurance reimbursement has made every clinician psychiatry’s bitch.15
If you prefer to work with just individuals, you’ll probably fit better in a MHC program than you would in a MFT program. However, nothing in a MHC program or training will preclude you from exploring whatever theories or counseling approach eventually stimulates your interest.
The late George C. Scott, legendary actor, ex-Marine, and real-life brawler, once played one of the toughest characters ever seen on the screen. No, I don’t mean that one. I’m referring to Neil Brock, New York City social worker, on the short-lived Eastside/Westside TV series.
Social workers don’t usually look as tough as George C. Scott. They look more like my wife, my sister-in-law, my cousin, and some of my friends and former co-workers (who all happen to be women). While social workers might not look tough, they have some of the toughest jobs around. They monitor and help children who live in disastrous family situations, empathize with the relatives of the sick and dying at hospitals and in Hospice care, and work with the elderly and otherwise infirm. Good social workers combine compassion with the kind of mental toughness that doesn’t hide in camouflage fatigues.
Social work started as a movement to alleviate the suffering of the disadvantaged, whether that suffering was due to poverty, sickness, homelessness, or other unfortunate circumstances. Aside from church charities, what is now known as social work was the first organized such effort. A glance at any issue of NASW’s16 newsletter suggests that the profession hasn’t strayed far from its roots as advocates for the less fortunate.
The most common job for a social worker is still as a liaison and mediator among resources that provide assistance to those in need, but many also practice counseling. Legendary family counselors, Virginia Satir, Insoo Kim Berg, and Steve deShazer were social workers.
Social work has practical advantages over other masters-level counseling professions: First, if you get tired of one direction in your career, you can change your focus. Social workers operate out of hospitals, child welfare agencies, geriatric services, mental health centers, and other service organizations. Second, the masters degree (MSW) is a terminal degree, i.e., you can get licensed as a social worker with it, in all 50 states.17 Getting a doctorate (DSW) is only important for those who wish to teach at a research university.18
On the downside, much of the base curriculum in MSW programs will not be useful to a counseling-focused career. While you can find counseling-focused MSW programs, you’ll have fewer choices than with MFT and MHC programs.
If you’re considering social work, the main questions to ask yourself are the following: (1) Is there a suitable MSW program close to where you live or are willing to move near? (2) Is there a likelihood that you’ll make use of the multiple career choices open to social workers? (3) Do you require the lower expense of a state school? As an older profession, MSW programs are more available in state schools, while MFT and professional counseling programs are mostly private. Hence, programs for a MSW can be cheaper, while MFT and mental health counseling programs will be easier to get into.19
If you can find relevant training, social work gives you counseling-related career choices second only to that of psychologists.
“None of you understand. I’m not locked up in here with YOU. You’re locked up in here with ME.”
Can a psychologist read your mind? Some people used to think so. I’ve been in close quarters with a few psychologists in my time, and they weren’t reading minds. Like the rest of us, they were reading Facebook. The supernatural skills of psychologists are non-existent. Sometimes, the natural skills aren’t that good either. I’ll get to that.
As with most professions, the invention of modern clinical (applied) psychology didn’t arrive whole. It trickled in from experimental psychology and other domains to help in areas that it’s still identified with: learning disabilities, IQ and personality testing, and counseling for emotional problems. In the United States, the chief catalyst for its current status arrived during World War II. Because psychiatrists were busy playing real doctor (treating war injuries), psychologists took over the treatment of war-generated emotional afflictions — specifically, “shell shock” (now known as post-traumatic stress disorder, or PTSD). With their couch21 in the door, psychologists were able to parlay their new-found clinical status into state licensing laws, and they eventually became the first non-MDs to be reimbursed by medical insurance.
To become a psychologist, you must first earn a doctorate in psychology, either a Ph.D or a Psy.D.22 Ph.Ds are most appropriate for those who envision a career as a professor at a research-oriented university — running a mini-fiefdom, with research grants and grad students to service it. Because of significant competition, the maze to that kind of career has increasing twists and turns, and the cheese at the end is less likely to be Roquefort and more likely to be Cheese Whiz.
In recent years, the more direct path to becoming a clinical psychologist is to go for the Psy.D.23 Psy.D programs were created in the late 60s and early 70s to produce psychologists with a stronger background in clinical work. In a Psy.D program, you spend less time devoted to pure research and more time devoted to research that’s directly related to counseling and psychotherapy. You spend less time reading dusty old classics that are trying to retain some dignity (though Half-Price Books won’t pay a dime for a shelf’s worth) and more time reading articles and books on evidenced-based practices. Finally, you spend less time with professors who have never done counseling and more time with those who have a clinical practice.
A Psy.D is the practical path to train as a clinical psychologist, except for one drawback — you are more likely to get significant financial help (grants, not loans) in a Ph.D program than in a Psy.D program. Servicing the professor’s fiefdom has its rewards.
The Special Theory of Psychologists
In theory, clinical psychologists should be the most capable of all psychotherapists. They’re the doctorate-level clinicians whose many years in school are oriented towards the study of people problems rather than studying chemistry and cutting up cadavers.24 They engage in original research on human behavior,25 write a book-length paper in double-secret jargon (the dissertation) on that research, and serve an internship that includes learning to do extensive psychological evaluations as well as the training to be a psychotherapist.
Are the so-called “scientist/practitioners” of the counseling field the most capable of all psychotherapists? Not necessarily. Some of the academic hoops, especially ones that school geeks excel in, are irrelevant or even antithetical to the primary goal of counseling people. Not every clinician wannabe is capable of combining the nose-to-the-grindstone focus of completing a doctoral program with the resourcefulness and creativity necessary to help human beings deal with problems in living. Being good at school is not the same as being good with people.
Students in four-year colleges are primarily taught by cheaply paid instructors and grad students, while tenure-track professors engage in research and write papers, in partnership with their grad students. If you wish to get that Ph.D, you’ll be one of those grad students who is teaching and working on the professors’ research. Along with assisting your professors, you’ll have to do research for your own Ph.D dissertation. In other words, to get a Ph.D, you’ll have to enlist in geeky academia for a duration longer than the U.S. involvement in World War II.
The General Theory of Psychologists
On the other hand, being good at school means that psychologists are at least good at something. There are masters-level programs (primarily, in professional schools) where the sole admittance criterion is whether you can pay the tuition.26 In my brief (and uncelebrated) time teaching masters-level grad students, I had some who belonged and some who must have received their baccalaureates from Santa Claus — at least the ones who weren’t naughty.
On the whole, for the aspiring clinician, becoming a licensed psychologist — if you want to put in the time and money — is the most reliable route to a successful and interesting career in clinical work. Psychologists enjoy vocational and income opportunities well beyond masters-level therapists. A doctorate in psychology can be the path to numerous professions: college professor, organizational or educational consultant, technology researcher in user interface design, forensics to assist law-enforcement or lawyers, advertising (which was invented by the nephew27 of Sigmund Freud), or any field that uses knowledge of human behavior.
“It has been said of psychiatrists that they studied medicine but don’t practice it, and practice psychology, which they never studied.”
You’ve seen enough TV and movies to get the picture that psychiatrists are either psychoanalysts or serial killers. That’s inaccurate: First, only a minority of psychiatrists still practice any kind of psychotherapy. Second, most present-day psychiatrists I’ve met aren’t clever enough to get away with even one murder, let alone a series.28
Since they’re no longer therapists, and any physician with bad handwriting can dash out a prescription, what is the role of psychiatrists in today’s mental health system? I’m going to offer three points of view:
Psychiatrists are the angels of mercy, who relieve the suffering of the mentally ill. Guided by the latest edition of the scientifically validated Diagnostic and Statistical Manual of Mental Disorders (DSM), psychiatrists diagnose mental illnesses and prescribe psychiatric medicines that carefully target and correct genetically-determined chemical imbalances.
Psychiatrists are the unconventional-people police. Unpredictable people are scary: they act weird in public places; they purposely overdose on drugs; and they stop eating, bathing, and otherwise caring for their well-being. They also scare or bother their own family members and annoy disinterested strangers. Psychiatrists take these unpredictable people off the hands of other doctors and/or family members by zapping these unpredictable people with medications and guiding them into hospital wards.
Psychiatrists are drug dealers: Psychiatrists hawk drugs that (1) relieve people of inconvenient emotions that result from relationship conflicts, work stress, financial downturns, and other common occurrences of modern life; (2) suppress unconventional behaviors (see above); and (3) manage children’s backlash to the antiquated character of the modern classroom.29
I contend that, if not for the protective influence of the American Medical Association and American Psychiatric Association, the psychiatrist’s role would become increasingly challenged, perhaps even significantly diminished. Maybe we’re already on that path. As a profession, psychiatry is under attack for being ineffective and for having dubious ethics. The psychiatric approach starts with a diagnosis using the latest DSM, but the accuracy of that method has been recently questioned by the National Institute of Mental Heath (NIMH) to the extent that the NIMH has withdrawn research funding. That is a very big statement. Along with being ineffective, the profession of psychiatry is also under attack for being in bed with Big Pharma and for partnering with drug companies to expand the industry of mental illness. Any profession that was less influential than psychiatry would have a hard time surviving similar questions of effectiveness and integrity.30
It wasn’t always like this. Psychiatrists were once pioneers — first in Europe, in the first half of the 20th century, starting with the obvious figure of Carl Jung (his mentor, Freud, was a neurologist), but even more so in the United States during the second half of the 20th century: Harry Stack Sullivan was a pioneer in looking at mental problems as stemming from problems between people rather than from intra-psychic conflicts; Milton Erickson’s form of hypnotherapy is a primary influence on modern brief therapy; Fritz Perls founded Gestalt Therapy; Aaron Beck invented cognitive-behavioral therapy; many within the family therapy movement, such as Nathan Ackerman, Murray Bowen, Carl Whitaker, Don Jackson, and Salvador Minuchin have been psychiatrists; and some, such as R.D. Laing and Thomas Szasz, were even primary figures in the anti-psychiatry movement.
The culture of psychiatry has obviously changed and Big Pharma, big insurance, and big lobby have a coordinated influence in that change. They’ve grabbed most of the territory in the mental health field31 (at least the lucrative part), by defining all psychological problems as biologically determined, and hence, insurance reimbursable. Psychiatry is more about self-promotion than client well-being.
What if you still wish to be a psychiatrist who practices psychotherapy? The psychiatric intern with visions of couches in her head isn’t going to find many residencies that focus on psychotherapy. You’re probably going to have to find training on your own, after you’ve completed four years of medical school and four years of residency. Considering that you’ll already have a school debt of a couple hundred-thousand, what are the chances you won’t say, “screw therapy”?
So, why become a psychiatrist? Tough question. For the relatively easy money? Maybe, but with the concern over healthcare costs, cheaper alternatives might prevail: First, psychiatric med reviews aren’t that hard and psychiatric nurse practitioners are a cheaper alternative to psychiatrists. Second, four years of med school doesn’t contribute much to learning to be a psychotherapist. No matter how many cadavers med students dissect, they aren’t going to locate the id, ego, and super-ego. Don’t expect psychotherapy referrals from insurance reimbursers; psychologists and counselors are cheaper. If you’re going to be in the counseling profession, the best reason to be a psychiatrist is so you don’t have to be condescended to by psychiatrists.
Counseling Professions Summary
Consider marriage and family, first, if you wish to focus on couples and families, or you view problems primarily as conflicts between people. Consider mental health counseling, first, if you wish to work primarily with individuals, view problems as mostly conflicts within oneself, and can’t spend the time and money to get a doctorate in psychology. Consider social work, first, if you wish to have the versatility to change professional direction and the security of a broadly recognized degree. Consider psychology, first, if you wish to have a large variety of ways to earn money within a single vocation, can and wish to spend sufficient years attaining the degree and license, are sufficiently good at school, might wish to teach college, and will enjoy the prestige of a doctorate-level professional. Consider psychiatry, first, if you’ve earned your MD, but discovered that you weren’t good at medicine, wish to make a lot of money32, are motivated to be one of the few good psychiatrists, or heroically wish to contribute to reforming psychiatry from within.
Credentials — Grad School
Until about 60 years ago, the lone qualification to practice psychotherapy and counseling was to find a sign shop that could fix you up with a nice shingle. Easy, right? Not as easy as you think. That was before Google and GPS. To find a sign shop, you had to either read a map or ask directions, and in those days psychotherapists were mostly men33 — who notoriously didn’t ask for directions.34 Then, licenses to practice came along, which required graduate degrees, which explains why this article will have very little information about sign shops and much about relevant graduate degrees.
Academic Training for the Professions
No grad school experience is going to train you beyond a basic level as a counselor or psychotherapist. If you want to become a good clinician, you’ll have to find your own training after you finish your degree. Nevertheless, your investment in time, money, and most of all, passion (or maybe, most of all, money), in pursuit of a graduate degree, should give you at least a rolling start. Here’s a look at the necessary schooling for the counseling professions.35
Imagine you wished to become a professional football player, and you were told the following would be required to make that ambition come true: First, study Newtonian physics,36 the science of forces and impacts, so you can understand the physical science of the game. Second, study the techniques for every position. Third, learn the popular offensive, defensive, and special teams strategies in vogue during the last two decades. Fourth, play minor-league baseball for several years. (Yes, I did say baseball.) Fifth, play football for a couple of months. Absurd, you say? Spend all those years learning theory (and much of it irrelevant), play a different sport for years, and football, only briefly? That’s supposed to prepare you to play professional football?
Yes, that would be absurd. And if you want to become a psychotherapist, and you take the path of psychiatry to get there, you’d be engaging in a similarly irrelevant path. Four years of med school, four years of residency — you’d have less counseling experience than a community college hot-line volunteer. In med school, you’ll be training for physical medicine.37 Four years of psychiatry training will give you practice in the deft wielding of a prescription pad. If you have your heart set on combining psychiatry with psychotherapy, be prepared for heavy competition for those few residencies that emphasize psychotherapy. If your goal is to become a psychotherapist, you’ll probably have to self-finance all the relevant training. Add that cost to the median school debt for MDs of more than $160,000. (Note that this and the following dollar amounts are current as of this writing.)
It’s hard to see it any other way: if you believe psychiatry is the on-ramp to becoming a psychotherapist, stop, you’re going the wrong way![^38][^38] Unless you plan to become a conventional (prescription machine) psychiatrist, who just dabbles in psychotherapy (and who wouldn’t want a dilettante for a shrink?), you should probably skip the MD.
Ratings 10 – 1 (higher scorers are better)
Training relevance (for counseling and psychotherapy): 2
Future income: 8
Training time: 1
If not psychiatry, what?
At first glance, getting a masters in either marriage and family therapy (MFT), counseling, or social work appears to be the practical (quick) route to getting on with your career. Getting a doctorate in psychology (a Psy.D or Ph.D) looks to be the long path, not as impractical as psychiatry, but still an unnecessarily indirect route to a counseling career. However, it’s not that simple. In most states, after you finish your masters in social work, counseling, or marriage and family therapy, you’re in for two or more years of supervised contact hours (typically, 3000 hours), before you can qualify to be licensed as an independent clinician. For masters-level clinicians, all those contact hours need to follow your grad degree.38 However, for example, in Washington State, while the requirement for psychologists is the same 3000 hours (total), all 3000 hours may be done before attaining the doctorate degree, if it’s accomplished during the required and approved internship.39 In short, the time from beginning your grad program to getting in all your supervised hours may not be much different for masters-level clinicians as it is for psychologists.
State licensing laws vary to the extent that, before you calculate the time involved to become a licensed therapist, you should figure the exact requirements for your state and your profession and understand precisely the supervised practicum requirements. It may change your mind about which degree to pursue.
If you’re contemplating becoming a clinical psychologist, there are various graduate programs to consider. Most states40 allow clinical psychologists to qualify for licensure by getting a Ph.D (Doctor of Philosophy) in psychology, a Psy.D (Doctor of Psychology), or an Ed.D (Doctor of Education) with a counseling emphasis. You must get one of these degrees from an accredited institution, which may be a public university (e.g., UCLA), a private university (e.g., USC), or a professional school (e.g., Alliant).
The advantage of a public university is lower tuition (if you’re a state resident) and opportunities for financing your degree by working as a teaching assistant and/or research associate. The disadvantage is that most of these doctoral programs will be for research-based Ph.Ds rather than clinical-based Psy.Ds. Private universities will be similar, but with far higher tuition, though Ph.D students usually get tuition grants.
Professional schools cater to those who are already working in the field, as they have pragmatic attendance systems; you can usually maintain your practice while you get your degree. Professional schools also provide an opportunity for those who fail to get admitted to a conventional university or college. Doctoral programs are extremely competitive, and those with primarily an interest in counseling, rather than in research and teaching, will have a far easier time getting admitted to a professional school than to a conventional university program. There’s a catch (and you knew there would be): tuition for professional schools is not subsidized by taxes or alumni donations, and the cost is, to put it in polite terms, prestigious. The doctoral certificate will be right at home on an extravagant engagement-ring setting.
For example, the tuition for in-state doctoral students at the University of Washington is a bit over $5000 (at the time of this writing) per quarter. But admittance to the psych Ph.D program includes paid tuition and appointment as a research associate or teaching assistant. At the California School of Professional Psychology, at current rates, if you complete your Psy.D in (the minimum of) four years (more than half take longer), the total tuition will hit about $128,000. Ouch! If you didn’t just sign a contract to be a cast member of The Walking Dead, that’s probably not sitting in your checking account (and if you did sign that contract, why are you reading this?).
According to the American Psychological Association, the median debt of a Psy.D grad is $120,000, a Ph.D research grad, $30,000, and Ph.D in “health service” (I presume, clinical psychology), $80,000. This is even with the stipend of between (about) $18,000 to 30,000 (annual rate) that is included in the mandatory internship.
With interest, the debt to attain a doctorate is closer to a mortgage than a car purchase, without the tax write-off. The average salary of a psychologist is between 70,000 and 75,000 thousand a year. The tax men and women will get a third of that. Hope for the invention of longevity drugs, so you’ll have time to pay off your loan.
Training relevance (for counseling and psychotherapy) Psy.D: 8; Ph.D (clinical): 7
Cost: professional school: 2; university (assuming research and teaching assistant grants, and tuition grant): 7
Future income: 6
Training time: 7 – 5
Master’s Programs — Social Work, MFT, & Professional Counseling
There’s now little difference in academic requirements for licensing social workers, MFTs, or MHCs. The state licensing boards 41 have settled on two-year graduate degrees as the minimum schooling needed towards a license to practice independently (that is, without supervision) for all three professions.
Masters-level grad programs have considerable overlap in coursework. The difference will be in emphasis. MSW programs emphasize the influence of socio-economic conditions of clientele. MFT programs will look more to systemic influences — especially that of the family system — as central causes of relationship conflicts that bring clients to treatment. Mental health counseling curriculum tends toward a traditional mental health approach that focuses on biological and psychodynamic sources of problems.
Because of the overlap of curriculum, if you’re considering a masters-level program, you should consider professional identity as less important than attributes such as the availability of quality internships. Field experience will be far more useful than classroom theory. Good supervision will provide more confidence and skill development than the particulars on your graduate diploma. Less tuition debt (than with doctorate programs) translates into being able to choose jobs based more on career interests than immediate salary.
Let’s look at the advantages and disadvantages of each type of program.
MSW program advantages
Recognized as a profession long before that of MFTs and MHCs, there are MSW programs that reside in large prestigious universities, with the perk that they will have a better choice of quality internships (and maybe paid ones).
If you’re a resident, your big state university will have far lower tuition than that of professional schools where MFT and MHC programs are commonly housed.
MSW program disadvantages
Your program will have fewer classes relevant to counseling and psychotherapy.
There might be fewer professors with clinical experience.
Admissions will be more competitive in large universities.
MFT program advantages
Family systems model of problems and treatment (if you’re so inclined).
A large variety of grad programs (especially in California) to choose from, including those in state universities.
MFT program disadvantages
High tuition in professional programs.
Difficult to find paid internships.
High-quality internships have lots of competition.
A wide range in program quality.
California dominates the number of training programs.
The least consistent licensing standards across states. Going to school in one state might not qualify you for a license in another. The AAMFT has created a national exam to assist states in designing licensing requirements, but it’s not as well accepted as the national exam for professional counselors (MHC).
Counseling program advantages
Choice of counseling program emphasis — substance abuse, or mental health.
A large variety of grad programs to choose from, including those in state universities.
Licensing requirements across states for MHCs are far more standard than those for MFTs. This is largely a result of more recent licensing legislation across states, and the common adoption of a national test.
Counseling program disadvantages
High tuition in professional programs.
Difficult to find paid internships.
High-quality internships have lots of competition.
A wide variation in program quality.
If you select and are admitted to an excellent and prestigious masters program, you’ll get good training, pay relatively low tuition, and you’ll move through it in two years. And you’ll have advantages in the job market. That scenario compares well with going the psychologist route. A handful of MSW programs best fit the above profile, but counseling and MFTs in state schools can come close. While you can make good money in private practice, working within a medical facility, or in some state jobs, typically, masters-level clinicians are poorly paid.
Clinical rather than research-oriented psychologists will be most comfortable in Psy.D programs. Professional schools for both masters and doctorates may provide an excellent school experience, but are expensive.
If you have your heart set on becoming a psychiatrist, I’ve probably lost you by now.
Training relevance (for counseling and psychotherapy) MSW: 3 – 6.5; MFT: 8; MHC: 6.5
Prestige: 4 – 5
Cost: 5 – 8
Future income: 2 – 5
Training time: 8
Credentials — License and Practicum Laws
In 1975, musician Paul Simon famously gave us 50 Ways to Leave Your Lover. The song our collection of distinct state health departments sing to aspiring counselors is 50 ways to make you run for cover. Think rap beat.
The most painful aspect of state licensing is state licensing. Most countries, such as Canada, have one national set of laws for health-care providers. While there are advantages to local governance, for example, when it concerns unique local economies, having 50-plus42 sets of laws that govern health professions doesn’t provide any obvious benefits, while the variance of these laws are painful to any health professional who moves to a new state. For example, at the masters level, a grad program that qualifies you to apply for licensure in one state may not qualify you to apply for licensure in a different state. And having a license in one state does not guarantee you’ll qualify for the same license in another state.
To illustrate: I received my MFT (then called MFCC) license in California in 1976 and moved to the State Of Washington in 1983, which at the time did not have licensing for masters-level clinicians. Between 1988 and 2001, Washington progressed through counselor registration, certification, and finally, licensing. As a Clinical Member of AAMFT and current MFT license holder in California, I was grandfathered (granted without further qualifying) into those licenses. Sometime in the 90s, I stopped paying dues for my California license. Here’s where it gets fun. If I were to move back to California, though a Clinical Fellow of the AAMFT,43 a Washington State licensed MFT, and a former California licensed MFT, I would not qualify for a current license. My graduate degree in psychology44 pre-dated MFT grad programs by a couple of years, and the curriculum reflected the traditional individual psychology emphasis. And even if my old grad program did qualify, I graduated too long ago for it to qualify me for a license.
I see one possibility for national regulation of healthcare professionals. Some counselors are working with clients over the Web but currently can only practice distance counseling within the state they’re licensed.45 That makes no sense — it’s distance counseling. I expect physicians will eventually want to do internet consults, and doctors get what they want. Voila! Interstate commerce, which is regulated by the Federal Government. In the meantime, I suggest the following:
(1) After you get your license, live in that state until you retire or die; (2) if you think you might move out of state, someday, attend a nationally accredited masters program or train as a psychologist or psychiatrist, whose licenses to practice translate easily from state to state; (3) If you get a MFT license, do your practicum supervision under an accredited AAMFT supervisor, even if all the ones in your area suck; (4) If you really want to move out-of-state, choose a state with reasonable license reciprocity, for example, South Dakota or Washington; (5) if there is any chance you’ll move back, keep up your old license.
If you enjoy crossword puzzles, Sudoku, riddles, Zen Koans, the IRS tax manual, and diving head-first into empty swimming pools, then you may enjoy decoding the practicum requirements for your mental health profession. The rest of you will not enjoy figuring the practicum requirements for your mental health profession. As I stated previously, various states have various requirements, and the assorted professions have assorted requirements. While clinical psychology licensing requirements for all the states appear to be offloaded to the American Psychological Association, inconsistencies and contradictions within a state licensing description may throw you off the scent.
My advice to figuring your practicum requirements: Along with trying to decipher your state’s website, check your professional association’s site; ask someone who was recently licensed (because requirements change); and ask at your school program. Do all of these as a cross check.
In my State of Washington, one of the requirements to become a qualified supervisor is 15 hours of supervision training. My wife, a clinical social worker with decades of experience took her training at an NASW-sponsored two-day session. Included in the session was the showing of a supervision video by the session trainers, who explained that they had lots of trouble finding a social work supervision video. Not hard to believe, because what they settled for should not have been a training video, it should have been a bloopers reel.
The video showed a social work student walking into a hospital ward, having a short and awkward initial session with a schizophrenic patient. Much of the encounter consisted of an obviously confused patient berating an obviously intimidated student social worker. The follow-up supervision session was like a re-enactment, except this time, with the supervisor berating the student. (There’s nothing like a good tag team to shore up a student’s confidence.) The student social worker responded to her supervisor as she was treated, as if she were a scolded child confessing her guilt.
In the discussion that followed, my wife suggested that the supervisor’s role should be to put students in situations where the students would be successful. At the very least, the students should learn something that will help in future sessions, and as the saying goes, at least, do no harm. It was apparent that the supervisor did none of that. What she did was set her student up for failure and humiliation. The lesson learned by the student was you’re on your own, and avoid mistakes at all costs, because you’ll pay for them in embarrassment. It wasn’t the student who should have been embarrassed, it was her supervisor. She had neither the student’s nor the patient’s best interests at heart. From all appearances, she was a bully hazing an intimidated student.
I expect that the supervisor my wife witnessed in the video would be a lousy supervisor for any intern.46 Unfortunately, there are going to be some of those. And I am sure there are going to be supervisors who are good for some interns, and not for others. There are also those precious few supervisors who I believe would be good for any student therapist, and in my first-year internship, I was fortunate to have one. I’ll discuss that below, but first I want to discuss my second-year supervision, which was useful in an unintended way.
Ich bin ein Berliner
For my second-year internship, I was placed in a clinic serving one of the wealthiest counties in the country. The internship program was run by a psychologist, Hildegarde Berliner, whose husband Bernard Berliner, a German-trained psychiatrist, helped pioneer psychoanalytic training on the west coast. Hildegarde Berliner, in turn, through sheer force of will, had turned this community mental health clinic into her personal psychoanalytic training institute. Though she was neither the agency nor clinical director, Ms. Berliner did not just run the intern meetings, she reigned over all clinical meetings.
The Berliners had fled their German homeland in the 30s to escape the Nazis. Prior to their move to America, Bernard Berliner had trained to become a psychoanalyst. Hildegarde Berliner (HB) once related an anecdote that shed light on the difficult relationship that developed between the two of us. In Germany, psychoanalysts-in-training attended classes that were called kinderseminars (children’s seminars), because those in training were regarded as children by their training analysts.
Bernard Berliner, a World War I vet in his 40s, and already an experienced psychiatrist, was viewed as a child by his training analysts. Though HB was educated as a psychologist in America, her attitude towards interns was obviously influenced by her cultural background and her mentor husband.47 In retrospect, I consider myself fortunate that she didn’t warm a bottle of formula for me.
Along with her cultural attitudes, HB had a second source of personal authority — the prestige that psychoanalysis still held in the mental health system. Many years before evidenced-based therapy reared its head to compete with medications for managed-care insurance bucks, psychodynamic-based therapy was still on top of the hill. Humanistic-based therapies appealed mostly to college students and those in extended adolescence. Cognitive and behavioral were still just dating, or meeting in secret48. And Big Pharma hadn’t yet imposed its will on the mental health system. Most psychiatrists still practiced psychotherapy — either psychoanalysis or psychoanalytic-influenced (psychodynamic) therapy — and as ever, psychiatrists had the highest status in the mental health system.49
It was typical, then (in the 70s), that psychodynamic therapy was still dominant in community mental health agencies. What wasn’t common was that no other approach was tolerated, even for discussion. Leaving behind the family therapy that I practiced in my previous internship seemed a step backward to me. At this fancy mental health clinic, both adults and children were always seen only in individual sessions. This was so, not just for interns, but for all the therapists in the agency.
Jumping into both the frying pan and the fire I, alone among the interns, had added to HB’s authority over me by choosing her as my individual supervisor. She and I clashed regularly; she didn’t trust my work. Rather than viewing her as support, I regarded her as someone who was in search of gotchas. At her insistence, I wrote post-session process notes, on which she marked mistakes with red pen.50 As with the social work student described above, I felt I was being rebuked as if I were a child.
I may have given you the impression that the root of my quarrel with HB stemmed from her psychoanalytic allegiance, but I was not yet invested in any theoretical orientation. I had several approaches on my nay list — Gestalt, the Skinner brand of behaviorism, Roger’s person-centered — and, beyond my admiration for Harry Stack Sullivan, little on my aye list. The root of my quarrel with HB was her that’s how we think here attitude.51
Looking back, I have to admit that I was, indeed, the dummy. I wouldn’t enter a Catholic church and argue with the priest that the Holy Trinity was but a point of view. Despite my belief that a community mental health agency should be secular, not the Church of Freud, it was what it was, and I was just an intern. More to the point, this agency had long served as one of the internship resources of my program. And despite my complaints, I profited from the experience, just for different reasons than a less headstrong intern might have.
My disagreements with HB became the initial catalyst for my thinking long and hard about approaches to psychotherapy, a habit that I have not shaken. In retrospect, I have accepted that I learned as much or more from a discordant experience as I would have from an additional harmonious one. I’m going to return to my first-year supervision and compare the long term effect as a contrast to my experience with HB.
I left my heart in San Francisco State University
“The cure for boredom is curiosity. There is no cure for curiosity.”
(From an interview with famous hypnotherapist, Milton Erickson, MD.)
Interviewer: Why did she tell you?
Erickson: Because I really wanted to know.
There’s a clichéd belief among the general public, as well as clinicians themselves, that counselors (in general) have superior listening skills. Not so much, unless that means superior at listening to their inner dialogue. During sessions, counselors are often pre-occupied with where their clients fit into their (the counselor’s) favored theory of personality, about transference issues, or which is the appropriate DSM code. While counseling programs explicitly teach listening skills, if a clinician isn’t already curious about what makes people tick, no class will change that.
When I was in my early 20s, I was unhappy over a break-up with my (then) girlfriend and wondered about my part in the failed relationship. At the time, I was in a masters program in clinical psychology, and being curious what my friends saw in the theories of Carl Jung, I decided to quench two curiosities with one experience. After some time on a waiting list at the San Francisco C.J. Jung Institute, I got an appointment with an “advanced intern.”
The therapist, a middle-aged woman, introduced herself and led me to her office. After discussing my above-mentioned relationship, and telling her of my concerns, we came to a lull. She didn’t follow-up on my concerns, so we sat awhile in nervous silence. Finally, she asked if I had any hobbies. I explained that I was an avid photographer. She proceeded to describe my photographs to me, expressing enthusiasm over the beautiful colors in the highlights and shadows of my nature photographs. To the seeming relief for both of us, our time was up.
The session both disappointed and amused me. My therapist seemed uninterested in discussing my relationship concerns but perked up only when describing my photographs. I assume her intention was to segue to an interest in my creative side (a focus of Jungian analysis), but this resulted in the opposite effect. I did not take pictures, as she described, of natural settings in color; I took pictures of people in black and white. The photographs she enthused over existed in only her fantasy. From this first (and only) session, I concluded that the therapy would be about her interests and concerns rather than mine.
Unsurprisingly, many counselors become interested in psychology because of deep questions about themselves that stem from a difficult childhood or life crisis. An encounter with a helpful counselor may have been the catalyst for their career path. Nothing wrong with that; there would be far fewer counselors if that weren’t the case. Unfortunately, not all counselors make that transition from curiosity about self to curiosity about others.
Recently, I looked back on my masters paper, written 36 years ago, and realized that the young me might have some wisdom for the old me. My masters paper was on therapy supervision. During my first-year internship, I was placed in a child and family clinic in Daly City, just south of San Franciso. I had group supervision with eleven fellow masters students in the San Francisco State University clinical psychology program, and individual supervision with (the late) Professor Robert Suczek.
“What’s your concern?” That was Dr. Suczek’s primary verbal contribution to the supervision hour. He remained mostly silent while I talked. Occasionally, he’d ask a question. Now and then, I’d express my curiosity regarding his theoretical orientation, and he’d invariably reply: “My name is Robert Suczek. My only goal (as a therapist) is to understand.”
There were times, in these supervision sessions, when I’d worry aloud whether I should take on a certain client — especially those who expressed great anxiety that their counseling sessions (with me) would be their last chance (to make it). “Why should their last chance be entrusted to me, a fledgling counselor?” I would want to know. Dr. Suczek would reassure me that I’d do fine, that I’d figure it out. How would he know that? Where did his faith come from?
I believe that Dr. Suczek had an unshakable faith in both the resources of clients, and of student therapists.52 His expectation, that I could and would muddle through to be of use to my clients, was as much or more of a signal of respect to clients as it was to me as a novice therapist.
Sesame Street invented the game one of these things is not like the other. The concept of isomorphism is the opposite: it means that one process is the very model of the other. For example, family systems models were originally discussed primarily as isomorphisms of natural ecological and cybernetic systems. I believe that the most important aspect of early supervision is the isomorphism between therapy and supervision. The attitudes supervisors display towards interns are likely to get passed on as attitudes interns display towards clients. And these attitudes are likely to be persistent throughout a counselor’s career.
If as a supervisor you focus on diagnoses, symptoms, resistance and other demeaning caricatures of client behavior, you’ll pass that on to those you supervise. If you focus on the normality of interpersonal problems found within all human relationships and the resources that most clients have to make these problems diminish with a bit of effort, you’ll pass that on to those you supervise. I believe that, early in our training, the attitudes we bring to practice with our clients are far more important than specific therapeutic approaches. While there are some approaches that embody respectful attitudes and expectations to a greater degree than do others, I think the differences are more within individual practitioners.
The Red and the Black
In the early days of personal computers, software games came with various sorts of pirating protection. One form of protection was a very long password printed on a square of cardboard using black type on a red background. Dark red and black cannot be distinguished by a copy machine, so you could not lend that password (and hence, the game) to a friend, casually. I believe that, as much as it felt like a root canal at the time, I benefited hugely from my time with Ms. Berliner.53 As with black print on a red background, I might have failed to distinguish counseling approaches without the glaring contrast between that of Ms. Berliner’s attitudes and mine. Comfort is… umm… comfortable… But sometimes a challenge is more useful. In retrospect, my experience with Ms. Berliner was an excellent complement to my comfortable first-year experience.
The supervision stages I went through were, first, supportive and modeling, second, challenging (more descriptively — mutually confrontational). There was no third stage of supervision for me, but if there was, it would have been assistance with learning a specific approach to counseling.
Shortly after receiving my masters, I developed a strong interest in systems theory and with the related therapeutic approaches. On my own I read incessantly, and lucky to live in the epicenter54 of the budding theory of systems-oriented therapy, I attended conferences and available workshops. At the time, there were no academic programs that supported a systemic approach to counseling and only a handful of books. I tried ideas in my practice and kept doing what worked and discarded what didn’t. In short, my third supervisor — and the guide to a specific approach — was the bearded guy in the mirror.
I’ve laid out three stages of supervision: supportive, challenging, and specific (coaching). And I got them, primarily in stages, from three mostly distinct circumstances. I believe most counselors would suggest that all three of these stages can and should happen, simultaneously. Why can’t a supervisor both support and challenge, while coaching a specific therapeutic approach? Is not mixing support with challenge a good model, a good isomorphic model? Probably. But there is something to be said for learning from conflict what you would not learn otherwise.55 There’s no ideal supervision, but over time if not simultaneously, I believe that it should include all the elements I’ve described: modeling, support, challenge, and coaching.
Game of Thorns (MHS pt 1)
“When I spoke to Stanford professor Bob Sutton, he told me his #1 piece of advice to students was this: ‘When you take a job take a long look at the people you’re going to be working with — because the odds are you’re going to become like them, they are not going to become like you.’”
When I began my outpatient work, my inclination, my training, and clinical tradition were aligned: I started sessions by actually listening to the reasons my clients came to see me. As private pay for private practice and government grants for community clinics gave way to managed care, initial sessions became more about recording stuff on an intake form and coming up with a diagnosis for insurance reimbursement. Have you ever gone to the emergency room for a painful but not life-threatening injury or illness? You know how unnerving it can be: hurt and scared, you’re flooded with admittance and insurance forms. Counseling clients come to initial sessions with emotional pain: hurt and scared, they’re flooded with admittance and insurance forms; then, rather than discuss that emotional pain with their counselor, they must answer a heap of questions relevant to only the intake form. No wonder that the most common number of sessions clients attend is a big, fat, one.
You may believe that it is simple to separate how clinical work is reimbursed (for a psychiatric diagnosis), and how you think about client problems. It’s harder than you think. Novices who spend their time around psychiatrists and veteran counselors get colonized quickly. Hear diagnostic jargon and DSM codes, daily, and you’ll soon conclude that to be respected as a grownup clinician, you better use those terms. But if you succumb, you’ll never see your clients as humans again. From then on, they’re cases — people not with emotions, personal histories, and lives like your own, but clients with diagnoses, with medical charts as evidence.
Follow the Money
Working in the mental health system is like watching your favorite television show: you hate Comcast but put up with it because you love Game of Thrones. Here’s what you’ll put up with to earn a living: (1) You must keep detailed medical records to satisfy state requirements and scramble to comply with state and federal statutes covering privacy and security of medical records. (2) There are no healthcare professionals with grad degrees who make as little as the average masters-level clinician. (3) While doctors can afford a staff to assist with records and billing, therapists in private practice usually do all that on their own. (4) Psychiatrists always get to play on their home court by using the disease model for insurance payments; marriage and family therapists, primarily trained in interpersonal-conflict models, and social workers, primarily trained in social justice models, must always be the visiting team. (5) Those boring Using the DSM classes you took in grad school will turn out to be your most important classes.
Insurance reimbursement started on a high note, but evolved into a Faustian bargain. In the 70s, state legislatures started passing laws that gave masters-level clinicians insurance parity, which meant that they became full-fledged mental health professionals. The intended consequence is that all covered mental health professionals had to use the DSM to provide a medically recognized mental illness diagnosis. Over time, the criteria for reimbursement became increasingly oriented towards the disease model. The designation, adjustment reaction, the non-mental illness diagnosis, was no longer accepted. The unintended consequence is that all mental health professionals became psychiatry and Big Pharma’s bitches.
Just because the distribution of that money is, ahem, less than equal, doesn’t mean that some players in the Mental Health System (MHS) aren’t doing well. For counselors, social workers, and even most psychologists, the money distribution looks like hungry baby birds waiting for a piece of worm. For psychiatrists and pharmaceutical corporations, the money distribution looks like pigs at the trough.
Psychiatrists have always made good money, they’re doctors after all. But the increased partnership with the pharmaceutical industry has allowed them to dominate the mental health industry in a new way. When they were the only clinicians that could take insurance for psychotherapy, they dominated the 50-minute hour approach. But the release of the chronically mentally ill into communities increased the demand to subject them to chemical restraint56. That demand could come indirectly from the involved family or directly from the legal system or from clients themselves. Fewer and fewer psychiatrists engaged in talk therapy. Insurance companies preferred to pay them for 15 minutes of medication review once a month, and psychiatrists found four sessions an hour to be more lucrative than one.
Your First Professional Position
If you’re just entering the counseling profession with your newly minted masters degree, you’re likely to start with a low-status, low-paid position. After job-hunting for a while, more than likely, you’ll not only settle for one of those jobs, you’ll be thrilled to get one.57 If you’ve paid tuition for a couple of years, and had an unpaid internship, making even a low salary is going to look comparatively good.
Along with coming to terms that receiving some money to work is better than paying money to work (during grad school), what else is good about low-paying jobs in counseling? There are several benefits:
The more areas in the system in which you work, the more you’ll know the systemic issues your client may encounter. For example, if you get a client whose parental competence is being challenged or overseen by Child Protective Services, past experience working for a similar agency will give you additional insight into how to assist them. If you get a client who’s been involuntarily admitted to a psychiatric inpatient ward, and you’ve worked inpatient or crisis, you’ll have additional insight into how to assist them.
You’ll know more about various client issues than those who have dealt with only the worried well or psychiatrists who see clients for a 15-minute med review once a month. Those in entry-level positions usually get experience with a wide spectrum of clientele, usually far wider than those in higher-level positions. You’ll have an opportunity to learn more about issues that bring people to counselors.
The variety of clients can help you choose your career direction. Working with a variety of clients and their issues can help you choose a career path, which in the long run will be more useful than an initial high salary.
The Paradox of Mental Health Treatment Goals
“When the going gets weird, the weird turn pro.”*_Hunter S. Thompson
Medicine may be difficult, but some aspects are refreshingly straightforward. For example, a patient comes to a physician because she has an infection with a resulting high fever. Physician treats patient with antibiotics. Patient’s infection goes away, and the case is considered successfully treated.58
Contrast with a counseling client. If you work at agencies that make most of their income from managed care, their profit will increase if sessions are strung out to get the maximum in insurance benefits. Ditto for you if you work in private practice. On the other hand, if you work at an agency where the service is primarily pre-paid, such as a health maintenance organization, you serve the agency best by getting your clientele moving on successfully with their lives in as few sessions as possible. When clinicians move from a setting that rewards long-term, “in-depth” therapy to one that rewards brief therapy, or vice versa, it takes some skillful mental gymnastics to rationalize that the approach you’re currently using is the clinically appropriate one.
Economics 101 — MHS (pt 2)
Just as I can’t completely explain how licensing works, because there are 50 states (plus territories) with their own regulatory agencies, I can’t completely explain how mental health systems work. But for the most part, the mental health systems work like any other health system — primarily through managed care. The main difference is that, because billing for mental health sessions is more straightforward than billing for the complexity of medical services, there are far more sole practitioners in mental health.
With the waning of government-run outpatient clinics, many mental health services have moved to preferred provider agencies. Who staffs these agencies? If it’s your first job, chances are it’s you. Guess why insurers contract with these agencies? Because health care insurers can contract for lowered fees.
In the good ol’ days™, prestigious universities chose their grad students from a large pool of applicants. The graduates of these masters programs in social work, psychology, (and later) mental health counseling, and marriage and family therapy were reasonably rare and rated some prestige and earning power. For reasons on which I can only speculate, from the 70s on, lots more people wanted to become counselors, and numerous professional schools sprang up to indulge them. Tuition supported, these schools were oriented to accommodate as many students as possible. As in other professions in attractive urban areas, job-seeking graduates were plenty. Too many seekers after too many jobs usually means low pay. Hence, mental health clinics are filled with masters-level clinicians who make less than those in most professions of equal college training. A lucrative private practice, the fantasy of most counselors going in, is attained by a minority of business-savvy counselors.
Systems Theory (MHS pt 3)
Maybe sometime in grad school, you decided to be a systems-oriented counselor, specifically a family systems-oriented counselor. Soon you’ll learn that the mental health system is full of systems.
Adult Protective Services: A vulnerable adult may be financially exploited, or abused by a relative, friend, or caregiver. These situations may be complicated by the exploiter being the only one giving much attention to the elder. Unless you live in a very rural area, there’s probably an Adult Protective Services agency that would deal with this. However, mental health professionals are mandatory reporters when they suspect such abuse or exploitation, so you may need to make a referral.
Child Protective Services: Even rural areas usually have their own CPS agencies. You may have to provide court-ordered clinical services to a family. You are a mandatory reporter if you suspect abuse of a minor.
Public School System: There’s a drug epidemic in public school systems, and for inexplicable reasons, law officials can’t track down the drug peddlers. Let me give them a hand.
Young children are being given drugs for behavioral issues in the classroom: amphetamines, anti-psychotics, anti-anxiety, and anti-depression pills. Long-term effects, be damned. Ah, well, children make good guinea pigs.
Health insurance system: But only if you want to get paid.
Legal System: Large cities have their own public health employees, but if you live in a rural area, you might provide services to the local jail. More likely, you may see someone who has been court-ordered for anger-management treatment due to domestic or other violent acts.
Involuntary Treatment System: Individual counties or large cities have their own resources to deal with (usually) state laws regarding involuntary treatment. Typically, an individual may be detained if an evaluation by a designated mental health professional finds the individual is one of the following: as a result of a mental illness that is acute or chronic, (and found in the DSM), is a danger to self, or a danger to others, or gravely disabled. Danger to self or others needs to be imminent, likely to occur within a day or two. Gravely disabled means that an individual can’t care for his or her basic health and safety. Involuntary detainment is usually in increments of 72 hours, 14 days, 90 days, and 180 days. Each detainment period is a legal proceeding. Usually, the first 72-hour hold takes place within a local psychiatric ward. The longer holds typically take place in a state hospital. This can vary in accordance with available mental health resources.
Healthcare system: It should go without saying that the mental health system operates within the larger healthcare system.
Continuing Education (MHS pt 4)
The continuing education requirement in most states is based on two presumptions: (1) Mental health professionals need the fear of the stick to make them advance their skills. (2) Spending a few hours listening to a so-called expert or reading a book on a subject lead Mental health professionals to advance their skills. If you need state regulations as motivation to get better at your profession, then you probably chose the wrong profession.
My state of Washington requires 36 CEs (continuing education) units every other year, 26 of which can be done online. I believe that’s representative of most states’ regulations. For psychologists, it’s 60 units every three years, all of which can be done online.
There are numerous websites that provide continuing education at a fraction of the cost of in-person trainings. Online trainings are usually either book-based, webinars, or audio lessons. For small-unit classes, there is often online reading material created for just that class. Usually, online tests are the means of proof that you consumed (an appropriate connotation) the information. I use secure.ce-credit.com.
The most practical way to deal with this leave-no-counselor-left-behind nonsense is to get the ebook version used for the online class, bring up the test, and search for the answer in the ebook for each question. As far as I can tell, this is neither illegal nor unethical. May the farce be with you.
Records and Privacy — (MHS pt 5)
This is information as I understand it. It is neither legal advice nor technical advice; I am neither a lawyer nor engineer. The following is my interpretation of the relevant privacy and security requirements pertaining to Protected Health Information (PHI), and other relevant laws, and how I have implemented the security and privacy of clients’ health records. For legal advice, consult with your attorney. For technical advice, ask a ten-year-old nerd.
If you’re licensed as a psychiatrist, psychologist, social worker, marriage and family therapist, or professional (mental health) counselor, you are a healthcare professional; you are subject to all your state and federal regulations on healthcare privacy and security. Your state regulations are found with all your other state laws. Federal laws are found under the Health Insurance Portability and Accountability Act (HIPAA) enacted in 1996, and modified (became more stringent) in 2003 and 2013.
The main advice a lawyer gave me is that our State (of Washington) healthcare privacy laws are more stringent than HIPAA regulations, so if you’re compliant with the state laws, you’re going to be compliant with HIPAA regulations. For me, here’s where that argument falls apart. First, HIPAA regulations are not necessarily less or more stringent, as they are more vague. They don’t always tell you precisely what compliance consists of, sometimes you just get general guidelines. For example, you’re supposed to make a “reasonable” effort to… Who decides what’s reasonable? Second, the penalties for non-compliance for HIPAA can run into the hundreds of thousands of dollars. Vagueness sucks.
It’s obvious that when these regulations were written, they had in mind large healthcare organizations that can afford lawyers and compliance officers. Where does that leave small group practices? Where does that leave counselors in private practice? My guess is that it leaves most of them ignoring the whole damn thing, assuming (or hoping) they’re too small to be on enforcement radar.
After attending two trainings, conferring with a lawyer, and spending too many hours researching online, the following is what I believe to be true about complying with HIPAA regulations:
You are a covered (need to be in compliance) entity if you have ever sent information through electronic means that held PHI (protected health information) in order to attain financial reimbursement for healthcare services. Typically, this would be submitting client information for insurance reimbursement, and the like.
Under HIPAA rules, your healthcare records need to be private, meaning that you have taken reasonable (there’s that word) measures to keep unauthorized personnel from viewing the PHI of your clientele.
If you use a service to assist with your HIPPA compliance, they must be willing to sign a Business Associates Agreement (BAA).
There are many additional regulations, including training personnel, computer placement, checklist audit, a compliance officer, password security, and so on — most of which are more relevant to counselor groups larger than a private practitioner.
The easiest way to comply is to use a HIPAA compliant practice management service for your record-keeping and insurance submissions. They will provide a Business Associates Agreement. They’re optimized for DSM diagnoses, electronic billing submission, scheduling, record keeping, credit card management, and tax reports. The downside is their complexity. I don’t take insurance, so I don’t use any, but if I were to start a practice now, I would use a practice management service just for the HIPAA compliance. Simple Practice and Therasoft are on the low-price end. While I do not have personal experience with either, they’re highly rated by lots of users.
What some informational sites get wrong about HIPAA: HIPAA does not mention that healthcare records need to be secure in the sense of available. Those regulations are under your state’s laws, and it means that health records can survive a disaster, such as a fire, flood, or visit from Godzilla. To comply with state laws concerning health care records availability, keeping duplicate records at a second site (in physical or electronic form) is the most common means. A fireproof, waterproof safe may also suffice. How long you have to keep healthcare records depends on your state. Additional common state regulations: What they will most likely include is a disclosure statement on counseling approach, regulations (akin to HIPAA’s) on records disclosure, security, a release of information form that includes precise limits of what, how long, and for whom Protected Health Information can be exchanged. (The days of overly general, and open-ended record release permission has ended.)
If you don’t use a practice management solution, at minimum, do the following:
Keep your records behind two locks. If you store records, electronically, keep your computer behind two locks.
Encrypt your hard drives. Have at least one backup on an offsite location. Modern SSD (solid state drives), which have taken the place of hard disks, make it difficult to securely erase files, so encryption is even more important. On Mac and Windows, you must turn encryption on. On iPads and iPhones, just create a six-digit passcode and mark erase after 10 failed passcodes. For Android phones, see Resources, below.
For your wireless Internet connection, the modem/router supplied by your Internet service provider (ISP) (such as Comcast and Verizon), probably includes the most secure wireless encryption (WPA2/AES) if it was installed after 2007. Otherwise, to maintain wireless security, obtain an upgrade from your provider. You can do it yourself by buying the modem/router (cable, FIOS, and DSL use different versions) and installing it yourself. I won’t give instructions, because if you can’t learn on your own using Web search or your ISP’s instructions, then you shouldn’t mess with it.
If you use a Web service for backups, it needs to be HIPAA compliant and provide a Business Associates Agreement. The easiest solution is Dropbox, which is not HIPAA compliant on its own (unless you use the business plan with the minimum of five paid users). We subscribe to Sookasa which puts a HIPAA compliant encrypted folder inside Dropbox59. In addition to the Dropbox password, your Sookasa protected folder will have its own password. Take care to back up Protected Health Care Information (PHI) in only the Sookasa protected folder. One terabyte (1000 GB) of Dropbox storage is currently $10 per month or $100 per year. Sookasa costs us $10 per month.
The most financially competitive solution to our Dropbox/Sookasa combination is Carbonite for Office at $270 per year for 250 GB. The advantage of Carbonite over Dropbox/Sookasa is, while I must log into Sookasa each time I wish to back up a file, Carbonite for Office will work in the background without any involvement from the user. If you search around, you’ll find many online HIPAA solutions, but most cater to large healthcare operations with prices to match. Sookasa, Carbonite, and the practice management services (see above) that cater to small practices are the only current inexpensive solutions.
Update: The HIPAA compliant email service we use (emailpros.com) has implmented a HIPAA compliant cloud service (eBox), which we are now using for backup in place of the Dropbox/Sookasa combination. We pay $15 per month for 300 GB of storage.
Do not sync any data containing PHI on your Apple devices by using iCloud. iCloud is not HIPAA compliant. Apple’s own mail service is not HIPAA compliant.
Use a HIPPA compliant email service, either through practice management software or a standalone service. We use Email Pros, which has proved excellent.
Free Gmail (email@example.com) is not compliant. Paid Google services (including Gmail), where you use them with a custom domain name (firstname.lastname@example.org), can be compliant, as Google will provide a Business Associates Agreement.
For billing, do not use a conventional web-based billing service. Quickbooks Online, and Freshbooks (an otherwise superb service) are not HIPAA compliant. They will not supply a Business Associates Agreement. If you don’t use a compliant practice management service, use desktop software for billing on your secure computer. The U.S. Mail is legally as secure as it gets. If you send billing forms as email attachments, have your clients sign a form (we include it in our service agreement) disclosing the security risks of email. You can send PDFs securely with passwords, but we have found that clients have difficulty opening them.
“And you may ask yourself — ‘Well…How did I get here?’ ”
It’s possible, even likely, to make some of the most important decisions you’ll ever make as a counselor, without being aware that you’ve made them. Subtle and unsubtle influences are everywhere. You may choose your training program, wisely, but the supervisors you’re saddled with during internships and early jobs is usually luck. Your early career colleagues might be conventional thinkers, brave explorers, or everything in-between. Geography, fashion, and time of entry into the field all play a part in the context of your chosen vocation. When I started, the field was dominated by men. Now, it’s dominated by women. When I started, psychodynamic approaches were just being challenged by humanistic and systemic styles. Now, humanistic and systematic ideas are part of the counseling dialect. Of all the professions, there are few that include more personal choice of approaches than in the counseling field. The following are some of the meta-decisions you’ll encounter:
Are your clients, cases, or people with problems?
Seen your doctor lately? Chances are, not for long. A host of cheaper assistants (and the cheaper assistants have their own even cheaper assistants) take your pulse, blood pressure, blood, urine, and fluids you didn’t know you have. If you’re unlucky, they may even slip you something and harvest a kidney to help pay for their own health insurance. You may have the most personable doctor in the world, but in modern medicine, you’re more a computer readout than a person with dis-ease.
The mental health system has no equivalent to vitals and fluid tests, so (as I’ve stated to the point of weariness for readers) clinicians must fake it with the DSM. As everyone knows, we do that by counting behavioral symptoms, and if we reach the magic number within a DSM category, yay — reimbursement!
So your new client is now a collection of symptoms and a DSM number that resembles the balance in a counselor’s bank account. Counselors are conversant with the concept of historical baggage, for example, emotional baggage in the form of a difficult childhood, or the baggage of bad decisions that lead to sharing offspring with an ex. To that, the mental health system has added the baggage of casehood. (More on that in the appendix — How to Suck as a Therapist.) Following their first recorded DSM diagnosis, clients don’t get to present themselves as who they are in the present. They are defined and labeled forever. We can claim that it’s for the client’s good, but the history of groups who have been defined and labeled by others is now widely accepted as a form of oppression. Continuing to regard your clients as just people with problems, especially when you’re overworked and underpaid, will be an ongoing challenge.
The second meta-decision you’ll make as a counselor is, is the work of the client done primarily in your office or out in the world?
When I was training, there were two dominant categories of counseling: psychodynamic, which largely evolved during the first half of the 20th century, and systemic, which largely evolved during the second half of the 20th century. Practitioners of the former may differ in their theories of personality and in their concepts of abnormal psychology and motivation, but mostly agree that the major work is done in the session, and that the important stuff happens between therapist and client. The focus is on insight and catharsis60. This category includes the original analytical therapies practiced by Freud, Jung, Adler, Horney, Sullivan, early hypnotherapy, and modern offshoots such as Fritz Perls’s Gestalt, and Carl Rogers’s person-centered. Practitioners of the latter believe that the major work is done in the context of the client’s everyday life. This category includes Ericksonian Hypnotherapy, strategic therapy, cognitive-behavioral, Rational-Emotive, Reality Therapy (mostly), and Neurolinguistic Programming (NLP).
While lots of counselors mix and match, when pushed, most will claim that one or the other is superficial. The adherents of the first group will contend that they’re working with the underlying cause of the problem but need to throw in some practical problem-solving stuff to keep the client interested. The adherents of the second group will contend that the talky insight stuff is necessary to develop rapport, so the client will cooperate with the behavioral homework.
My presumption is that therapy is about change. When clients come in, they want to change either a behavior, a pattern of interaction with a significant other (and sometimes with insignificant others), or their attitude towards or feelings about a current behavior or situation.61 So it’s always about change of some sort.
The first therapist group believes that healing and behavioral change follow insight and analysis. The second group believes that behavioral change produces insight, but that insight may remain subconscious, which is just as well because behavioral change, not insight, is the goal.
In short, the decision of what kind of therapist you’ll be follows from your theory of change: insight leads to behavioral change, or behavioral experiment (client homework) leads to behavioral change. Again, these two modes of counseling aren’t mutually exclusive, but which you favor will guide your thought process.
The third meta-decision you’ll make as a counselor is what will my specific approach be?
As I stated earlier, according to Wikipedia, there are over 200 known styles of psychotherapy. This ridiculous number owes less to novel ideas, and more to money and ego. Every time some college professor or random clinician comes up with a slight variant, it’s a whole new school of counseling. Soon, it’s offered as a continuing education class where, after the seminar, you can invest in three DVDs and a book for $195. That’s just the beginning. You can get certified by taking eight weeks of intensive training and supervision, for just $5995. When a counseling approach is not working for a clinician, rather than get better at that approach, clinicians often go shopping.62
I think novelty in counseling is a good thing. You can’t drag seminal thinkers, whole, into today’s context. First, we’d need to agree that all the questions of human behavior had been answered decades ago. Second, we’d have to regard culture and (by extension) cultural evolution, as irrelevant to psychological problems. I can’t imagine, were they alive today, that Freud, Jung, Adler, and Horney would have wanted their original theories poured into concrete. On the other hand, novelty should be in ideas, not marketing. And maybe we should be looking to venerable rather than drive-through sources for ideas. I’m interested in what the Dali Lama has to say about contentment, but I draw the line at McDonald’s Double-Mindfulness burgers.
Katie Holmes = Evidenced Based Practice
Years ago, Tom Cruise was jumping up and down on Oprah’s couch, demonstrating his feelings toward (then) fiancé, Katie Holmes. Cruise could just as well have been illustrating how health insurance companies feel about evidenced-based practice (EBP). As much as I criticize insurance companies, I don’t blame them for not wanting to pay endlessly for vaguely-defined goals. Unfortunately, the evidence on insurance companies’ heartthrob, EBP, has much in common with the elusive weapons of mass destruction: the evidence has more to do with how badly you want the evidence to be there than what’s manifest (see Addendum — Evidenced-Based Practice). Nevertheless, regardless of how shaky the grounds are for EBP in the mental health field, insurance companies will use it; there’s nothing better to go on, and EBP research aligns better with short-term concrete approaches than indefinite-length counseling.63
Above, I mentioned that when one’s counseling approach is not working well, counselors go shopping. There are several reasons why your approach may not be working for you:
(1) You may have chosen a style that does not fit your personality. I have been heavily influenced by the famous hypnotherapist, Milton Erickson, but I had to come to terms with not having a proactive style. I could make use of his insights, and learn to use language with more precision, but I was not going to use hypnotic inductions.
After taking part in a cognitive-behavioral therapy research setting (as a facilitator), and reading a couple of books on the approach, I realized that it did not matter how useful CBT could be, I could not bear to practice it. There are several other approaches that were not a good fit for me, for example, Gestalt, person-centered, and psychodynamic. I leave those styles to other practitioners.
(2) You may not have sufficient training in the style you have chosen. When I chose to be a brief strategic counselor, most experienced clinicians were using a psychodynamic approach. You could fit all the experienced brief strategic counselors in a mini-van. You could carry all the relevant books64 without using a backpack. In other words, I had to train myself, by reading the handful of available books, attending workshops and conferences, but mostly using trial and error. And I had to walk through 10 feet of snow…
Getting better at your primary approach will usually provide more help than adding a bunch of styles. Today, most counselors, novice or experienced, can get advanced personal training, watch DVDs and Webinars, and download any number of available ebooks on their Kindles, phones, and tablets.
(3) You may not be cut out to be a counselor. People who have hobbies often believe that turning their avocation into a vocation is ideal. Then they learn that the business of photography, jewelry design, or gardening is not the same as the art and craft of it. Likewise with the counseling business. Being the primary confidant of your friends is not the same as working in the mental health system.
How will you know that you’re destined to be a counselor? Here’s one way: if you read this whole guide, and you’re still enthusiastic about being or becoming a counselor, then nothing you’ve read here will discourage you.
How to Have a Career
The counseling field is often both a difficult professional environment and a competitive business environment. That doesn’t even take into consideration the challenge of becoming a competent clinician. If you work in an agency, you will find that your bosses aren’t the compassionate bunch that you’d expect of trained counselors. As in most professions, your superiors may have reached their positions by being good at office politics, rather than being good at clinical work or leadership.
Occasionally, people land in really good organizations. If that happens early in your career, you might expect that will be the norm. While I encourage people to be adventurous, if you do find a decent-paying job in a comfortable organization, don’t assume you’ll find another situation that matches it, let alone exceeds it.
Before you commit to a counseling career, look at the statistics on the average and median incomes for the mental health professions. You need either a carefully crafted business plan or a willingness to sacrifice riches (that is, being able to pay your bills) for the love of the work. Even if the former is true, that you think you can make big money, I hope that anyone who doesn’t have a passion for counseling goes into something else. Working 40 hours a week at something you don’t find interesting and enjoyable (not every moment, to be sure) is miserable. And anyone who can make lots of money from counseling will make even more in the marketing field.
A satisfying and possibly lucrative career
Pick some counselors’ web sites at random. They list 20 to 30 problems they treat. They will provide a safe space to take you on a journey to find your authentic self. By implication, their primary approach is insight-oriented talk therapy, with no theory that would explain how it will help you. But in case you are too anxious or depressed for that insight-oriented journey, they keep cognitive behavioral therapy in their back pocket, right next to their iPhone.
Luckily for both counselors and clients, many people just need someone to listen. They don’t need meds, dramatic breakthroughs, or a U-Haul load of insight. They just need someone to stop texting and listen. You could be that person. Unfortunately, so could dozens of other counselors in your area. It might be a good idea to find a way to stand above the crowd of counselors.
Be the proctologist of counselors: The easiest way to stand out is to specialize in something, preferably something that most counselors prefer to stay away from. Most counselors don’t like to deal with boys in their teens (especially if they get in trouble with the law), personality disorders, significant sexual problems, life-threatening eating disorders, or domestic violence. If you want to carve out a career in private practice, invest in advanced training to deal with one of the icky categories. Get really good at it, and once you do, it will be far more satisfying than icky. You’ll get plenty of referrals, and eventually have opportunities to mentor, teach, and consult.
Complement a group practice: If you have a specialty, become the go-to person in a group practice. If you are the expert in what no one else wants to do, or what no one else does well, you will be sought.
There are counselors who make money. If you don’t follow the crowd, or take the easy path, you can be one of them.
Institutions usually start with the interest of the customers, but over time segue to serve the providers, or worse, the monied interests. If you decide to work in the mental health system, you will have to find a way to make it work for you and your clients.
When my daughter started her masters program in education, I suggested that she would not learn much in class, that her learning opportunities would come from doing research and writing a thesis. I was advising her that the program would be what she’d make of it. I also have a young friend who recently became a public school teacher, and another friend who just started a second career, as a MFT. What these roles have in common is that they will all take place in institutions that have survived well past their pull dates. And in all these cases, when their institution doesn’t support it, they will have to make it work for themselves and for their clients or students. They’re all confident, emotionally strong people. I have faith, a belief that they’ll do well and make their little part of a deficient system, better.
I hope anyone who’s choosing the counseling profession goes into it with their eyes wide open, with the confidence to make the system work for them and for their clients.
Appendix — Evidenced Based Practice
“Is advertising a psychotherapy as ‘evidence supported,’ any less vacuous than “Pepsi’s the one”?”
_James Coyne, Ph.D.
The inspiration for evidenced-based practice in mental health treatment came out of the success of evidence-based medicine (EBP) and its offspring in other healthcare. But when it comes to research, mental health treatment is not like any other healthcare. Cancer patients don’t get better while on a waiting list. Heart disease patients don’t get better while on a waiting list. Diabetes patients don’t get better while on a waiting list. In contrast, some mental health system clients, who are suffering sufficiently to rate an insurance-reimbursable DSM diagnosis, do get better while on a waiting list. Which brings me to how healthcare treatment research is done.
To put a drug on the market, a pharmaceutical company has to provide sufficient evidence that the drug is efficacious. To be considered as a reimbursable therapy treatment, most insurance companies now require that counseling meet the same requirement. Efficacious does not mean what you think it means. It means better than nothing. It does not mean better than reading the Dali Lama. It does not mean better than consuming a McDonalds Double-Mindfulness burger. It just means better than nothing. The requirement for mental health practitioners to get reimbursed for their work is to use an approach that’s better than nothing. And it’s even worse than it sounds. Gaming the system in research for both medications and counseling is standard operating procedure. This should not come as a surprise: research in pharmaceuticals is almost always paid for by the producing pharmaceutical company. Research in psychotherapy is usually done by the practitioners using the approach being studied.
Aside from outright bias, there are other reasons why EBP is messy for counselors:
First, it requires a strict medical model, that is, a disease model. Insurance companies won’t pay for relationship issues unless they’re translated into a cluster of individual symptoms. Your clients will not be having marital difficulties, they will be depressed, as demonstrated by the required number of depressive symptoms. In the bizarre world of psychiatry, every day is opposite day, so decades of failed research has lead to the foregone conclusion that depression is caused by a genetic predisposition. Your clients will not be allowed to just be bored with school. Despite that they can play a video game or Dungeons and Dragons for hours on end, they will be suffering from Attention Deficit Hyperactivity Disorder.
Second, you’ll have to create concrete goals with a timeline for achieving them. If you’re inclined towards a psychodynamic or person-centered approach, you may not be comfortable with concrete goals. If you’re a systems-oriented therapist you may not be comfortable with individual rather than relationship goals.
Third, you’ll have to justify your work to health care insurance managers who will almost assuredly have less knowledge than you. After learning how the real world of reimbursement looks, you might personally acquire those concrete symptoms of depression and anxiety so beloved by reimbursers.
Appendix — Counselors and Integrity
“The secret of success is sincerity. Once you can fake that you’ve got it made.”
Counseling is one of those professions where the difficulty of the work is inversely proportional to its prestige and pay. Working with the worried well, as they are facetiously called, using insight-oriented therapy is the world of private psychoanalysts with hourly fees often in the hundreds. At the other extreme, crisis work, perhaps the most difficult, is often the realm of interns and volunteers. Other low-status counseling situations include any residential treatment, working with schizophrenics, and sadly, working with children.
When my friend (I’ll call her, Danielle) told me that, for her first grad-school internship, she applied to work with chronically conduct-disordered teenaged boys, I thought she was nuts. I believed that she was in for more frustration and less progress with clients than was good for an intern. Was I wrong. Rather than being frustrated, Danielle thrived on the experience. While she anticipated only the smallest of progress with these emotionally-damaged children, that bit of progress was more rewarding and a better learning experience than conventional training in a more prestigious position in an outpatient clinic.
My attitude towards Danielle’s choice changed when I realized that this early counseling experience was similar to mine. During my first years of counseling, I worked with autistic children, teens emotionally dependent on drugs, and severely mentally disturbed adults. When working with any of the above clientele, the bottom line is no bullshit. Because these client groups have severe trust issues, a counselor’s integrity matters above all. A designer leather couch in your office won’t help you. You have no choice but to be who you are, because all these clientele are sensitive to pretense.
Because working with these emotionally injured boys rewarded integrity, Danielle gained confidence for her future practice. Skill and technique take experience to acquire, and there are no shortcuts, but integrity can’t be learned any more than it can be faked. So as these boys responded to Danielle, as positively as they were capable, she learned that she has the foundation to help people. And that results in positive reinforcement for integrity — a virtuous cycle.
How do you tell if you are (as a counselor), or someone else is, unpretentious? Here are some guidelines: Are your actions for the benefit of the client, or are they to make you look like a better Freudian, cognitive-behavioralist, family therapist, or whatever you believe your professional identity depends on? Are your actions as a counselor designed to crank up your ego in some such way, or to be more showy to your colleagues? (Subtlety doesn’t show up in case presentations as well as drama.) Do you explain to clients and acquaintances (with a hint of impatience) that counseling is superficial, psychotherapy, profound, and that you are a therapist?
Nearly all clients, as well they should be, are wary of giving trust to a counselor, and trust is a prerequisite for getting anything done in sessions. For those who try to get by on pretense, it only works on others who try to get by on pretense. It’s a sort of agreement that, if you promise not to look at me carefully, I promise not to look at you carefully. Most people do not enter into these (usually, subconscious) agreements, and I would not count on such mutually-agreed bullshit to impress your clients. Danielle has integrity, and it will work for her throughout her career.
Appendix — How to suck as a counselor — ignore that person in front of you
I was teaching a class to masters students in counseling when I was challenged by a student as to how I could work with women or gays. This wasn’t a polite challenge, it was more of an accusation: Who do you think you are, believing that you can be an effective counselor for those who’ve had extremely different life experiences as you? Wiping the flung tomatoes off my shirt, I explained that I can be an effective counselor for those who’ve had different life experiences as I, because it’s not about me, it’s about the client.
One way to suck as a counselor is to believe that you understand your client merely because you share a significant life experience. It doesn’t matter whether you’re both women or men, gay or straight, black, white, or share any ethnicity. It doesn’t matter if you practice the same religion, were both abused as children, both had substance-abusing parents, both are vegans or omnivores, conservatives or liberals, or both suffer from rooting for losing sports teams. Individuals come with a variety of life experiences, and one-size identity counseling does not fit all.
What do I mean by identity counseling? It’s whenever the adjective that comes before the word “counseling” is alluding to the client rather than the approach. LBGT counseling is alluding to the sex (or transformed sex) of the client. Feminist counseling alludes to the client’s lack of power in society. Christian counseling describes the client’s core beliefs. In contrast, brief, psychodynamic, Gestalt, and person-centered refer to the therapeutic approach of the counselor. I can and have worked with all of the former, successfully, while practicing one of the latter, brief therapy. To me, each client is unique. It does a disservice to label them as belonging to either an identity group or a category of mental illness (which I’ll get to below).
Identity politics in counseling is far from new. The theories of those who founded modern psychotherapeutic practices — Freud, Jung, and Sullivan — all contained elements of cultural, religious, or personal provincialism. Their personal experiences and those of their clients were not as universal as these early theorists believed. Pioneers, however, don’t have the benefit of learning from the mistakes of predecessors, and later generations of counselors and psychotherapists should know that their personal issues are not universal. Over-identifying with your clients65 may be hazardous to their mental health.
The counter argument to mine is that some experiences are so overwhelming that they do define you. To the extent that’s true, that’s part of the problem. If accepting who you are means you’ve been colonized by identity politics, then you’re accepting how others see you, rather than how you see yourself. This seems to be a betrayal of the whole point of identity politics: don’t let the prejudices of others define you.
As with many things, identity politics started out trying to be helpful. Be proud of who you are, your background, your ancestry, your ethnic group, your gender, your sexuality, your genetically-influenced body type, a significant life experience. Don’t let the majority culture disrespect you. Don’t fall into the Stockholm Syndrome of attitudes, where you agree with your oppressors’ or abusers’ beliefs. However, when identity champions become too influential, they can become the new oppressor, the new abuser. Now they’ll tell you the right way to think and feel.
Most counselors who use identity politics to market their services have a genuine belief that what they have in common with certain clients will be of great benefit in their work with those clients. And to some degree that will be true. But counselors who do promote identity politics must be vigilant that they use their commonalities as the briefest of starting points in therapy; that they’re humble in their assumptions of how much they can assume about their clients; that they remain curious and respectful of their clients’ uniqueness.
I once did an internship at a clinic that was resistant to the trend of viewing personal problems from a systems perspective and remained steadfastly psychoanalytic. Case presentations would go something like this: The therapist would discuss the client’s issues and then state the difficulties of working with that client. As befits an approach that has little to offer in the way of a theory of change,66 rarely did any clinician offer help. Invariably, the dominant clinician would state that “this is a very difficult patient.”67 And, nearly on cue, another clinician would ask, “How do you see this client, diagnostically?” We played the diagnostic game for a bit and moved on. In my nine months there, I don’t recall a single presentation that ended in a new approach to the client.
A second way to suck as a counselor is to invest too much into diagnosing your clients. And how do you know what’s too much? As pointed out many years ago by psychiatrist Thomas Szaz, among others, psychiatric illnesses are diagnosed by only observation of behavior. There are no blood tests, urine analyses, or biopsies that tell a mental health professional that someone is schizophrenic, has a bi-polar disorder, or is clinically depressed. The chemical imbalance theory of mental illness is a pharmaceutical industry and psychiatric sourced fairy tale, where the promoting parties got to marry the very wealthy (if not necessarily handsome) prince.68
Clients who have been in “the system” for a number of years, thanks to computerized medical records, will have shed personhood in favor of casehood. No longer will these clients be judged on their current behavior, because they carry the ball and chain of past diagnoses. And I will emphasize once more, those diagnoses came from the subjective minds of random mental health workers, many of whom — even when they mean well — are poorly trained, poorly paid, and overworked.69
If you went into the counseling field, unless you were hugely misguided you didn’t do it for the money, you did it to help people. As a counselor, a necessary prerequisite to helping people is to respect them, and respect begins with treating people as individuals rather than as stereotypes. Just as with playing identity politics with your clients, focusing on a diagnosis is a way to ignore who is in front of you, to disrespect and dehumanize a human being. Obviously, that won’t contribute to curing what ails him or her.
In conclusion, the way to suck as a counselor is to ignore the human being in front of you, and prefer the brand, whether it comes in the guise of identity politics or the DSM.
Appendix — The psychotherapy of Doc Martin, by Dr. Rachel Timoney
(This is a form of fan fiction, intended solely for educational purposes, that combines events from the Doc Martin TV show, Season 7, with stuff I make up.)
Dr. Rachel Timoney was looking forward to her first session with the eminent Dr. Martin Ellingham. She didn’t know much about him, other than he was rumored to have abruptly resigned his prestigious position as head of vascular medicine at Imperial College London. Chance would bring them together for an initial psychotherapy session. Dr. Ellingham (Doc Martin, to the locals) had taken a position in Portwenn, an isolated fishing village on the Celtic Sea. And she was spending a few months in Portwenn, writing and seeing a few patients.
Rachel Timoney was once considered a prodigy in her field. Nine years ago, at age 23, she was granted a doctorate in psychotherapeutic theory. Her research had gained a moderate bit of fame, even getting into a few newspapers at the time. Even she knew that being highly regarded as a psychotherapy expert at age 23 would be beyond stupid. Mathematicians do breakthrough work at 23. Physicists do breakthrough work at 23. Even those in the arts do breakthrough work at 23. Counselors do not do breakthrough work at 23. There are certain things you can learn through only experience, and if anything, those gifted in academia have typically sacrificed life experiences in order to excel in studies. There’s an age between infancy and senility that someone can become a good therapist, and it ain’t 23.
In the years following receiving her doctorate, Timoney has worked on living up to her reputation. She’s done well, but from what she knew of him, she believed that having Dr. Martin Ellingham in therapy would be a novel challenge. It proved to be that.
Seconds after he sits for their initial session, Martin informs Timoney that he expects she’d diagnose him as having attachment disorder. (Timoney notes silently that Martin describes himself as if he were a third party.) Martin explains that he was “an unwanted, unloved child” and gives a brief account of his upbringing by his cold and self-centered parents. (Later, Timoney would recount to her mentor that if Harry Potter had Doc Martin’s parents, rather than sacrifice their lives for his, they would have swapped him to Voldemort for a MacDonald’s breakfast Groupon.)
Martin makes it clear that he is aware of his interpersonal shortcomings. In discussing his marital difficulties, he accepts the entire blame. Responding to Martin’s depiction of his life, Timoney comments that he is as blunt with himself as he is with others. Martin had never considered that and feels his body relax into the thought.
At the close of the session, Timoney suggests that it’s rare that one member of a couple is the sole source of conflict and asks that his wife Louisa come for an appointment.
Dr. Timoney learns from their session that Louisa is an accomplished, articulate Portwenn schoolteacher. What Louisa is not, is eager to be in the session. She makes cracks about Timoney’s youth, implying that Timoney is inexperienced and naïve. Louisa contends that her martial problems are entirely due to Martin’s deficits in sensitivity and that he should (as the English say) get them sorted without her involvement.
Responding to Dr. Timoney’s questions, Louisa states that her parents were “fine, normal as you like,” moments later adding that her mother abandoned the family when she was 12, but “I didn’t really need a mother by then.” And, by the way, her father “spent some time in prison” when she was a young child. After listening to herself describe her childhood as normal as you like, with reluctance, Louisa agrees to attend couple counseling.
In Martin and Louisa’s first couples session, Louisa begins with an account of their relationship. Louisa describes their awkward courtship: boy gets girl, boy loses girl, boy marries girl, girl has baby, boy loses girl. If it were a TV show, Louisa explains, it’d be the usual get-them-to-watch-the-next-season stuff. But it’s not a TV show.70 Martin and Louisa don’t stay apart because of contrivances. They don’t miss a reconciliation because one of them is seen hugging an attractive stranger who turns out to be a sibling, while viewers yell explanations at the TV screen. Their problem is straightforward and never-changing. As much as Louisa wants to be with Martin, she’s constantly frustrated by his interpersonal limitations.
As Timoney has learned through her training, struggling couples often have repetitive interactional patterns that result in seemingly irresolvable conflicts. Commonly-used interventions or experiments (as she prefers to think of them) can be used successfully with many couples. For example, have them experiment with a small (but designed to interrupt) behavioral change in the middle of a pattern of conflict. Or, if one or both members of the couple believes that conflict is bad, and have no way to deal with anger and resentment other than to withdraw (after all, avoiding conflict worked for their parents, right up to the divorce), the therapist can design a practice for successful conflict resolution.
As we shall see, commonly-used interventions don’t work for everyone. And they do not for Martin and Louisa. Their pasts have left Martin with a limited repertoire of behavior and Louisa with small boundaries of trust. Their situation calls for a specialist, not a general practitioner. Timoney attempts three homework experiments that fail:
(1) Homework: Timoney has figured that Martin and Louisa have problems with physical intimacy, they are told to hug three times a day, while stating something nice about each other.
While it’s true that Martin is not a toucher, he does like holding Louisa. In this case, the not touching was an effect, not a cause of their psychological distance, and the homework just creates additional awkwardness. To add to the awkwardness, Louisa never thinks of anything positive to say to Martin.
(2) Homework: Because Martin is a control freak (affirmed by both Martin and Louisa), they are told to have an outing in which Louisa is in total charge. In theory, this will help balance their relationship.
Louisa decides on a picnic to the beach, where Martin is uncomfortable with the random elements of a beach and a picnic, but tries to give Louisa a normal family outing. The outing is eventually interrupted by a medical emergency that Martin must attend to.
(3) Homework: Martin and Louisa did not have a typical courtship, that is, they didn’t date. Timoney suggests some conventional courtship outings. Martin and Louisa plan a restaurant date.
In just minutes spent at the restaurant (because of yet another medical emergency that requires Martin), Martin and Louisa experience the whole of their relationship awkwardness.
There’s a smorgasbord of reasons why these homework assignments were doomed. Leave room for dessert:
First, two of the assignments were exercises to get Martin and Louisa to engage more. That’s more, not better. More, not different. There wasn’t anything in these exercises that would help them engage better.
Second, each assignment was bound to make Martin feel even more awkward and more vulnerable. Martin’s increased awkwardness exacerbated the very things that Louisa finds unattractive in her husband. That is not a recipe to increase intimacy.
Third, characterizing Martin as a control freak is simplistic. He’s compulsive — habitual and tidy, beyond what most consider practical. But he’s not trying to control the behavior of others; he’s trying to control his environment in which other humans happen to be present. Being habitual and tidy is a common adaptation for those who have dealt with psychologically chaotic circumstances, especially in childhood. Even more significant, as Martin desperately wants to be with Louisa, she has the most meaningful control, control over his happiness. Martin is in control of nothing beyond his medical practice; he’s the most psychologically fragile person in Portwenn.
Fourth, Timoney misses an opportunity (which I’ll explain below) to cast Martin in a more positive light, which could have contributed to a major improvement in their relationship.
In Timoney’s mind, if her tried-and-true conflict-resolution schemes don’t work, it can’t be her fault. She salves her shrinking-ego (pun intended) through the time-tested technique of blaming her clients. After Martin and Louisa inform Timoney that they won’t be returning, she tells them that they’re “one of the most challenging cases I have ever come across.”
Dr. Timoney gets a Mulligan (in golf, a do-over)
After Martin and Louisa decide to end counseling, Rachel Timoney feels relief, guilt, and regret — relief that she won’t have to watch herself struggle with her work, guilt that she feels that way, and regret that she did not help her clients. Timoney decides to confer with her old professor. Sure, he’s past his prime. He babbles too much, repeats himself, but now and then, he still conjures some inventive advice. But before she calls him, Timoney has a WTF moment. She knows what he’d say. Instead of calling her professor, Timoney contacts Martin and Louisa, apologizes for her last remarks, and states that she has some fresh ideas. Surprised by the apology, they agree to give counseling another try.
Anticipating the call to her professor, the conversation Timoney had with herself exposed that her interventions reeked of this worked in the past, so why be creative? She was being lazy: the experiments were designed with the relationship in mind, but not with the people in the relationship in mind. While couple counseling can counter interactional patterns that lead to relationship problems, that doesn’t mean you can ignore the distinctiveness that individuals bring to relationships.
Couples Therapy: it’s not just for couples anymore
Timoney notes that Louisa was right; she should have started with Martin. But not because he’s the one who needs to get his problems sorted. Despite the notoriety that Timoney got for her research, she forgot to implement her own hard-won knowledge. What her research yielded71 is that, when engaging in couple counseling, confronting a resistant client is rowing upstream.
Due to the influences of substance-abuse treatment and early family therapy, confronting clients became fashionable in the 1970s. When parents brought a child for treatment, they were told that the child’s behavior was usually a symptom of a dysfunctional marriage and poor parenting. A child client became labeled as the identified patient; the real patient, the parents were told, was the dysfunctional family, with the unspoken (and sometimes spoken) message that the parents were at fault. While confrontation made for dramatic teaching videos — therapist as action hero — the approach too often chased away the clients.72 After all, if the clients were willing to face their own problems, there wouldn’t have been all those identified-patient children in the first place.
Given the above, Timoney decides that the best course is to hold off on working directly with the relationship. As both Martin and Louisa feel that the major relationship problems lie with Martin, to avoid needless friction, Timoney opts for one-person couple therapy, the other leg of Timoney’s research.
Timoney (as have many before her) found that a change in one member of a couple can have a profound and positive effect on the relationship. Timoney knew that therapists have been practicing one-person couples therapy for decades, but have been intimidated against stating so by the family therapy mafia, who define family therapy by who comes to the session. That’s silly and never should have happened. Many family therapists apparently never moved past Piaget’s concrete-operational stage of development: once family therapy moved from the psychodynamic model to systems theory, it should have been obvious that if the client lives in a family, all therapy is family therapy.
Therapy with Martin
In discussing goals with Martin, he agrees that he would like to become more comfortable — fluid is the word agreed on — in his interactions with Louisa and with his infant son. He wants to make sure that he doesn’t recreate the relationships his parents had with him and with each other.
The experiments with Martin commence:
If you live in a cosmopolitan area where men commonly wear business suits, or you have watched episodes of Mad Men, you’ll notice that the men always unbutton their jackets when they sit and button them when they stand. A well-tailored suit jacket has no give, so a buttoned jacket pulls at the waist when the wearer is seated. Timoney jots this in her memory, because it provides an inroad into a subtle experiment.
From the time he rises to when he retires for the night, Martin dresses precisely the same, in a suit with the top two buttons fastened on his three-button jacket. And you’ll observe that he never unfastens his suit jacket buttons, even when building a sandcastle with his son on the beach. A change in dress will give Martin the experience that nothing catastrophic will happen if he changes one habit.
In order, over several weeks:
To help Martin have the experience of overcoming a compulsive habit: (1) Timoney asks Martin to unbutton his jacket whenever he sits. (2) Next, she has him leave his jacket unbuttoned all day. (3) Last, she asks Martin to buy and wear casual clothes on his non-office days (presumably, the weekend). While change in one habit may seem trivial, the experience of that change can be a dramatic confidence builder.
To help Martin expand his repertoire of interpersonal responses and range of affect, Timoney exploits Martin’s desire for an enhanced relationship with his son: As stated, above, it’s obvious that Martin wishes to be involved with his son’s upbringing in a manner that sharply contrasts with how he (Martin) was raised. But he needs instruction and encouragement. While Martin gladly holds and bathes James, he does not exchange facial or noise expressions. We can assume that Martin’s deficit is a result of being neglected in infancy, that no facial expression mirroring took place between Martin and his parents.
(1) Timoney asks Martin to exchange facial and noise expressions with James. As James has learned to smile from his mother, Martin has the opportunity to both initiate and respond. (2) Rather than exchange hugs (as above), Timoney asks that Martin and Louisa trade smiles. (3) Timoney asks Martin to progressively expand his gestures of relationship beyond his son and wife. First, smile at his aunt (the one other person for whom he has affection), then his receptionist, then patients. This mildest demonstration of affect can teach him to better interact with others.
Marital grad school
After the above experiments, Timoney asks Martin and Louisa to come in together, once more. The experiments yielded a larger shift in their relationship than expected. To Timoney’s surprise, Louisa discloses that when she first met Martin he was more outgoing and considerate. While never the life of the party, he was sensitive and generous to many in Portwenn and is acting that way again.73 Timoney realizes that she had made an assumption that Martin had always been this inhibited in his mood, sensitivity, and affect. Not learning otherwise was a rookie mistake.
Many couples have trouble in their relationship because they had no model of a good marriage. As both had parents with poor marriages, this could describe the experiences of both Martin and Louisa. However, some react the opposite of what you’d expect. Rather than stay away from marriage, because they experienced poor models, they idealize what a good marriage would be like. Timoney asks each of them what a normal marriage is like. After some discussion, both admit that, while they have fantasies of a normal marriage, they guess that no such thing exists. Timoney states that fantasies of the extreme, positive or negative, usually get in the way.
Wrapping up: In their solo session, Timoney had suggested to Louisa that, given her background of abandonment by her parents, she (purposely) married someone who would leave her. As we find out, Louisa believes the exact opposite, that Martin is the most dependable and loyal man she’d ever meet. Given her background of abandonment, it’s easy to see that she picked Martin, not because he would leave her, but because he wouldn’t. If Timoney had made a better effort to bring this to light, it could have changed the context of their marital relationship. If every time Louisa glances at Martin and sees not someone who has a limited range of sensitivity and affect, but someone who loves her without reservation and will always be there for her and their children, Louisa’s entire attitude towards their marriage could shift.74
In the final session, Dr. Timoney, Louisa, and Martin discuss the wide variety of successful marriages. They conclude that Louisa chose Martin for his loyalty, and Martin chose Louisa because he saw in her that he could get the warmth and connection he desired.
Appendix — Jailhouse Rock, a brief intervention
Part 1 – Short-Term Change Strategy: You can’t control any behavior but your own
In a town in South Dakota, I was working in emergency services, which included consultation to the local jail. The manager in charge of the jail guards called my boss and explained that they had a prisoner who was driving the guards and other prisoners crazy. My boss told the jail manager that she had someone who likes to work with that sort of thing. Lucky me.
The prisoner, a man in his forties was wreaking havoc. The crime that put him there was minor, but he was causing more problems for the jail staff than all the other prisoners combined. His jail transgressions included putting a match to his mattress and banging on his cell walls for hours on end; the noise, of course, drove everyone nuts. The jail staff disciplined him the only way they knew how; they took away all his privileges until there were none to take away. Despite the punishment, his defiant behavior continued. The baffled and frustrated staff had blown through their repertoire with no payoff. Far from being subdued, this man continued his incessant demand for cigarettes, but the guards were in no mood to reward him with the time to supervise his smoking, mandatory after he ignited a fire in his cell.
My boss met with me and suggested that we come up with a strict behavioral modification plan for the guards to implement. Instinctively, I shook my head side to side. The guards were already using an informal behavioral modification plan used by parents everywhere: eat your broccoli and you’ll get dessert. Or, in this case, behave and you’ll get smoke breaks when we have the time. If that was going to work, it would have already.
After meeting with the jail manager, I determined that the prisoner was not mentally ill, that his response to an intervention would be predictable. So I laid it out: The prisoner was to be given cigarettes, with the guard supervising his smoking, four times per shift at totally arbitrary intervals. By arbitrary, I explained that the cigarette breaks should in no way be connected to the prisoner’s behavior. I strongly cautioned against the guards referring to the cigarettes as a reward.
To obtain cooperation, I guaranteed success, but only if my instructions were followed to the letter. Of course (why else would I be telling this story?), the prisoner stopped his disruptive behavior, within the next shift. The jail staff was happy, the prisoner was happy, his lawyer was happy, and I was happy. No other problems with him arose during his two-month stay.
Why did the intervention work? The answer comes in two parts: the reason the prisoner stopped his early disruptive behavior, and the reason the prisoner did not cause any new disruptions during the rest of his stay.
The first part is simple. The guards and the prisoner got caught in a power struggle early on, but once the guards knew how they were going to behave — regardless of how the prisoner was going to behave — the power struggle was over. The guards knew that they were in control of their own behavior and stopped worrying about being in control of the prisoner’s behavior — a good idea since the only behavior you can control is your own.
Part 2 – Long-Term Change Strategy: Unearned Fish
If all there was to the above intervention was that the guards no longer responded to the prisoner’s disruption, I believe that the guards would have been in for an unwelcome encore of mischief. But there was a subtle alteration in the guards’ behavior that created a continuing change in the relationship between the prisoner and the guards: they gave the prisoner cigarette breaks, not as a reward, but as a kindness.
Once your basic physical needs are met, relationships become more important than anything else. And by relationships, I don’t mean just family, friends, and co-workers, I mean how you get along or don’t get along with everyone you deal with. Every person in your life, for better or worse, can have an effect on your sense of self, which is why you say thank you (or not) to someone you’ll never see again. Or why you might get into a stupid power struggle with prison guards, even when it makes your own life miserable.
People often respond to reward and punishment as you’d expect. If I tell my daughter that I will give her a candy bar if she cleans her room — and she does, and I do — I will draw the conclusion that she was motivated by the promise of candy. But what if she went along with my requests most of the time but not always? The most likely reasons for her occasional refusals are, that she is tired, that she’d rather do something more amusing at the time, or that she’s mad at me.
If my daughter prefers doing something else over the reward of candy, then my control over what constitutes a reward at any particular time is limited. Or, if my daughter is angry with me, then she’s not likely to either give me the satisfaction of a clean room or of accepting candy from me. My daughter may prefer to suffer the consequences rather than submit to my authority.
So what does this say about reward and punishment? That it cannot be separated from the relationship between the involved parties. By what’s most important to her at the time, my daughter gives me permission to reward her or not.
John Lilly was the scientist whose study of dolphins gave them Lassie-like popularity during the 70s. When he was training them to perform (as we humans would characterize it), he noticed that if the dolphin took too long to learn a trick, and was subsequently not rewarded with fish for a long time, the dolphin would become demoralized. That is, it appeared that the dolphin was having a more difficult time learning after a threshold of repetitive failures was reached. Lilly found that the training of the dolphin could be revitalized by giving “unearned fish.”75 The unearned fish was a reward despite the absence of success with the trainer’s trick. Lilly speculated that the unearned fish served to demonstrate (to the dolphins) that the relationship between trainer and dolphin went beyond rewards for learning tricks.
The strategy of unearned fish was stumbled upon after much frustration, failure, and false assumptions about the root of the dolphin’s behavior. The trainers had to break out of the mindset that they were dealing with only the dolphin’s modest desire to be fed. They had to allow for more complexity than simplistic views of reward and punishment. What was missing was the possibility that dolphin and trainer were in a relationship that went beyond a pure commerce exchange.
Back to my task at the jail:
I explained why the guards’ change in behavior had the desired effect in the short run: the guards knew that they were in control of their own behavior and stopped worrying about being in control of the prisoner’s behavior, which ended the power struggle.
Why did this seemingly non-sensical change in the guards’ behavior have the desired effect? Because both the jail staff and the prisoner were allowed to break out of their one-dimensional relationship with each other. Both had regarded all their interactions as part of a power struggle. The guards’ lone weapon was reward and punishment, leaving the prisoner with two lousy choices: surrender or defiance — neither with which he could feel comfortable. The introduction of a friendly gesture on the staff’s part — at the very height of animosity between staff and prisoner — allowed both an exit from their rigid, predictable stance.
The prerequisite for this working was that there be no catch whatsoever. Fine print would have cast the gesture in the same old dingy light. So unearned fish is not simply an undeserved reward. It is an assertion that the relationship between the giver and receiver of a reward is not solely dependent on what have you done for me lately? Or to put it another way, it implies the understanding that all relationships have a history and future (in the mind if not concrete terms). And most people (and some other mammals, apparently) prefer to be on good terms rather than bad. To change a relationship, sometimes all that is necessary is for it to be allowed to be different, and let nature take its course.
Don’t try this at home
The above is merely a description of a brief intervention that resulted in a hoped-for outcome. It was designed for a specific setting with specific circumstances. It is not intended as an example of how to get your kids to do their homework.
The take-aways for readers that I would hope for are the following: (1) You can’t control any behavior but your own. (2) If you’re locked in a power struggle, your way out is to know how you’re going to behave regardless of the behavior of the other party. (3) The reason why reward and punishment doesn’t seem to work so well is that it doesn’t work so well; people are complex with complex motivations. (4) No matter what the circumstances, relationships matter to people.
(Details were altered to protect confidentiality.)
Appendix — How to Work With Schizophrenics
Most important is how you relate. Unfortunately, it’s mostly don’ts.
Don’t expect your relationship to accumulate trust or predictability. Don’t assume that what happened in previous sessions will carry over. Forget Carl Rodgers and Person-Centered Therapy. Think Bill Murray in Groundhog Day.
Don’t use relationship language between you and the client. Don’t tell them they can trust you or that you care about them. Talk is meaningless; only your behavior counts. Don’t make any promises that you can’t make happen within five minutes (the lone exception is, if they bring up imminent harm to self or others, you can promise an eval from a mental health professional).
Counselors have dealt with clients’ delusions in a variety of ways. From “don’t talk like that, it’s crazy,” to discussing their delusional universe76, at length. Good luck with that. Given your task, it’s probably going to go nowhere useful.
What to do? It’s not that complicated. Do what you always do with clients. Whatever symptoms your clients are having (delusions included), how are those symptoms getting in the way of what they want? What they might want: to stay out of the hospital; to avoid being evaluated by mental health professionals for involuntary treatment; to see a mental health clinician less often. Whatever it is, that’s all you’re responsible for helping with. Occasionally, someone will want more. Great, help them with that.
Appendix — Playing the Black Card
Undergoing classic psychoanalysis, these days, is a bit like owning an American Express Black Card. The “Black Card,” (formally, the Centurion Card) is issued by invitation, only, and the lucky dot-com zillionaires pay a (in the U.S.) $7,500 initiation fee and a $2,500 yearly fee. Short of becoming a President of the United States (Presidents notoriously don’t carry a wallet) you can’t have more on-the-go financial prestige than the Black Card. Here’s the punch line: if you gave the chauffeur the day off, and you’re feeling cool tooling around in your Lamborghini, and you want to grab a cup of coffee, the most prestigious credit card on Earth probably won’t get accepted by the street parking meter.
Like the American Express Black Card, psychoanalysis is the expensive and prestigious kind of psychotherapy, but commonly not useful to help with the challenges of everyday life that often require relief within a short time. And why would a treatment invented in the late nineteenth century be the therapy of choice in the twenty-first? Nevertheless, having your “worried well” clientele lie on your couch for the traditional multiple hours a week, at several-hundred a session, while you sit behind them scribbling notes (or playing games on your iPad), is a gig any therapist would want.
Appendix — Psychotherapy as car reviews
Psychoanalysis — Rolls: Expensive, ponderous, impractical, real leather seating; almost no one really drives one. Very British, Upstairs (Super-Ego) Downstairs (id).
Hypnosis — Tesla: Fast and sleek, but quickly runs out of energy.
NLP: Not a car, a set of tools designed to work on all the dream cars that were never built.
CBT — SUV: Everyone drives one, even when something else is more appropriate.
Strategic — VW Turbo-Diesel: fast, efficient, and not always aboveboard77.
Gestalt — Jaguar: fast, sleek, and showy. Never gets you anywhere, because it’s better to look good than be good.
Rogerian — Prius: Dull and earnest.
Jungian — Citroen: Weird, for European snobs.
Psychiatry - DeLorean: the prestigious con78 that won’t go away.
Mindfulness - Electric cars: The next thing, until the next thing.
Solution Focused Therapy – Self-driving cars: You don’t know how it works, and sometimes it really does.
Gary Bloom worked in the mental health system for several decades, in numerous settings, with every client population, and every age group, while employing various counseling approaches. He dabbled in supervision, and taught several grad-school courses where he rates himself as under appreciated.
Gary lives just north of Seattle, where he fails to take part in hiking, biking, skiing, boating, and other staples of the Pacific Northwest. He does, however, manage the business end of his wife’s care consultation practice, train in Tai Chi, roast coffee for himself and his family, root for the Seahawks, fondle his beloved Apple devices, continue to give his adult children unsolicited advice, and refer to himself in the third person.
Wikipedia lists nearly 200 types of psychotherapy. ↩︎
Just a bit, ironic, eh? ↩︎
Prior to the 70s, short of being a convicted felon, the mother nearly always got custody. No-fault divorce law paved the way for shared child custody. ↩︎
I’m using psychoanalysis, generically, for psychodynamically-oriented psychotherapy. ↩︎
Even now, more than half of all licensed MFTs in the United States are in California. ↩︎
Ph.D., Pys.D, or (Ed.D in some states). ↩︎
Doctors, psychologists, social workers, nurses, and lawyers were also able to qualify for the MFCC license. ↩︎
Depending on the state, they might be known as Licensed Professional Counselors, Mental Health Counselors, and Licensed Professional Clinical Counselors. I use the term mental health counselors in this guide because that’s what’s used in my state. ↩︎
In some states, only psychiatrists and psychologists are authorized to work with the so-called severely mentally ill. ↩︎
If this is important to you, check with your state laws. ↩︎
In Nebraska, masters-level clinicians are designated with the same license, but may apply for a certification specialty. ↩︎
To be discussed more thoroughly in the education chapter. ↩︎
“Treatment” is a medical-model term, which doesn’t fit within systemic thinking. Unfortunately, it’s the only generally accepted term for providing counseling help. ↩︎
I’ll discuss the ramifications of this in the mental health system posts. ↩︎
National Association of Social Workers ↩︎
Contrast with masters in psychology, which is insufficient to get licensed as a psychologist. ↩︎
A masters in MFT, and in professional counseling, are also now terminal degrees, but as they are relatively recent degrees, in many healthcare agencies, they do not yet have the same professional recognition as MSWs. ↩︎
Private schools are not subsidized, and need all the students they can handle. ↩︎
Rorschach is a diminutive, but resourceful and violent crime fighter, from Alan Moore’s Watchmen. With this quote, he’s threatening his fellow prison inmates, most of whom are twice his size. Rorschach wears a fluid mask, designed after the Rorschach psychological projective test. ↩︎
Not really, since a couch implies psychoanalysis, and only psychiatrists were allowed to be trained in the United States as full-fledged psychoanalysts, until — wait for it — 1988. The powers that be at the American Psychoanalytic Association must have finally come to their senses, since the founder of psychoanalysis was training lay analysts (non-MDs) from the beginning. Nah, kidding, they did not come to their senses; the crusty old psychiatrists-only organization had to let in non-MDs because they lost a restraint-of-trade class action lawsuit to psychologists. Yep, the American Psychoanalytic Association lost because of the same law that broke up the Standard Oil monopoly in 1911. ↩︎
In some states, a doctorate in education, with an emphasis in in counseling, also qualifies for a license. ↩︎
Doctor of Psychology ↩︎
That is, they’re not psychiatrists. ↩︎
Sometimes, psychologists study animal behavior, seeking information that could apply to humans. Psychologists who go the animal studies route usually hope to become college professors. ↩︎
I’ll get back to this, but I’ll state here that it’s not hard to become a licensed clinician. The only absolute requirement is enough money to go to school, and the fortitude to make it through school and collect internship hours. The hard part is learning to become a good clinician. ↩︎
Edward Bernays ↩︎
Psychiatrists are well above the norm in killing only themselves. ↩︎
To be fair, family physicians and pediatricians prescribe the majority of drugs for anxiety, depression, and ADHD, while psychiatrists are more involved with the so-called severe mental illnesses. However, it’s the psychiatric establishment (American Psychiatric Association and Big Pharma) that legitimizes drug prescriptions for healthy reactions to life’s challenges. (You should be depressed after your divorce.) ↩︎
Of course, I’m not accusing every psychiatrist of ineffectiveness and corruption, but I haven’t personally run into a single one who displayed concern about the foundation of their practice. ↩︎
I try to avoid the term “mental health field,” but there’s no recognized alternative. ↩︎
More money than the other mental health professions, less than many medical specialties. ↩︎
Two generations, later, most psychotherapists are women. ↩︎
That joke is passé to anyone born during the 21st century. ↩︎
Please note: unlike most clinicians, I do not differentiate between counseling and psychotherapy. ↩︎
And to study physics, you must first have a good grasp of calculus. So study that first. ↩︎
I don’t really believe there’s a clear distinction of physical and mental well-being. All I mean by physical medicine is where the treatment is either medicines or surgery. ↩︎
Even when I don’t say “most states,” check with yours for their licensure requirements. Do not take my general statements as applying to you. ↩︎
The American Psychological Association creates internships standards. ↩︎
Each time I use the phrase, “most states,” you check that it applies to the one where you wish to practice. ↩︎
I’ve looked at several, not all. Check your state’s requirements. ↩︎
Don’t forget territories. ↩︎
I’ve since stopped renewing my membership in the AAMFT. ↩︎
Psychology Department - College of Science & Engineering - San Francisco State University. ↩︎
Same rules go for so-called messaging therapy sites such as Talkspace. ↩︎
I’m using the term, intern, very loosely, to mean anyone being supervised for licensing, or specific training (e.g., psychoanalysis, or cognitive-behavioral therapy) in counseling. Student implies still going to school. Supervisee isn’t a real word, Supervised brings to mind a verb, not a person. Trainee sounds like a McDonalds hire. Protege sounds like the supervisor is trying to create a clone. Mentee and mentoree aren’t real words and, ugh, anyway. You have a better term; send it along. ↩︎
HB was 23 years BB’s junior and started out as his secretary. ↩︎
Before it was widely labeled as such, Albert Ellis was a pioneer in cognitive-behavioral therapy. ↩︎
If you arrived at maturity in the 21st century (first of all, congratulations, many of us never matured), you may be under the impression that psychiatrists have always just done meds, that cognitive-behavioral therapy was always widely practiced, that systemic-based therapies has been, forever, taught in counseling programs, that Freud was just some old sexist pig who has nothing to do with how the great majority of psychotherapists still practice , and that Gutenberg invented the Kindle. ↩︎
My dreams were filled with flashbacks of post-traumatic English class syndrome. ↩︎
That is a quote. ↩︎
An approach that I would, many years later, find intriguing in Solution Focused Based Therapy. ↩︎
Coincidently, both Ms. Berliner and I earned an MS from San Francisco State, but did not complete our doctorates. (I was told that she couldn’t pass the required statistics class.) She was grandfathered into her psychology license. ↩︎
Mental Research Institute, Palo Alto, California ↩︎
Psychoanalysts might discuss the role of positive and negative transference here. ↩︎
Using so-called anti-psychotic drugs that act as heavy tranquilizers. ↩︎
I keep using the word status in counseling jobs. What do I mean? Though I believe most figure it out, quickly, I’ll explain. In the mental health system, status and pay have an inverse relationship with the difficulty of the clientele. The toughest jobs are usually anything to do with children, residential work, crisis and emergency services, case work with the chronic clientele, and hospital services — positions notoriously filled by overworked, overstressed, and poorly paid clinicians. At the same time, some psychoanalysts (especially, East Coast psychiatrists) make hundreds per hour listening to the worried well complain about their mothers. ↩︎
Yes, I am oversimplifying. ↩︎
Sookasa now also works with Google Drive, Box, and Microsoft Office 365, but only Sookasa’s Dropbox version currently has an iPad and iPhone app. ↩︎
In the most traditional approaches, add transference issues. ↩︎
Marriage counseling is different. Spouses usually come in with the motivation that the other person change. ↩︎
Counselors who pay large prices in order to get certified, are usually looking for a marketing gambit as well as a new skill. ↩︎
EBP can have an indirect positive effect on counseling. Commonly overlooked by clinicians is how useful concrete goals — an important element in EBP — can be. The very process of setting goals can produce more useful information than traditional investigations of family and childhood issues. In one promising style, solution focused brief therapy, an indirect but careful form of goal-setting (roughly, how would your life look if your problems disappeared?) is much of the counseling. ↩︎
Decades before the Kindle. ↩︎
We used to call that counter-transference. We still can. ↩︎
As a theory of change, insight has an undeserved emphasis. ↩︎
What we called them in the olden days. ↩︎
In other words, psychiatrists and Big Pharma made a lot of money, by promoting this fairy tale. ↩︎
Let me be clear that I include psychiatrists among this group. ↩︎
Well, yeah, it is. ↩︎
I’m making this up. The specifics of Timoney’s research were never brought up in the TV show. ↩︎
Reminds me of the old joke: The operation was a success, but the patient died. ↩︎
This change in point of view is a cornerstone of approaches influenced by the famous hypnotherapist, Milton Erickson, and in various cognitive-behavior approaches. ↩︎
Bateson, Gregory, Mind and Nature: A Necessary Unity (New York:E. P. Dutton, 1979), 123 ↩︎
I Never Promised You a Rose Garden, by Hannah Green ↩︎
VW installed software that deceived the pollution measuring devices. ↩︎
John Delorean tried to keep his company afloat by dealing cocaine. ↩︎