What, Another Rough Week?!?
After another rough week (the insurance company I mentioned last time put the kibosh on yet another of my dear insurance clients’ therapy), I have been philosophical this weekend about the work I do and what I see unfolding hour after hour on the couch in my office. What makes therapy meaningful and transformative?
There are probably as many answers to that question as there are theories of psychotherapy, but the insurance companies I have worked for will tell you (and have told me repeatedly) that Cognitive Behavioral Therapy (CBT), and only CBT is acceptable under my clients’ insurance plans. I have nothing against CBT as one tool among many that competent therapists wield, but to say that CBT “cures” Generalized Anxiety Disorder (which, to my understanding, is likely due to a biological propensity) in 16 sessions (as stated in said insurance company’s guidance to clinicians) is ridiculous at best. Insurance companies’ love affair with CBT is a result of the copious amounts of money that Aaron Beck, the originator of this treatment modality, and his colleagues have managed (impressively!) to garner for research into the effectiveness of Beck’s baby, CBT. Because of this Everest-sized mountain of research, CBT is considered an “evidence-based” treatment, and the many other psychotherapy methods (which therapists working with clients day after day know are equally as or even more effective in creating long-term change) are overshadowed. The dominance of CBT in our field (at least for those of us still working with insurance companies) reminds me of the joke about the fellow looking for his keys at night, under the light of a streetlamp. When asked where he lost his keys, he points to the darkness beyond but says he’s only looking under the lamp because he can’t see outside the light it casts. In the case of psychotherapy, the darkness beyond contains so many riches, which, unfortunately, have not been as well-researched or as well-publicized as has been CBT. Some of these “riches” include psychodynamic psychotherapy (see my last blog post for research references proving the efficacy of this type of therapy), EMDR (the standard 90-minute sessions of which are not reimbursable, according to the insurance company of which I speak, and which has 20+ years of research backing its effectiveness: www.emdr.com), interpersonal psychotherapy (www.interpersonalpsychotherapy.org/about-ipt/: this website contains references to research articles indicating its efficacy), Emotionally Focused Therapy (www.iceeft.com: this website also contains references to research articles), and so many other transformative forms of psychotherapy.
So, What’s the Real Scoop? (Or What in Heck is Really Happening on That Couch?)
A small group of dedicated researchers has been studying the question that’s been gnawing at me this weekend for some years now: what really creates transformation in psychotherapy (Bruce Wampold and Michael Lambert are some big names in this field, and my beloved ex-supervisor, Dr. George Rosenfeld, PhD wrote a lovely book on this topic and his life as a psychotherapist: Beyond Evidence-Based Psychotherapy http://amzn.to/W1bJjJ).
Their research has shown that certain common factors are a better predictor of positive psychotherapeutic change than are particular treatment modalities (such as CBT). The common factors research points again and again to the quality of the therapeutic relationship between the client and the therapist as a huge predictor of client improvement, regardless of the type of psychotherapy being offered. I know this in my heart as a therapist, but when I suggested to the most recent insurance reviewer that my client cited the support I gave him (i.e., our relationship) as being key to managing his stressful life, the response I received was: “support plays no role in psychotherapy.” I was flabbergasted, and, after a brief, shocked pause, did my girl scout best to defend the power of the relationship I have with this client. But the reviewer just talked over me and would not hear what I had to say. It’s a sad day for psychotherapy when insurance companies treat therapists with disrespect, act as if we are interchangeable (i.e., the particularities of the therapeutic relationships don’t matter), essentially limit therapy for all but clients in crisis, minimize the power of and disallow all approaches except CBT, and assume long-term biologically-based issues can be “cured” in a handful of sessions. Insurance companies, because their main focus is to save money by limiting service, will never be a good source of payment for the most meaningful, transformative things that happen in my office and on that couch of mine: a nuanced, complex, delicious mix of interpersonal interaction between me and my adored client, which is at times very practical (I can hear Aaron Beck smile), but is often unpredictable, requires huge amounts of energy and creativity on my part, is occasionally messy, is sometimes confusing, can be frustrating, is essentially ineffable, and is ultimately, at least for the majority of folks who are committed, do their work, and stick with it for whatever amount of time it takes, change-inducing and healing. I’ve seen this meaningful, transformative therapy happen before my eyes many, many times. That is what keeps me coming back to that chair across from the couch, and why I know I have the best job in the world (despite these repeatedly difficult conversations with insurance reviewers). That’s my view of the couch.