Health care and human services are NOT profit making enterprises.

I don't operate my practice for profit, and as a Social Worker I see people in need of service regardless of their ability to pay. It's an ethical commitment when I joined the profession and is required in our code of ethics.

I realized when I chose the profession I would never get rich and could make a lot more money in many other professions. I chose Social Work though because of my values which have served me well for 54 years even though I often worked 2 and 3 jobs to derive enough income to support my family of nine children.

How mental health professionals ever chose to sell their souls to the insurance companies still mystifies me. I realize it is a slippery slope and people get sucked in slowly below their conscious awareness. Nonetheless when it becomes increasingly clear that the devil is in charge of the system, what makes people cooperate?

Framing - It's importance in psychotherapy and life.

Taken from Richard Nisbett’s book, Mindware, highlighting the importance of framing:

Consider the Trappist monks in two (apocryphal) stories. 

Monk 1 asked his abbot whether it would be all right to smoke while he prayed. Scandalized, the abbot said, “Of course not; that borders on sacrilege.”

Monk 2 asked his abbot whether it would be all right to pray while he smoked. “Of course,” said the abbot, “God wants to hear from us at any time.

Editor's note:

I learned about framing from Dr. Susan McDaniel back in the 1980s when she was training a group of us at Park Ridge Mental Health Center in Brockport, NY in strategic family therapy. The frame can make all the difference in achieving positive outcomes in psychotherapy.

Most of us are familiar with the idea of framing even though we might not call it that. Most of us are familiar with the question "is the glass half full or half empty?"

Framing also is called "point of view", "thought system," "perspective," "bias," "lens," "filter," and a number of other things. Framing is what contributes to our interpretation of the facts not the fact itself. Most of cognitive processing consists of interpretation which is the creation of our own reality and therefore an illusion. One of the fundamental ideas about Cognitive Behavioral Therapy, CBT, is to help the person change their frame so they can interpret their experiences in most positive and less depressing ways.

The basic existential questions.

The existential psychotherapy approach posits that the inner conflict bedeviling us issues not only from our struggle with suppressed instinctual strivings or internalized significant adults or shards of forgotten traumatic memories, but also from our confrontation with the “givens” of existence.

Yalom, Irvin. The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients . HarperCollins. Kindle Edition. 

Dr. Paul Pearsall wrote that the three big existential questions which most human beings consider are: why was I born, what is the purpose of my life, and what happens when I die? These questions rarely come up explicitly in psychotherapy but they are the background story lying in the unconscious whatever the client’s complaint. Sometimes they do come up in the course of therapy and the competent therapist must be able to manage them in a non anxious manner. Knowing the answers to these questions is the basis for understanding what makes a person tick. In order for the therapist to manage these concerns in a non anxious way, the therapist must have some understanding of his/her own answers. As the Temple of Apollo at Delphi famously had engraved over the entrance, “Know thyself.”

A competent human service professional is a lifelong learner

Since first entering the field of psychiatry, I have had two abiding interests: group therapy and existential therapy.

Yalom, Irvin. The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients . HarperCollins. Kindle Edition. 

Like Dr. Yalom from the earliest years of my career I was very interested in and practiced group therapy and what he calls existential therapy. Then in the 80s I had the good fortune to become trained as a family therapist and in the 90s I learned Solution Focused Brief Therapy and Narrative Therapy.

Throughout my practice I truly have been “eclectic” drawing ideas and models from various models of psychotherapy, but my fundamental understanding of human nature, functioning, and change is based on what is called the bio-psycho-social- spiritual model.

Social Workers are trained to conceptualize human behavior based on the “person in situation” model. The courses we take on human development and behavior are often labeled as “human behavior and social environment” HBSE. There usually are two or three courses. HBSE I, HBSE II, HBSE III.

Understanding human growth and development while helpful is not enough for the practitioner to be a good clinician. The practitioner has to learn how to apply this knowledge developing skills and competencies in working with clients individually, in couples, in families, in communities, in societies, and even multiculturally.

A good Social Work practitioner is always learning from clients, colleagues, scientists, and life. A good Social Worker is a lifelong learner and autodidact. I have always thought of myself, and sometimes refer to myself to others laughingly, as a “scholarly social worker” as I am always reading and studying for fun. I enjoy always learning more about human nature, social systems, and myself.

Whither psychotherapy?

So I worry about psychotherapy—about how it may be deformed by economic pressures and impoverished by radically abbreviated training programs. Nonetheless, I am confident that, in the future, a cohort of therapists coming from a variety of educational disciplines (psychology, counseling, social work, pastoral counseling, clinical philosophy) will continue to pursue rigorous postgraduate training and, even in the crush of HMO reality, will find patients desiring extensive growth and change willing to make an open-ended commitment to therapy.

Yalom, Irvin. The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients . HarperCollins. Kindle Edition. 

Social Workers make up the largest percentage of mental health professionals in the United States at about 60% while psychiatrists make up 10%, clinical psychologists 23%, and psychiatric nurse practitioners about 5%. There also are other groups of licensed mental health professionals in some states such as licensed mental health counselors, and licensed marriage and family therapists.

Increasingly, health insurance reimbursement for psychotherapy has been restricted and made difficult to access. As a married male with nine children I was forced out of private practice because with reimbursement rates from insurance companies for a unit of service so low, and there are only so many hours in the day, revenue did not cover my practice expenses and cost of living. At this point of my life, at age 77, I still practice 3 days per week seeing about 20 clients per week and I am what I call a “gentleman psychotherapist” like a “gentleman farmer” in yesteryear. 

Dr. Yalom is very optimistic about psychotherapy continuing as a profession. In our current climate of telehealth it has devolved into case management and psychoeducational coaching for symptom relief.

To continue, psychotherapy will have to be rebranded as an activity other than a medical service. Psychotherapy is more akin to education and the facilitation of growth and development. Mental health services sold its soul to the devil when it sought health insurance reimbursement as a commodified service targeted to symptom reduction rather than personal growth.

There are other paths to consider such as considering mental health as a public health concern as was the case during the days of the Community Mental Health Model following deinstitutionalization of State Hospitals. This will require a return to deficit financing of agencies such as community mental health centers.

"This is good. I feel so much better."

‘All sorrows can be borne’, the writer Karen Blixen once said, ‘if you put them in a story, or tell a story about them’, and this belief is often thought to lie behind much of the work of psychoanalysis: not just a talking cure but a telling cure.

Green, Kelda. Rethinking Therapeutic Reading: Lessons from Seneca, Montaigne, Wordsworth and George Eliot (Anthem Studies in Bibliotherapy and Well-Being) (p. 7). Anthem Press. Kindle Edition. 

Listening, attentive listening without interruption, is such a rare and healing experience. Being a sounding board, a shoulder to cry on, an empathic presence who becomes what Alice Miller calls "an enlightened witness" is one of the most difficult and significant activities of helping. Edwin Friedman calls this kind of listening the activity of providing "a non anxious" presence.

Suffering shared is reduced in intensity and creates a perspective of of increased objectivity so that it can be managed.

After this kind of listening I will sometimes ask, "What do you call it?" or "What do you make of all this?" or "What is the moral of the story, the lesson to be learned." We discuss this for a while struggling to find a name for the causes of the suffering. I often point out, "If you can't name it, you can't manage it. Naming it is 90% of getting on a better track."

Then, I ask, "What more did you want to get out of our meeting" and the person often says, "This is good. I feel so much better."