Once upon a time, the only psychotherapy to speak of was Dr. Freud’s psychoanalysis: Typically, the patient would come in—usually for an hour or so five times a week—lie down on a couch, and talk about whatever came to mind. This process would generally continue for a number of years until (as Freud put it) the patient’s “neurotic misery” was transformed into ordinary, everyday misery. (Freud must have been a lot of fun around the water cooler.)
Today, there are hundreds (if not thousands) of approaches to psychotherapy, most of which aim at more specific kinds of symptom relief. Although opinions differ as to how long psychotherapy treatment should take, most therapists today would probably agree that “years”—plural—is a little long, and that more than one or two sessions per week is a bit excessive. Today, the buzzwords in therapy are “brief,” “solution-focused,” “time-limited,” and “short-term.”
Furthermore, continuing economic pressures are increasingly forcing therapists to try to see more and more clients each day simply in order to stay in business, while increasing regulation of behavioral health services by government and Managed Care Organizations (MCOs) has resulted in an explosion of paperwork. Like everybody else, therapists are working hard to do more faster, and with less in the way of resources. It’s not surprising that quite a few things glossed over or entirely lost in the shuffle of initial paperwork and orientation to therapy.
1. Managed Care is My Copilot
Regardless of whether you are using insurance to pay for services, chances are that the changes Managed Care has brought to the business of psychotherapy are having some impact on your access to and experience of therapy.
Managed behavioral healthcare aims to reduce the costs of mental health treatment while maintaining a high standard of quality with regard to the treatment that is provided. The idea, crazy as it sounds, is that services should be (and can be!) made more affordable by streamlining, centralizing, and standardizing many aspects of care. Managed Care Organizations (MCOs) frequently review therapists’ files as part of routine Quality Assurance (QA) audits. Many MCOs will agree to pay for only a few sessions at a time, and require that the therapist provide a verbal or written assessment of the client’s progress in therapy before authorizing more sessions.
The vast majority of MCOs are only willing to pay for psychotherapy as treatment for a specific, identifiable psychiatric condition. This means that if you are using your insurance to pay for treatment, your therapist must submit a psychiatric diagnosis with his or her bill. The treatment plan you develop with your therapist must include interventions designed to address the symptoms associated with your diagnosed condition, and your therapist’s case notes for each session should reflect the goals and interventions identified in this treatment plan. Some MCOs require that particular Empirically Validated Treatments (EVTs) be used in the treatment of certain psychiatric conditions.
Even in these scientifically enlightened times a lot of people remain wary of being labeled “mentally ill.” Furthermore, there remains considerable disagreement over the reliability, validity, and usefulness of psychiatric diagnosis. Words have power, after all, and a diagnostic label can seriously impact the way both client and therapist view the problems to be addressed in therapy. This brings us to…
2. Your Diagnosis Isn’t The Most Important Thing About You—Or Your Therapy.
So if you’re in therapy, odds are you’ve been diagnosed with at least one psychiatric disorder. Perhaps your symptoms have been classified as “Major Depressive” or “Bipolar” Disorder. Maybe you meet the criteria for “Panic Disorder” or “Attention Deficit Hyperactivity Disorder” (ADHD). Or it may be that you are experiencing an “Adjustment Disorder” in response to some recent stressful event. In any event, your therapist, doctor, or psychiatrist will likely have gone over the symptoms with you, as well as the types of treatment that usually help people recover.
For many people, receiving a psychiatric diagnosis is accompanied by a feeling of relief. After all, if there’s a name for what ails you, then you’re certainly not the only person ever to have experienced this particular flavor of distress. What’s more, since others have blazed this trail before you, it’s likely that somebody’s figured out some treatments that work!
Some people find the diagnostic experience a little less pleasant. Psychiatric diagnosis is far from a precise science: what one doctor or therapist describes as “Anxiety” may be seen by another as “Mania.” Sometimes receiving a psychiatric diagnosis can feel profoundly insulting or dehumanizing. Somehow a list of symptoms doesn’t do justice to the actual struggles of most clients.
There’s a lot that’s right about all of these reactions to psychiatric diagnosis. It’s important to remember that scientists are still puzzling out the mysteries of body, brain, and mind, as well as the impact of society and culture on this nebulous concept we call “mental health.” Some of the very same medications may be used to effectively treat anxiety, depression, and other psychiatric conditions, and the same general principles and techniques often guide psychotherapy for a relatively wide variety of psychiatric disorders. A good diagnosis does indeed offer hope based on the scientific investigation of mental illness and human behavior, but does not define individual human beings, their problems, or any single best course of treatment. Psychiatric diagnosis is only a starting point: a beginning, rather than the end of treatment.
3. Therapy Does Not Equal Forensic Evaluation
It's not uncommon for therapists to be asked to provide documentation to support a client's legal case, generally as part of a divorce proceeding or disability claim. This can be a bit tricky from the therapist's perspective for a couple of reasons.
First of all, the focus of therapy is to help client “get better”--which is usually assumed to involve both reducing symptoms of emotional distress and increasing the client's engagement in day-to-day activities. This means that the general focus of the therapist's thinking—and therefore of his or her case notes—is toward helping the client to find ways to be self-sufficient, independent, and active in work and leisure activities. Though not entirely incompatible, this philosophical stance often seems at odds with the client's legal argument that, for example, he or she is unable to work.
In addition, most therapists' assessments and case notes are designed to document client responses to therapeutic interventions and progress toward goals. Again, although this does not necessarily mean that such documentation is irrelevant to legal proceedings, its usefulness may be limited—especially since therapy notes are usually based entirely on the client's report and observations made during session by the therapist.
Therapy notes are best used to show that a client regularly participated in psychotherapy to address a given problem or psychiatric condition, to document his or her reported response to treatment, and to record therapist observations. Individuals seeking psychological or psychiatric assessment solely to support a legal case are usually better served by seeking the services of a psychologist or psychiatrist who specializes in court-related evaluations.
4. Your Confidentiality is My Priority
Confidentiality has always been an essential aspect of psychotherapy. Most of the concerns addressed in therapy are quite personal, somewhat embarrassing (at minimum), or potentially devastating to the client’s close relationships or career. Client-therapist confidentiality is protected by a number of state and federal laws, as well as the ethical codes of every professional organization of psychotherapists. The basic rule of thumb is that without a written consent, signed and dated by you (or, in exceedingly rare circumstances, ordered by a judge), your therapist can release absolutely no information about you or your therapy; this includes acknowledging that you are even receiving therapy at his or her office!
This emphasis on confidentiality can sometimes result in awkward or frustrating experiences for clients. Say you bump into your therapist at the grocery store: Unless you make a point of stopping to greet him or her, your therapist may appear not to notice or recognize you at all. This is probably not merely a case of your therapist being an ass (although, alas, psychotherapists are human beings and thus perfectly capable of making asses of themselves from time to time!). Your therapist is most likely trying to respect your privacy and the confidentiality of your relationship.
Of course, there are times when a therapist is legally and ethically bound to break confidentiality. Therapists must break confidentiality when in their professional opinion there is an imminent threat of physical harm to the client or someone else. In these situations, the therapist must share whatever information is necessary to protect the client or others from harm. In cases involving child or elder abuse, the therapist will contact the local child or geriatric protective services agency. When the situation involves threats of suicide or homicide, the therapist will usually take steps first to make a safety plan or contract, or to convince his or her client to seek voluntary admission to an inpatient psychiatric unit. In some cases, the therapist must contact police or seek an involuntary commitment order to force the client into inpatient care.
This does not mean klaxons start blaring every time a client mentions thoughts of death, or in frustration exclaims that “Sometimes I’d just like to kill that so-and-so…” The key term here is imminent danger. Many people (perhaps most people!) find themselves thinking about suicide at one time or another in their lives, and intense feelings of anger or frustration can often be expressed using violent imagery. In order to break confidentiality, the therapist must assess the seriousness of the threat, including (among other things) both the feasibility and potential lethality of any of the client’s plans.
5. I Want You to Feel Comfortable, But My Job is To Challenge You
Most therapists working today would probably agree that one of the essential conditions for successful therapy is a therapeutic relationship between client and therapist. This kind of relationship is generally characterized by three qualities: genuineness, empathy, and unconditional positive regard on the part of the therapist.
Genuineness simply means that the therapist is honestly invested in the client's therapy; there is no artificiality or submersion in some sort of professional role, and the therapist is honest with the client regarding his or her responses to material discussed in therapy. Empathy is the therapist's ability to accurately assess the client's feelings and personal meanings regarding material discussed in session, and to communicate this understanding to the client; this enables the client to “feel heard” and understood in therapy. Unconditional positive regard is simply non-judgmental acceptance of the client as a human being, regardless of the client's feelings or past experiences. The therapist communicates an honest, nonpossessive caring attitude toward the client, allowing the client to experience and share emotions and thoughts without fear of being judged.
This does not mean that the therapist must approve of or agree with everything the client says or does, nor does it mean that therapy is all “warm fuzzies” and narcissistic self-indulgence for the clients. It is quite possible (and also quite necessary!) to remain genuine and to communicate both empathy and acceptance while at the same time disagreeing with a client. This is the art and challenge of psychotherapy!
Effective therapy is often very much focused on change: The client, after all, usually seeks therapy out of a desire to change some difficult situation or recurring feelings of emotional distress. Part of the therapist's job is to help the client find ways to make these changes possible—and reminding the client that no-one (not even the therapist) can make these changes for him or her.
Yes, a good therapist wants the session to be a “safe,” place for the client. Yes, a good therapist will often take steps to make the office as welcoming and comfortable as possible. And yes, a good therapist will continually challenge the client to re-examine old beliefs and behavioral patterns, and to experiment with new perspectives and ways of doing things.
References and Further Reading
Freud's quip about misery can be found in the concluding paragraphs of Josef Breuer and Sigmund Freud's Studies in Hysteria.
More information regarding the therapeutic relationship can be found in:
Rogers, Carl. (1995). On Becoming a Person: A Therapist's View of Psychotherapy. New York: Houghton Mifflin.
Rogers, Carl. (1980). A Way of Being. New York: Houghton Mifflin.
Yalom, Irvin. (2002). The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. New York: HarperCollins.