The Incorporation of Holistic Treatment into a Brief Treatment Framework

© Tammie Byram Fowles, MSW, Ph.D.

From:  Finding the Forest: Treating Survivors of Trauma Integrating Brief, Holistic, and Narrative Techniques by Tammie Byram Fowles

     Robert is 34 years of age.  He is divorced with three children to support. After child support is withdrawn from his paycheck, and rent and other essential living expenses are paid for, he has only $21.00 a week remaining. Robert's anxiety is growing by leaps and bounds. He hardly sleeps, has lost his appetite, has difficulty concentrating, and has begun experiencing shortness of breath and sharp pains in his chest.  Twice In the past week he has had to leave work early because he thought he was having a heart attack.  His physician informed him that he believed Robert was experiencing panic attacks and suggested counseling.  When he returned to work the next day his supervisor presented him with a written warning for too many absences, adding to his growing fear that he’ll be among those selected for the next rumored lay off.  Robert wants to see a counselor, but when he attempted to make an appointment, he learned that therapy would cost him a minimum of $60.00 per session until his annual deductible was met, at which point he would be responsible for $30.00 per visit.  He simply doesn’t have the money, and yet he fears for both his sanity and his life.  

     While both Robert and Sharon were in crisis and were motivated to seek counseling, tragically, neither of them managed to make an appointment with a therapist.  And they’re not alone; far too many Americans face similar dilemmas.  According to a mental health report delivered by the surgeon General’s office in 1999, “Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services.”[1]  The report also declares that the burden of mental illness on both health and productivity throughout the world has been "profoundly underestimated."  A 1996 study conducted by the World Bank, Harvard University, and the World Health Organization revealed that mental illnesses rank second (with cardiovascular diseases in first place) on the list of diseases that burden the United States and other countries with established market economies.  According to Michael F. Hogan, appointed chair of the president’s Freedom Commission on Mental Health in 2002, “America’s mental health service delivery system is in shambles.”[2] 

     As medical costs escalate, and funding for both mental health and social services are rapidly diminishing, the rates of depression and anxiety continue to rise.  In 2002, The Mental Health Association of Minnesota sounded the following alarm: “Today’s budget shortfalls further threaten a system that has suffered from a lack of coordination, insurance discrimination, and payments to providers that fail to cover the true costs of delivering care, ironically during a time of increased demand.”  Further, the association cited a daunting list of deficiencies in the current mental health and social services systems including cases where individuals were being turned away from inpatient units, psychiatrists not accepting new patients or having three to six month waiting lists, and the short supply of outpatient and support services available to those in need.

     The days of close-knit families and communities that provided ready-made support for just about every American are over.  Instead, the average adult today must often find his or her own way, constructing a safety net piece by piece. Children are often required to fend for themselves as their parents’ frantically struggle to keep the family intact, the bills paid, and maintain the household.  In this mobile and fast moving society where we've grown dependent upon grocery stores and electric companies, many of us are required to develop a new kind of self-reliance as we deal with the complexities of parenting, relationships and life crisis's without the loving concern of family, mentors, and old friends nearby.  Today, a number of people who might have in the past been able to turn to their established support systems, now resort to seeking the assistance of a stranger, a trained therapist, during difficult times. While yester year’s stigma of going to a therapist may have diminished in the new millennia, leaving more people amenable to using such services, sadly, it seems that many cannot afford it.

     Those who are in a position to obtain psychotherapy services often arrive at the therapist’s office with the expectation that he or she will administer a magical cure, while they, the recipients, remain relatively passive. Some people appear to view therapy as a process whereby all they need to do is to vent their feelings and divulge their private thoughts in order for healing to occur. Others are prepared to work hard within the confines of the therapist's office, only to resume their normal activities once the session is concluded, postponing further work until their next session.  Few recognize that healing requires as much and usually more effort between visits. 

    It's commonly believed that therapy occurs once per week, a perception that isn't necessarily so, and for many, isn't even financially possible. Therapy can provide significant benefits without the constraints of a weekly 50 - minute hour, particularly when utilized in conjunction with other resources. 

     Providers of medical and mental health services were not the only ones who suffered and continue to suffer the aches and pains brought on by the dramatic metamorphosis of our health care system.  The clients and patients for whom many of us trained so rigorously in order to effectively serve have sustained tremendous losses as well.  Initially I tried to minimize my clients' losses by redesigning my practice, and worked to repair the leaks in my own little lifeboat, so to speak, in order to survive the incoming tide of managed care. The truth of the matter is that my practice grew significantly as a result of my successful attempts to understand the politics, and win the favor of managed care companies.   

     During that time I heard repeatedly of the distress of clients who had been working successfully with therapists whom they trusted only to be informed by their insurance company that their therapist was no longer covered by their new insurance plan. I witnessed the anguish of a severely depressed woman whose therapist informed her that her weekly sessions would need to be reduced to monthly visits in order to ensure that her sessions were approved by her managed care case reviewer. I became painfully aware of the numerous people in need of services who were being placed on lengthy waiting lists. I tried for the most part to not think about them too much. My own craft was solid and sea worthy, and I had paper work to complete and people to see. I tried for a very long time to ignore my nagging concerns about some of the more disturbing aspects of managed care. Then one day I was forced to take a very close look at what was happening to my practice, to my clients, and to myself.  In 1995, weary of negotiating with case reviewers, and worn down by stressing my clients’ deficits and pathologies in order to obtain reimbursement for further sessions, I made the agonizing decision to close my practice. I made a promise to myself on the painful day that I closed my office door for the last time that if I ever were to work with clients again, I would never compromise my professional and personal beliefs and values in order to obtain payment for my services.  My doors remained closed for seven years.

     Brief Treatment from my view refers to therapy that is conducted in as time-effective manner as possible ranging from 1 to 20 sessions. The rapid rise of managed care not only makes utilization of brief treatment methods desirable, but necessary. As more and more providers of health care find their referrals increasingly limited by managed care companies, we are responding by attempting to adapt and adjust to the requirements of managed care.

     While there have been numerous models of brief treatment developed over the years, certain common characteristics exist among them including:

     The Provider, a newsletter distributed to providers by MCC Behavioral Care, recently published, Eight Characteristics of Therapy under Managed Care," based on the work of Michael Hoyt and Carol Austad. The eight characteristics established by Hoyt and Austad common to managed care are:

     Clearly, the model described by Hoyt and Austad isn't particularly compatible with the traditional, open-ended psychotherapy model that was the treatment of choice for so long. It is however, clearly in harmony with the tenants of brief treatment, in fact it describes the basics of most brief treatment models perfectly. Considering that the utilization of brief treatment methods is rapidly becoming a requirement of managed care, therapists are attempting in increasing numbers to respond to the demands this expanding trend involves. We make these adjustments for the most part in order to continue to serve our clients to the best of our abilities while also maintaining reimbursability by insurance companies. From my perspective, this is in some respects a time of reckoning (if we're able to put aside our indignation long enough to acknowledge the purpose of medical insurance in the first place.) Medical insurance was developed to assist subscribers in seeking treatment for illness, not to subsidize explorations intended to facilitate growth or reimburse therapists for providing marriage counseling. For a number of years that was exactly what insurance companies found themselves all too often doing. I hesitate to point out that wide spread abuses of the system contributed significantly to the current dilemma of therapists who all of the sudden find their work being policed by managed care companies.

     Our current interest in brief treatment in some respects can be viewed as a positive trend. While insurance companies insist that services be performed in a timely and cost effective manner, clients have the right to expect the same. However, if we simply scramble to incorporate the slickest brief treatment methods available in order to get the job done as expediently as possible, we run the risk of offering, in many cases, little more than a quick and all too often temporary fix.

HOLISTIC TREATMENT

     Brief treatment expects much (as it should) from both the therapist and the client, and it's here that I believe holistic treatment emerges as a compatible ally. In addressing holistic treatment as it relates to psychotherapy, I would like to first examine how the advent of holistic treatment creates a shift in roles and relationships. Traditional healthcare (the allopathic approach) places responsibility for cure in the hands primarily of the health care provider. The holistic approach returns it to its rightful owner, the client. While the provider clearly must take an active role in the resolution of the problem presented, clients are not expected to passively accept the ministrations of the provider, but must commit to doing their part. The central premise of the holistic approach, according to Richard Miles, contributing author of, As Above So Below: Paths to Spiritual Renewal in Daily Life, is that the individual is responsible for the development and maintenance of his or her health and well-being.

     Miles contends that the holistic approach rather than focusing on problems or symptoms, instead stresses the importance of clarity of intention and the development and maintenance of health and self-responsibility. In this context, problems may be viewed as a natural part of the life process as well as important feedback messages to be dealt with on a conscious level.

     A basic definition of the holistic practitioner, according to Miles, is one who provides the client with clear information about the processes of body, mind and spirit. With the support of the practitioner, the client is then able to make choices regarding a course of action that will offer more healthy and productive life experiences. In committing to a particular course of action, the client assumes ownership and responsibility for his or her own well-being.

     In accepting the holistic model, one acknowledges that everything we encounter and experience and are made of effects our health and well-being. All aspects of ourselves and our world including, physical, emotional, cognitive, spiritual and environmental play a role in the quality of our lives. This first premise is easily accepted; however, when one considers its' implication --that we must attend to all of the elements that compose our lives, the challenge is then presented. Placing our lives in the hands of experts to render solutions can seem far less daunting then the work involved in prevention and self-care. For example, it seems simpler to follow the latest fad diet to the letter than to address the wide range of issues connected to unwanted weight gain. Further, one is reinforced when the weight fades away with the use of such a diet. All too often, however, satisfaction eventually is followed by disillusionment later, when the pounds return or when some other difficulty moves in to take their place.

     Our practices are filled with individuals who ask us in one form or another to take their pain away. We would gladly oblige them and often try. We even succeed from time to time. The bottom line, however, as we all know, is that if our efforts are to be sustainable over the long haul, our clients will need to learn what steps are necessary for them to meet their own needs. They must also possess the motivation to act upon this knowledge. In spite of impressive techniques, modalities, and theories, there is no one magic bullet--no one particular insight, behavior, drug, or technique that results in lasting wellness. The very nature of life prevents this; we are always confronted with change and new challenges. Our stories are continually evolving.

     Holistic treatment requires that we stress to clients the importance of being responsive to all aspects of themselves. Brief treatment requires that we work efficiently, productively and responsibly. Both of these requirements (at a glance) might not seem particularly compatible, they still remain very clear obligations to me.

BirthQuake: The Journey to Wholeness

The most highly recommended Psychotherapy books

Workshops offered by Dr. Fowles

Back to SagePlace Home