Building A Practice You Can Live With
In Heoric Clients, Heoric Agencies: Partners for Change
Barry Duncan and Jacqueline Sparks
Nova Southeastern University, 2001
When I was part of the team that founded the Brief Family Therapy Center and ultimately developed the Solution Focused Brief Therapy Model, it was exhilarating to do outrageous things like kick resistance out of the therapy session and replace it with cooperation. Dabbling with revolutionary ideas infused me with unbridled enthusiasm and I joined a team of therapists that developed a mental health department at a new HMO. Together, staff therapists and administrators cooperated to create a system that put clients needs first. We presumed that the way to save money was to help members solve problems of living and alleviate stresses that could potentially exacerbate health problems. Physical health problems, as research has long since verified, are far more costly to treat in the long run.
In our fantasy come true system, DSM diagnoses were not requiredWe ensured our clients privacy by avoiding giving them mental illnesses in the first place. Instead, we listed problems in living as simply individual, couple, or family. Our clients were people seeking solutions. They didnt fit neatly into problem categories and the thought of developing specialties to address specific problems didnt even occur to us. Our case notes were intentionally sparse and purposefully vague. Protecting peoples privacy is essential to the promotion of a cooperative relationship.
There were two psychiatrists who worked for the department, however they did not supervise us. We certainly did have our differences. However, by avoiding hierarchically determined power designations, we were able to cooperate with each other in the best interest of client care.
In addition, I was able to create a two-year intensive training program and a paid internship with insurance benefits for new clinicians. During my tenure in this organization, over twenty-five therapists were able to meet the criteria for clinical membership in the American Association for Marriage and Family Therapy (AAMFT), and several of my colleagues achieved the designation of AAMFT Approved Supervisor. I was proud of my accomplishments and of the king of practice that I offered.
Does it sound too good to be true? It was. I doubt it could have been saved no matter what we did. I look back now and think it was a happy fluke. The HMO was young. Its administrators were busy getting their act together in other areas of service provision. I think at some level we knew we were getting away with something. Then all hell broke loose!
Every thing changed when a separate management company was formed and a medically oriented administrator took over. To the new managers, we looked different from other mental health providers and they got nervous. One of the most painful experiences of my professional life was experiencing the systematic destruction of everything we had built and the insidious poisoning of the cooperative relationships between staff members.
The new managers put psychiatry and the DSM in charge of gate keeping. The new system of keeping records seriously compromised the confidentiality of our clients. I found myself in an untenable position. On the one hand I was encouraging students to listen to their clients, respect them, and work with them to achieve their goals and outcomes. On the other hand, I had to tell them they must abuse and disrespect their clients with diagnoses, referrals to psychiatry for drugs, and paperwork that would cover their asses but would also compromise their clients integrity, credibility, and confidentiality. How could I preach one thing and tell them to practice another? I couldnt.
Four colleagues and I quit our jobs without one to go to. To attempt to implement the invaluable experiences we had at the HMO, three of us joined the Wisconsin AMFT Marketing Task Force. We organized ourselves around two very important ideas. One was our common identity as non-pathology oriented therapists. The other was that our clients needed to be an integral part of the plan. Our mission was to reach a market and provide our services to a better-informed public. The fact that so many AAMFT members were able to put aside their differences regarding models of therapy and focus on their similarities regarding a non-pathology orientation to achieve a common goal was quite an accomplishment. We were riding high once again.
With Barry Duncan and Scott Miller at the helm, a heroic effort and a gargantuan campaign to mobilize members in protest of the infamous brochure and all it stood for was launched. Some members perceived the liaison with the Drug Company as a way to better position themselves within the broader mainstream delivery system. Many were just apathetic. Others saw this liaison as the selling of our very heritage as MFTs. Those of us who protested the notion of prostituting ourselves to the medical power system were in the faces of those who were on the fence, and those who had already sold out. Thats not prostitution we told them, thats rape! Many didnt want to hear it.
Sounds dismal doesnt itmy perfect job crumbles before my eyes and my professional organization betrays me at my hour of need. But this is not a melodrama or the end of the story. Patty Barrett and I decided to strike out on our own without support from local or national organizations. We formed a Limited Liability Company called Confidential Counseling Services.
We decided that we would develop and market a practice based on our own ethics. Our clients are the customers, and we will not sell them out. We agreed we would not accept insurance payments for our services. We would not be the states agents of social control and therefore we would not see court ordered clients. We would not stigmatize people with useless diagnoses of mental illness. We would not share records with third parties, period.
We bill ourselves as problem solvers who can help people solve problems of everyday living. We keep our expenses down. Our business phone is in my home, and I am the receptionist. Patty takes care of our financial responsibilities, our record keeping and banking. We believe our services are valuable. We keep our rates reasonable and do not offer to slide the fee.
Some of our colleagues in private practice would have been happy to have us join them. A number of them offer clients the option of paying cash for services. We could not, however, affiliate ourselves with an existing clinic because State Certified Outpatient Mental Health Clinics in Wisconsin are mandated to use diagnoses from the DSM IV even when clients pay cash. Wed come this far and we were not about to compromise our ethics now. Three separate clinics agreed to rent office space to us on a per session basis without requiring us to formally join their practice.
Patty and I were on a mission t inform the public about whats wrong with the current mental health delivery system. We thought this would be the way to build a practice. We were wrong. We developed and distributed thousands of flyers and presented our expose at churches, schools, and professional workshops. It gradually became obvious to us that our negative advertising campaign was not producing the results wed hoped for. Weve learned that we need to let people know how we can be helpful to them, period. They get the picture soon enough when they call to inquire about our services or to make an appointment. We explain why we do not accept insurance payments. Very few potential clients decide not to see us because they choose instead to use their insurance. When that happens, we have an opportunity to arm them with questions they need to ask their therapist about diagnoses, confidentiality, and drugs.
Another thing weve learned is that tenacity pays off. I started writing essays about change strategies that people could use in their daily lives and began looking for a place to get them published. I targeted a community newspaper with a circulation of over 300,000 paying subscribers. I sent them about thirty of my essays in small batches before they agreed to give me a biweekly column. This column has become my best source of referrals.
We also learned that a positive attitude and personal contact with potential referral sources are essential. My partner became much more actively involved in the very large church to which she and her family belong. She leads parenting groups and makes herself available to do presentations periodically. She has gotten to know a number of the twenty ministers and her referrals have picked up as well.
While we do not drive Mercedes, we sleep well at night. We provide a valuable service for people who want help but do not want to go through the insurance and social control channels to get it. Some of these people might deny themselves this help if they didnt have a place where they could be protected from the system. I believe there is a larger market out there, and if we were into creating a larger practice we could reach mor of that market. For now, the small practice allows us to provide a service with integrity and we have the time and energy to concentratecreating, researching, and promoting our latest project, a program to help schools deal with violence and bullying.
However, just when I was off and running in a positive new direction, a former colleague asked me to give a speech at his church about the pathologizing of our culture. At first I said no. Im tired of that same old fight. Then I reconsidered and put together and delivered the paper that is currently available as an editorial on Scott and Barrys talkingcure.com web site. Another colleague was teaching a course in ethics for social workers. I asked him, How can we operate ethically within the context of a basically unethical system? To his credit, he invited me to present that question to the students in his course and to my credit, I accepted.
Sometimes I ask myself, why do I keep doing this? Why do I keep protesting the current state of affairs in the Mental Health Industry? I think about how psychiatry is messing with our minds, and literally with our brains. I think about how psychiatry, managed care, the drug companies, and our court system are insidiously robbing our clients of their liberty and excusing them from personal responsibility, and how they are using us to help them do it. I dont like being used and when I look at it this way, I do not question the why. I simply move on to the how. There are times when its essential to protest.
I use my column to promote solutions and strategies that work, and for consciousness raising. I also use it to promote cooperation over competition. I think the system I helped to develop at the HMO seventeen years ago was utopian. It could not have survived in the context of the larger social system, and we cannot, nor should we, go back there. The creation of that system was not a total failure however. In fact, I think of it as a huge success. If success or failure were determined solely on longevity, wed all be failures.
As for me, Im doing the work I love with integrity, and I am paid for doing it. The creative and cooperative experiences Ive had have immeasurably enriched my life on a personal level. I have something new and positive to work on, and I have a life.
These things I know for sure: We owe it to our clients to keep them from being abused by the system that is supposed to be helping them and our clients are our most powerful partners for change. I know that the ups and downs of this long and winding road, I must continue to be able to look myself in the mirror each day, and build a practice that I can live with.
Building something new is much more invigorating than criticizing the old. There are changes that can be made from within the system.