Reinventing the Growth Psychology Agenda:

 Towards a Therapeutic Counter-Culture

Maureen O'Hara, Ph.D.

 

The Need

I have been consulting with groups of MFCCs, social workers, and psychologists who are concerned about their future in an era of industrialized health care. The question on everyone's lips is, "Are depth psychotherapists a doomed species?"

 

The crisis is particularly intense for humanistically-oriented therapists who ask if they should accept the advice of professional groups like the American Psychological Association (APA) to retool by learning short-term symptom-focused behavioral approaches; should they leave the field altogether and open a bookstore (New Mexico is hot); or should they remain authentic to their original calling as whole-person healers, reject the MCOs (managed care organizations), and reinvigorate their own community of practice outside the medical sphere?

 

My reply is that psychotherapists have little to lose and a tremendous amount to gain if they reject outright the industrialization of the field, speak out about its unethical and dehumanizing practices, and lay out their own alternative growth-focused agenda outside the health care system altogether. Looking at evidence from the MCOs themselves, from what kind of services people want and value, and looking at social trends and new demographics (see Paul Ray's article, page 9), I believe the time is ripe for a new non-medicalized psychology profession which can effectively and economically address the deeper-felt psycho-spiritual needs of the coming century.

 

The Marketplace

Health care economists report that a vast and enlarging market exists for psychotherapy practitioners who will attend to deeply felt psycho-spiritual needs and to a range of mental health and psychological growth concerns. Americans as individuals and as a society have a long-standing commitment to self-improvement, self-fulfillment, and the pursuit of happiness. In 1994 alone 35 million Americans sought out some form of psychological counseling, psychotherapy, or psychiatric services. Countless others attended psychologically-oriented classes in public and private universities, colleges, junior colleges, and extension programs, churches, synagogues, and growth centers. Over 25 million bought self-help books. The most popular titles have to do with psycho-spiritual concerns such as care of the soul, improving relationships with each other and with the planet, good parenting, and recovery from a range of addictions.

 

We must interpret this as clear evidence that participation in activities which address a spectrum of psychological concerns, from the relief and healing of debilitating, mental suffering at one end to the pursuit of happiness and higher levels of personal fulfillment at the other, is a major priority of the American public, one to which they have shown themselves willing to devote considerable resources and energy and to which a large and diverse cadre of service providers, from analysts to Zen masters, has emerged in response.

 

Time to Reflect

Over the past few decades the mental health field has become so vast, so profitable, and so diverse, that at this juncture it seems timely for the public, practitioners, employers, government, and health insurance industry, to take some time out to discuss the whole question of what kinds of mental health services should be available, how much they should cost, how people should be trained to provide them, and who should pay for them.

 

The Third and Fourth Force

As long ago as the 1950s the founders of humanistic and transpersonal psychology (the so-called Third and Fourth Forces in psychology) declared their independence from medicalized psychology. Frederick Perls said "therapy is too valuable to be reserved only for those who are mentally ill." At growth centers across America, from Esalen in California to Greenhouse in Boston, followers of Rogers, Maslow, May, Satir, Moustakas, Perls, Bugenthal, Kelley, and many others extolled the virtues of putting the theories and practices of humanistic psychology to the service of the general public in search of more meaningful lives and enhanced relationship satisfactions.

 

These thinkers and practitioners proposed that psychotherapy rightly belonged to an altogether different discourse, one which leaned more toward the humanities than to medicine, more toward the arts than to positivist science. "Doctors" were replaced by "facilitators" and "counselors," and in place of being seen as "patients," consumers were regarded as empowered "participants" or "clients."

 

R. D. Laing remarked to Carl Rogers at their first meeting, "When you brought your chair out from behind the physician's desk and met your clients face to face, person to person, you changed everything about what psychotherapy was about." In the decade 1965-1975 in community centers, living rooms, fancy offices in Beverly Hills, on college campuses, behind prison doors, in classrooms, in the executive suite, and on factory floors, in racially tense neighborhoods, and in the military, humanistic facilitators brought the liberating theories and practices of this alternative, "democratic" form of service to people in many walks of life.

 

Follow the Money

Somehow, in the United States the commitment to a nonmedical, self-actualization agenda by credentialed practitioners got lost once lucrative third party insurance payment became available to psychologists (in the 1960s), to social workers (early 1970s), and to marriage and family therapists. Third-party insurance payments marked the beginning of the end for the brief but potent experiment in "giving psychology away."

 

With the arrival of the DSM system, the brainchild of a psychiatric profession desperately trying to hold on to its position as a respected science-based branch of medicine, therapists trained in growth-focused work began to give medical diagnoses to clients, speak "medicalese" with insurance companies, and reframe existential or quality of life concerns as mental illness. As their professional standing and incomes rose, so did the regulations and restrictions on practice. As the whole field became medicalized, consumers were once more classified as "patients" and once more seen as passive recipients of care rather than as active agents in their own change. Power was thus reclaimed by the "experts."

 

I am the first to admit that some of the more colorful experiments in mind expansion went over the edge into blatant exploitation and abuse, and I hold us in the humanistic movement responsible for not inventing ways to bring more accountability into our practice. But psychology's "cure", which was to return the field to an expert-based paternalism, to overemphasize our own importance, and to see clients as vulnerable "victims", played into the hands of those who were uncomfortable with emancipation movements. It also provided work for malpractice attorneys who now circle like sharks. It did not prevent malpractice, it still goes on, and it did not protect clients from exploitation. What it did do was change the healing paradigm from a partnership model to an authoritarian one, put the therapist and client back where they had been before Rogers.

 

Although impossible to estimate with accuracy, a conservative estimate would be that as much as half of all mental health care expenses currently paid for through health insurance benefits are devoted to helping people learn basic life-skills (communication, assertiveness, or self-expression), develop higher levels of consciousness and awareness, and address quality of life, marital satisfaction, or career issues - all of which might be acquired far more effectively through growth-oriented programs and psycho-educational training.

 

When Masters and Johnson first looked at sexual dysfunction, for instance - a cause of anxiety and a major factor in divorce in America - they estimated that as much as 90% of sexual problems could be attributed to lack of adequate education about their bodies, about values, and about communication. Nevertheless psychologists and counselors continue to treat sexual problems through the expensive and inefficient means of individual medical treatment. Marital discord is another example. When couples arrive for marital therapy (once called marriage counseling) one or other of the partners is frequently given a medical diagnosis and their health insurance company billed. Justification for this DSM-izing is more often financial than medical, with therapists arguing that if health insurance benefits are available, there is little harm in using them to defray the costs.

 

Therapeutic Counter-Culture

In the flap over managed care, it is easy to forget that over 40 million Americans have no health care benefits, and many who do have a laughably tiny mental health benefit. Already, a large number of people do not use insurance for psychological care. Many of these people turn to a parallel community, the therapeutic counter-culture, which is an informal network of licensed and non-licensed practitioners, growth centers, and institutions which offer psychologically oriented services to eager consumers with no help from insurance payments and no need for a diagnosis.

 

AHP conferences are a popular stop on the mental health underground. Many consumers freely state that they prefer non-licensed people because they treat them holistically and do not reduce their suffering to a list of symptoms and diagnostic categories. These consumers want therapists who will see them as whole persons with whole lives. If they can get that from licensed practitioners, they will; but if not, they will seek such services elsewhere.

 

Time for Soul Searching

To a very large degree Third and Fourth Force psychology lost their distinct identities when they enlisted in the medical world in pursuit of third party payments. Like much of the culture in the 1980s, we made a Faustian bargain and followed the money. It is true that some ethical humanistic practitioners enlisted in the medical world because medicine's tradition of systematic attention to quality control was a welcome antidote to nude marathons, abusive encounters, and other egregious boundary confusion. But the economic benefits of insurance reimbursement were a far greater influence in propelling the increasing medicalization of psychotherapy. The managed care crisis, which we well know by now will eliminate psychotherapy as we know it, means that all of us who believe that the practices developed by humanistic and transpersonal psychologists have a great deal to offer our society now have a golden opportunity to revisit the question of our lost souls.

 

A New Profession

In these radical times there is great need for radical thinking about how best to speak to the psycho-spiritual, relational, and community needs of a population caught up in psychologically disorienting times. We can be sure that the public will continue to want such services, and that less and less will be available through the mental health benefits. They will be shopping in the marketplace.

 

This would be a very good moment to "reinvent" the human potential movement and create a new psychological profession which speaks directly to a nonmedical personal growth and emancipation agenda. But if we are not to betray a public who is willing to trust us as teachers, facilitators, and therapists, this time we must face the issue of accountability, training, and quality control.

 

We need a new human service profession which sits at the intersection of mental health practice, education, human resource training, consciousness training, and pastoral care, and which explicitly and directly addresses the non-pathological, growth-focused psycho-spiritual and existential interests of individuals, families, and communities. Such a profession should have its own unique interdisciplinary curriculum and create an entirely new discourse - one which is not medicine, not social work, not academia, not religion, not the arts, not entertainment, and not sports and recreation, but which has aspects drawn from the best of all of these traditions.

 

To become a distinct "field," "discipline," or "profession" it would have to clarify and further develop its own body of knowledge, research methodologies, techniques, language, settings, criteria for evaluating standards, and its own definitions of what falls within its boundaries and scope of practice. It would legitimize the public's interests in their own growth and psycho-spiritual development and at the same time provide the means for would-be practitioners to become educated and trained to practice effectively, safely, and to recognize when an individual needs to be steered towards the medical world for another kind of care.

 

Embryonic signs of such a development are underway. The psychology departments at West Georgia College and Sonoma State are discussing new careers. California Institute for Integral Studies has a successful program in Women's Spirituality. Programs linking anthropology, women's studies, mythology, and psychology are popular at free standing graduate schools such as Fielding Institute, Saybrook Institute, Pacifica Graduate School, and others. CDPP, a group of non-APA graduate schools, spent time at its May 1996 meeting opening discussion on the issue. The National Psychology Advisory Association, an association of graduate students from CDPP schools, is also discussing alternative psychological careers. AHP now has a Professional Affairs Task Force which will focus on defining ethics, education, and practice in humanistically-oriented therapies.

 

At the recent Evolution in Psychotherapy Conference bonanza, speakers Lynn Hoffman (family therapist), Thomas Szaz (psychiatrist), and James Hillman (Jungian analyst), all called for a new direction in psychotherapy that will separate "medical approaches" from the psycho-spiritual-relational practices.

 

Those with the courage to hold to their holistic principles and reject the industrialization of the field represent the leading edge of a burgeoning psychological counter-culture emerging to meet the growth needs of a public that in many ways is ahead of them. Professionals will probably make less than they have been making riding the insurance gravy train. It is unlikely that any but the very successful would be able to earn the six-figure salaries many were able to earn in the 1980s. But neither will these salaries be earned in the medical system. Most predict that within MCOs the average therapist's salary will drop to between $35 per hour for Social Workers and Marriage and Family Therapists, and $55 per hour for Ph.D.s. My research suggests that many non-licensed practitioners already make these kinds of incomes and, preferring time over money, many of them report that their lives are full and rich. That is definitely not what those who work for MCOs report!

 

From our experiences here in San Diego, "ground zero" of the managed care explosion, it is obvious that MCOs will be unable to serve anything but the most basic symptom-control function. This means that many more opportunities for creative, psychologically-based services exist outside the medical model than ever again will be within it.

 

As an organization AHP missed its first opportunity to become a major player in the mental wellness community when it chose to push the envelope and explore the margins of consciousness rather than work out accountability and legitimizing structures needed for an organized profession to be taken seriously in this culture. It is important to add here that the British AHP chose to go in the other direction and to organize AHPP, a practitioner's association, representatives of which now sit shoulder to shoulder with other major therapeutic disciplines on the British Council for Psychotherapy. AHPP is recognized as a credentialing agency for psychotherapists. The managed care crisis provides us with a new opportunity.

 

The time is right for AHP, perhaps in conjunction with the Association for Transpersonal Psychology, to form a professional holistic psychology organization willing to establish standards, evaluate graduate training, credential practitioners, and promote holistic or integral forms of growth and healing practices. Just like our services, such legitimizing structures and procedures could be based on our own values and practices - they do not have to have the heavy handed authoritarianism characterized by nineteenth century institutions like APA, but such a move would mark a long overdue coming of age for our field. In my view this would provide a means whereby the public's desire for services that can aid them in their journeys toward higher orders of consciousness can be met by professionals who themselves have committed to the discipline of advanced study, training, and ethical development and who are willing to be held accountable by other members of their community.

 

The first step in such a movement would be for AHP's professionals to begin the necessary organizational work. It will take work, a lot of it, but it is, in my view, well worth it. Anyone interested in helping organize such a development should quickly upgrade their AHP membership to Professional Member, attend the Annual Conference in Tacoma, and get involved.

 

* * *Maureen O' Hara is a past president of the Association of Humanistic Psychology (AHP), serves on the Consortium for Diversified Psychology Programs (CDPP) as liaison for Division 32 of American Psychological Association (APA), and practices as a psychotherapist in Solana Beach, CA.

 

This article was originally published in the July/August 1996 issue of the Association for Humanistic Psychology's Perspective magazine.  It is reprinted here with permission.

Contents  Legal  Ethical  Professional  Contact Us  Bibliography  Round Table 

 Academy Home      Academy Programs

ACADEMY FOR THE STUDY OF THE PSYCHOANALYTIC ARTS