#42 – REVIEW – PREVIEW #3

The purpose of this blog is to describe a method of outpatient child and adolescent mental health work that uses family therapy as the primary treatment format. The project began six months before closing my 30+ year full time private practice and retiring. As events unfolded, the first step was devising an outcome study of what turned out to be 58 cases that terminated during a of period two calendar years. That decision came out of an intrinsic interest in numbers and a simple curiosity about how effective the work had been. The practice had been more than personally satisfying, but just what had the work accomplished and for whom?

The initial pre-test post-test calculations of clinical change led to one elaboration after another over the course of three months or so. During that time the consideration of writing arose. As has been noted a couple of times in previous posts, private practice is a ‘lean-forward’ life with the focus being ‘what’s next?’ Retrospection about process occurred mostly in the context of consultation and in sorting out what went awry in those cases that did. Doing so added added to the informal body of guidelines and cautions that formed a part of the processes’s vernacular, the do’s and don’t’s of day-to-day clinical work. Concentrated thought about the process as an entity had not occurred before, let alone organizing a layout. When thinking about the whole as the study developed, the notion that the process was fairly recursive and replicative became clear. At that point, I think, writing took on a life as well.

Whither Goest Family Therapy?

Child mental health as an institution in the 70’s was still sorting through the therapies primarily developed in the post-WW II era. Family therapy was one of several. The technique was developed, taught, and proselytized by Virginia Satir, Don Jackson, and others, and became a frequently utilized format, particularly in the Northeast states and on the West Coast. Family therapy was probably at its zenith in the late 70’s and early 80’s. For example, family therapy was the primary psychotherapeutic treatment taught to child psychiatry residents and fellows at the University of Washington Hospital’s field training program during that time. Those of us master’s level therapists who were using the approach in training programs and doing therapy in NPO clinics were convinced that this was the wave of the future, based on the results that were occurring.

The paradox at the time this study began was that family therapy had already been on the wane for more than a couple of decades. The north Eastside community, among other things the original heart of the Seattle metropolitan area’s renowned tech industry, is a kind of family halcyon that one would think a receptive area for a family therapy practice. However, from the mid-80’s onward and to the best of my knowledge, mine was the only practice that had organized all child and adolescent case processes through the family prism. Other youth therapists in the area would have occasional family sessions, but their work was predominantly oriented toward individual treatment.

Over time, I came to have working relationships with elementary, junior high, and high school counselors from three school districts. From time to time, I would ask one of them if they knew of anyone else doing primarily family therapy, thinking that clinicians who were doing so would also be in contact with the schools. The counselors know of what I spoke because the effectiveness of the family orientation was the reason they would use me as a referral source, but they’d all shake their heads, no one of which they heard or knew. That remained true through the significant infusion of outpatient therapists into the area after state licensing occurred in 1988.

Why the wane is complicated, at least from this perspective. Bear with the view, or skip to the more immediately germane material.

At least part of family therapy’s decreased presence was a result of a change in how the treatments of mental health symptoms had been conceptualized and hence implemented. Specifically, techniques such as CBT that were used for a client’s emotional and behavioral problems shifted away from an embedment in relational and growth orientations toward more programmatic applications.

 A major underlying economic thrust of national origins was an increased emphasis on efficiency. Like any other national industry, mental health treatment is impacted by the prevailing economic philosophy of the moment. Beginning in the late 70’s, the national economic policies turned away from an emphasis on government expenditures and controls that sought relative equality for all, generically termed Keynesian after Depression era economist John Maynard Keynes, to free markets that emphasized efficiency, production, and profit, e.g. Milton Friedman, et. al.* 

By the late 80’s, insurance companies were more aggressively controlling the provision of therapy services through devices like managed care, per person annual service limits, re-authorization procedures, preferred provider rates, etc. The average of 29.3 sessions per case in this outcome study here was not what insurance business managers had in mind. At what global cost or benefit the change generated is not clear. Barry Stevens would have suggested that ‘you can’t push the river.’

  • Read “The Economist’s Hour”, 2018, by Binyamin Applebaum, lead economics and business writer for the New York Times editorial board; additionally, Capital In The 21sr Century, 2014, Tomas Piketty esp. last chapter; The Deficit Myth, 2018, Stephanie Kelton, esp. Chapter 7; Good Economics in Hard Times, 2019, Banerjee and Duflo (2019 Nobel Prize for Economics); and/or maybe Debt: A 5000 Year History, 2011, David Graeber, esp. last chapter;

In 1990, Value Behavior Health (later known as Value Options and now part of Beacon Health) won a carve-out contract from Boeing’s health insurer, Regence Blue Shield, to manage the corporation’s mental health benefit. Representing by far the largest employer in the area, probably hundreds of therapists signed up for panel status. “Managed care” was a novelty for all of us. VBH organized an introductory workshop at the Seattle Center on a very warm May weekday in the center’s conference hall. About a hundred of us attended. The main speaker was an earnest young woman who ran through the basics. You get an automatic 10 sessions. MSWs and masters counselor types would be paid 55$ per session, some 20 – 25% lower than what masters level clinicians were charging for sessions at the time, but with the status of a ‘preferred provider’. The therapist could fill out a somewhat long re-authorization request for another 10 sessions that included diagnostic and progress data. Depending on VBH’s determination of need, you may or may not get it. If not, the client would have to pay out-of-pocket thereafter. The intimation of the presenter’s delivery suggested that private pay was sort of frowned upon, but OK because they had no formal way to check. However, clinician billing and re-authorization records could be “reviewed”. Murmurs started to surface. Then the challenging questions by Seattle’s leftist lot began, and the presenter calmly and smilingly answered as best she could, which she would do, but the thrill was clearly gone. Her small support staff started gathering together papers of their own, like this was the expected routine at all their venues. The young woman, who truly seemed to be a pleasant soul, stood silent for a few seconds with her hands clasped beneath her chin, and then said, as earnestly as ever, “What we’re looking for are professionals who share our philosophy.” There was silence, almost chilly. No one knew quite how to respond, but the message was clear – keep the processes short. 

Mental health as an institution of professionals is adaptive. Moving in the direction of efficient modalities like time-limited, solution focused, behavioral programs and even some EBT-type models has been relatively seamless. Therapists are referring child and adolescent clients more often to psychiatrists, pediatricians, and family doctors for medications as an adjunct to standard talk and/or behavioral therapies. Processes that are more structured and on the whole shorter that the 20+ session therapy were gaining favor. The insurance companies have been doing well. 

Since 2015, that top line has gone more toward vertical, the bottom line has probably dipped, and the middle line flattened. At least that’s the inference from public information available. Piketty researched back centuries about economic trends, and at the end of “Capital….”, he warned that if the skew in the distribution of wealth became too severe, the society would face revolution or war or depression. This was in 2013. Given 1/6/21, the warning has merit.

Efficiency produces vast amounts of wealth, but the pernicious side is that “free” competition clearly leads to greater economic disparity. The relative decline in living conditions for more than half of the population contributed to the significant increase in child and adolescent mental health problems, mostly in terms of anxiety. Unrelenting anxiety then leads to depression and behavior disorders. Where the generally accepted rates of diagnosable mental health disorders for youth at any given time was 15% a half century ago, that figure has been quoted contemporaneously at 25+%. We need to employ all the viable modalities, including family therapy, and the social means to support processes that demonstrate the capacity for effectiveness and to have the time necessary to achieve for the client. 

A last point, allegorically about efficiency and its impacts:

In the summer of 1972, the song “Does Anybody Really Know What Time It Is?” was getting a lot of attention. The title line began the refrain, and was followed by “Does anybody really care”. By the band Chicago, the tune could be seen as a kind of inferential ode to the title character of another song of the day, Lather, for whom time was a non-consideration. However irrational, such was one of the tenets among the young at that time. Now fifty years later and a vastly different circumstance of life, time for most people, time is a commodity for which there seems never quite enough, creating a reality of “Does anybody really not know what time it is, does anybody really not care…anymore”?

Increased anxiety has lots of mental health workers and school counselors very, very busy, god bless them…us.

Lots of mental health workers and school counselors are very, very busy, god bless them…us.

And then came the pandemic, and as the virus swept across the country, family therapy fell off the table that was already leaning in that direction due to matters that have little to do with its efficacy. In-office family therapy must have completely disappeared amidst all the needed safety precautions Family therapy by Zoom rudimentarily provides for multiple verbal inputs, but the therapist is deprived of most non-verbal behavior observation and all the real life communications that get quietly relayed. And then you have the factor of kids on Zoom…sitting still… for counseling.

To be adamant, in the midst of both good times and bad, family therapy still will be here. Family therapy in vivo has unique, timeless, serviceable qualities that preserve utility through the inevitable vicissitudes of social conditions and practice standards. As an intervention, the approach will always have a willing and wanting portion of the population. Like most socio-cultural staples, the demand for  the service may wax and wane with economic and political change, but will always be there to one degree or another as long as families have distressing and irresolvable difficulty.

Basic Advantages

The child’s problem(s) are also those of the family. Family members are present to help define the problem(s), explain the problem’s history, and describe the impacts. The family helps plot the course of intervention, and by doing so become more invested. They themselves are increasing their awarenesses and sensitivities, and altering their own relatedness patterns as may be helpful. They become involved in reinforcing the changes as they are occurring, and learn to work together through the inevitable relapses.

The therapist can witness random family functioning in detail. Much is happening non-verbally in a family gathering that helps the therapist understand in greater depth factors like: how the problems developed; what behavioral and relational reactions they generate; how they get reinforced; how do positive efforts get extinguished; where the antagonisms are, and so too the trusts. In the family, the therapist gains a collective opinion about the effects of clinical input and suggestions, helping to determine which show promise, which do not, what direction to take,  where the resistances may be, and who tracks what. 

Assuming: the whole is greater than the sum of its parts; positive change is usually infectious; resilience is more likely when the quality of relationships is higher. 

Keeping Up

The licensing that occurred in the late 80’s did help in a couple of ways. Master’s level therapists now could independently bill insurances, thus be freed of reliances on MDs and PhDs who ‘supervised’  the work of master’s level therapists and signed for insurance payments. At the same time, business found an open back door as insurances developed and exerted new expense controls, which in turn impacted therapy and psychiatry alike.

Along with the freedom of independent clinical functioning came required Certified Education Units for bi-annual recertification. Washington State’s biannual requirement is for 36 hours. This translated into six six-hour trainings, one every four months on the average. In reality, this became a rushed four workshops in the last six months of every two years. The units could be also gained just by reading training texts commercialized for the purpose, and answering a few questions on a “test” at the end, all taking less than an hour, sometimes fifteen minutes. I took the in-person training route, occasionally muttering but on the whole finding the workshops helpful.

A way to evaluate the benefit of any given training became apparent. If out of any CEU training came one material concept, or one specific tool that could be incorporated into the therapy process’s methods, something that could reliably produce the intended effect, the effort was worth the while. The same would be true here. Material concepts and specific tools are what is being offered here in the upcoming posts on the methods themselves.

Review 

Quickly, the first three posts covered the basic who, what, when, where, and why of the overall   project. Posts 4 – 23 detailed the outcome study along with a couple of elaborative vignettes. #24 was the first Review – Preview.

#25 – #41 covered the Relatedness/Axis 11 Sub-Group, seventeen posts in all. The term ‘personality disorder ‘ was not used for reasons covered in #25. For children and adolescents,  the use of term is premature and would be misconstrued in a way that could be a blow to their identity development. The chosen designation was ’Relatedness’, inasmuch as a labile set of relational thoughts, feelings, and behaviors were the primary manifestations of their difficulties. The term ‘Axis II’, a relativistic identifier used in the DSMs up to and including the IV-R, was used for adults with personality-type disorders. The category was bracketed by common mental health disorders on one side, and psychotic disorders on the other. 

With an N of 17 (of 56), these youth were the second largest sub-group of the study population. Those with suicidal ideation were the largest. In regards to the relatedness and Axis II group, Posts 25 – 33 focused on the incidence and treatments of the relatedness youth. #34 – #41 focused on those cases where the client youth had one or both parents or significant caretakers who were likely Axis II problems themselves. As a whole, these 17 cases provided an opportunity to present an integrated combination of data and casework considerations. 

The same could have been done with the suicidal ideation group. Not to diminish the seriousness of SI at all, the cases involving the relatedness group were more challenging from the clinical management perspective. They presented a ripe opportunity for delving into complicated clinical thinking concerning the intricate and potentially precarious situations they often develop. As such, they represented an alternate truth about casework. We envision positive outcomes with the development of good clinical relationships and the adroit  applications of method. In most instances, that happens. Alternately, normal clinical relationship work and normal case management encounter paradoxical responses that are difficult to re-direct. Stuff happens.

Compared to relatedness cases as a whole, those presenting with SI generally had more straight forward processes, better outcomes, and more traditional terminations. Still, the average CGAS gain for both groups as a whole were equivalent. The difference was that successful work within the relatedness group had high average gains, the less successful were very low, and they averaged out. When they were hard, they were very hard.

Preview

Four sections are planned, including: the therapy process; suicidal ideation and other notable sub-groups; a summary of outcome study findings; and the conclusion.

The therapy process section will be divided into 11 areas, most of them shorter posts than has been the case thus far. They include: the initial contact; the three- session assessment process consisting of the intake with the parents, the child interview, and the summary and recommendation session with the parents again; the first three conjoint  therapy sessions (usually # 4 – 6); a long section on ‘middle work’; termination process; retirement as the transition impacts clients; and setting up a private practice;

The only sub-group large enough to include some statistical analysis is those having suicidal ideation (N=21). All others are less than10. They include; single mothers (no single fathers in the study group); BIPOC/ESL; sexual identity issues; spectrum clients; referred out for medication evaluations; referred for other treatments; those with fathers completely out of the picture (no O.O.P. mothers in the group); those who received only individual counseling (format 4); clinical gains above 25 CGAS points; gains under 5 CGAS points; statistical outliers (three cases whose clinical gains were particularly low for the number of sessions used); and a  comparative look those who at those clients who terminated with a CGAS over 70 with those doing so at 70 and under. A few illustrative case vignettes throughout the sub-section are also planned.

The conclusion section is still a concept in progress. The larger context in which mental health work operates is the current consideration. Looking from a practitioners viewpoint at how child and adolescent mental health work impacts the community on the one hand, and how the larger forces of socio-politico-economic change impact how mental health work is practiced may have a certain value. Clinicians often face the impacts of external change on how they practice, which in turn may effect what kind of work they choose to do. Part of that exploration of moving toward the family approach when the predominant treatment philosophies have been trending inc other directions. 

For Whom

The therapy process information is largely instrumental. Most of the described interviewing techniques, tools, sequences, and approaches can be taken into most any therapy format on an experimental basis, by therapists anywhere from being in academic training to those with years of experience just to see what the particular effects of a particular method or technique may be. Nothing therein is inherently risky or dissuading from therapy.

Two target audiences come to mind. The first would be younger and newer therapists, those coming out of grad school or entering the field from other endeavors and searching to see what fits their interests, styles, and goals. The other would be established clinicians who have been working for public and/or private organizations providing community mental health services and are taking steps to build private practices. Given a specialty interest in child and adolescent work, family therapy as a potentially effective and useful format would be among the explorations and the presentation in the following posts would constitute an elemental introduction to the format. 

Recursiveness and Mastery

As stated earlier, the process as a whole is fairly recursive, i.e. repeatable. The structure and progression of treatment from the first contact to the terminating session has a certain sameness from step to step, often from question to question. This kind of approach has two advantages to providing care. 

One asset of recursiveness is that elements of the therapy process itself become another measuring device or evaluative tool. For example, in the first meeting with the child or adolescent, the assessment session, a five-tiered set of questions was developed to comfortably move from the initial greeting into the reasons why the young person is in the office, was employed with every case. Where in the sequence the new client begins to openly talk is an indicator of overall willingness and need vs. self-protection and wariness. That is helpful diagnostic information in and of itself, but also provides an important data point to discuss with the parents in the following assessment and summary session. Parents almost universally appreciated that kind of normative feedback, in this instance where their child fits in the range of comfort. In turn, that can also provide a base from which the child’s comfort may have grown during their first meeting, and that was usually the case. Parents like that, and the generation of trust is abetted. That tiered opening will be discussed in the sub-section of the client assessment session.

More generally, the recursiveness helps identify how people commonly react to certain steps or suggestions or phases that are part and parcel of the process. And then, what to make of someone who reacts differently from the norm and why do they do that, a question that may be overtly pursued but just as often registered internally as one more bit of information that helps to understand why that particular client is in the office, what they may need, and what direction to take. Examples will be given along the way. Some have already been given in earlier case vignettes.

Repetition also aids in gaining mastery, and mastery of skill is certainly one goal of the professional. Mastery entails considerable effort over time. Clarity of method matters.

On Mastery:  On a spring afternoon in1995, I’m at my desk during an open hour, clear of anything needing attention at the moment. For whatever random reason, I got into a holistic overview about the work. This was now ten years into the practice, a notable marker in and of itself. What dawned on me was that the process itself had reached a certain marker. Whatever came through the door, I knew what to do and basically how to go about doing it, and if I didn’t know what to do, I’d know what to do about that, help re-direct the individual in some way. I’d developed a process that worked most all the time. 

Acting like a developmentalist, I pulled over the notepad and devised a stage analysis. By the end of the first year, the basic nuts-and-bolts of running the practice were learned.  After three years, the work had encountered most of the serious problems and crises that would normally arise. After five years, the effects were beginning to have impact on the environment surrounding the practice, in a manner communalizing it. At ten years, the process had been mastered. That doesn’t mean growth and change had in some way stopped. Some level as yet to be experienced at that moment was still to come.

So, now how to test it? At the time, one activity of mine was playing Sunday morning basketball at a local Jewish community center. I played on the seniors court, mostly men 40 to 60. We played 4-on-4 on a 70 ft. cross court. First team to score 10 baskets wins and keeps the floor; those from the losing side head to the chairs behind the baseline and await their turn. While doing so, we’d usually talk amongst us while watching. The 20 or so regulars were a mix of professionals, corporates, small business owners, service people, etc.

I wondered what their experiences were like as they grew into their work specialties. Over the next three Sundays, I posed this question to around 15 of them – “In your work, how long did it take to to get to the point where you knew what to do with whatever kind of problem walked through, or you knew where to send them?”

They all took the question seriously, think five or ten seconds, and then give a specific number. Close to half of them said ’10 years’, by far the most quoted. The others ranged from 6 months to 3 or 4 years, as I recall.  One odd sidelight is that none of them ever asked me why I was asking. For even for us “old guys” , Sunday morning was all about the ball. 

This bit of informal field research demonstrated that piecing together a viable process takes continued learning, observation, experimentation, and, most of all, time. Using an effective approach, technique, or tool with consistency and in a similar manner from instance to instance is a mastery facilitator itself.

Having some kind of method to increase professional knowledge and skill base is as important as any other part of mental health’s endeavor. Being alert to new information and concepts, trying them out, doing anything that might help the development of one’s effective work is part and parcel of proficiency, and one definition of professionalism.

On Personalized Process

All treatment processes are personalized, regardless of the particular school of therapy or clientele or formats that shape one’s practice.The inherent distinction between medical and mental health treatments is the factor of relatedness. Mental health treatment addresses symptoms and disorders in the first order, but most any approach also impacts how the participant(s) relate. The therapy process is a shaper and conditioner of change, and the therapeutic relationship becomes a model of relatedness itself.

Interactional problems will gain some form of attention. That includes those interactions between family members, and those between the client(s) and the therapist. On occasion, the client-therapist communication is to resolve some problem that directly involves the therapist. How the therapist handles him or herself becomes yet one more model, and likely one that has an impact. At its base, the good relationship between client and clinician is a generator of trust.

Clients bring in their problems. The therapist brings in a panoply of interventions great and small. The comfort and belief in the interventions the therapist administers emanates from themselves. The tools the therapist uses are best those with which the therapist feels at home. As such, they represent some aspect of what the therapist believes. Just as the client wants to be better, the therapist wants to be effective. All treatment processes are personalized, regardless of the particular school of therapy or clientele or formats that shape one’s practice.The search for process enhancements that can be comfortably added to a professionals repertoire hopefully does not stop until that office door is closed for the last time.

Try what seems in your judgement to hold promise. Build your process. Trust yourself.

One more note – this post marks the beginning of describing the therapy process in considerable and digestible detail. If the material thus far strikes you as helpful and holding some promise, let others know. Thanks.

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