I have spent more than thirty years in private practice as a family counselor and therapist. I was in practice almost five years before Missouri passed a licensure law creating a category known as Licensed Professional Counselor. This was a reflection of a national movement to enhance and solidify the credentialing for Counselors. It was an effort to stake a claim to a name that would build an inherent identity and reputation. Licensed Professional Counselor (LPC) was supposed to become the step down in the hierarchy of professions, i.e. Psychiatrist, Psychologist, Licensed Professional Counselor, Social Worker, Marriage and Family Therapist, etc.. The goal at the time was to increase the standard of training that was behind the legally restricted title, both to protect the public from quacks and charlatans and to improve the marketability of the opportunity for the therapist.
As I have watched the profession evolve over the last thirty years, it seems to me that the focus has become more and more about legalisms, paperwork, limitations and carving out patient segments for matching counselor segments. There is a strong move to suggest that you can’t do internet counseling unless you have a specific credential approved and provided by the national organization. There is a similar restriction on the use of tools such as hypnosis in therapy, working with children with particular disorders or working with married couples and families. We all seem to need to specialize. We specialize by taking extensive, expensive and additional certification training regulated by the national organizations and the State Licensure Boards, who take their guidance from the National Organization. It is my opinion that what seems to be happening is that the generalized approach to being a skilled counselor, serving a wide variety of patients, is being legalized and specialized out of the market place.
At the same time, on another tangent, it seems to me that the universities who are educating the Counselors in Training to become Licensed Professional Counselors are changing their emphasis in the delivery of their programs away from clinical expertise, and more to a message and an expectation that one must get into a Ph.D. program. This requires the LPC to take an additional load of education and debt and jump through another set of restrictive hoops in order to be able to practice. I believe that the primary goal of these efforts is to act in restraint of trade. Ostensibly, it is to protect the public and guarantee that there is supervision, standardized training, standardized diagnostic labeling, standardized billing and office operation, standardized specialization of patient populations and so on.
I worry about all of this. I believe that good therapists, like good teachers, come to the table with a varied background of experience and knowledge. I think the critical ingredient in the productive work of therapy is the relationship that is established between the client and the therapist. I believe that it is the process of developing a relationship in a protected, safe situation that creates the healing environment for the therapy to be successful. If training programs begin to change their focus into an emphasis on research and paper writing, if the national conventions are populated by research presentations of increasingly discreet and selective examples of myopia that typically do not appear in a counseling office, then eventually the profession will lose its way and its validity. I do not think there is anything more important for a counselor in training to learn than the essence of the relational hour.
What are the clinical skills on which a good therapist needs to focus in order to help the random client who wanders into the office? What happens in the session that incorporates the theories and philosophical terms such as transference, projected identification, ego dystonic or ego syntonic behaviors? How relevant are terms like narcissist, bi-polar, borderline etc. for the average therapist who is working in a practice in the community at large, and not for a special unit at a University Hospital? No matter what the label of the diagnosis, what do I as the clinician need to be able to work effectively, ethically and helpfully with the client so that there is an opportunity for the client to make progress towards a healthier and more functional life?
How do we measure success in therapy? Who gets to decide when the therapy is ended? Is it the insurance company that determines payment? Is it the research statistician who claims that depression should be cured or improved enough in fifteen sessions or the therapist who says, “I believe in brief short term therapy and will only see you for twenty sessions or less, no matter what is going on?” Or, is it the client who says I want to come, I need to come, I am not finished yet?
One of the issues which evolved over the years that I have been in practice is note taking. When I was trained, I was taught that one does not take notes during the session. One must train their memories and observational powers so that after the session is over they will remember the salient points of reference. If the need is there to help them remember, make such notes as will help trigger their memories to work on behalf of the client. Today, the rule is be careful of what you write. Make sure that it is not an expression of personal opinion (i.e. George was depressed today, or George was suicidal today) but rather a quotation, “George said he was depressed today.” That way, when and if you are sued and an attorney questions the subpoenaed notes you have written, you won’t have to spend hours documenting your specific, exclusive and clinically focused courses on the nature of depression, the diagnosis of depression, and the treatment of depression, before you can testify about George himself and what he had to say.
Early in my practice, the lawyers recommended that we write down only that which was absolutely necessary. They warned us that our notes could always be obtained and dissected in court, taken out of context and be made to be about us, rather than a reference to our experience of the client. So, they simply said don’t do it. Today the national standard requires you to take notes, that they must be written with in twenty four hours of the session and that they must be phrased in certain “codes.” The clear expectation is that the notes are written for the legal system, not in service of the client.
I worked at the University level for twenty-five years, teaching students what I knew about how to practice as a clinical therapist. I helped them learn how to practice under the supervision of the rules and within the guidelines, but still to focus on the needs of the client and on the question: What will help the client get better? I warned them constantly that they would be in harm’s way each and every day that they worked in this field, but that they could not become paranoid and defensive to the point that it crippled their ability to be open to the client and make a relationship that was based on the needs of the client. I was adamant about my goal to focus on teaching them how to be clinicians, how to do the dance of therapy with the client and not spend too much time on legalisms and standardization of the product for the purposes of the insurance industry and the national organizations of the counseling profession.
It is a delicate dance we do when we set out to be therapist. We must practice with ethical care, we must be aware of the needs of the client and the demands of the law or the license board. We must figure out how to make a living in a career about which we feel strongly and we must attend to the client and their needs in such a way that they get better and go and tell their friends that you, the clinician, are worth coming to see, even if it costs them money!
I worry that the training programs are growing away from a focus on clinical expertise and that the increasingly intent movement towards standardization will lead to a one-size-fits-all set of standards based on diagnostic labels, check lists, defined number of sessions, symptom reduction on demand, paperwork skullduggery, and sub-categorization of specialties so much so that the generic practice of “therapist” will weaken and disappear. I know any number of therapists and LPC’s who have begun to move their professional focus over into a new category called Coaching. I hear from them that Coaching is in the early stages of the same kind of restrictive, reductionist movement that the counseling profession has experienced over the last twenty or so years.
What will become of the population of normal people who have relational and emotional problems who could benefit from therapy if we restrict and ruin the professions who could serve the need by “improved management and administration” strictures and requirements? I wonder. I worry.