psychotherapy

Advocacy for a Single-Payer System

| Jen L'Insalata

by Jen L’Insalata

Advocacy is an important component of the role of counselors. By definition, advocacy is the act of working toward improving the welfare of their clients by bringing awareness to issues within the mental health filed. Over the years the American Counseling Association had advocated for the advancement and strengthening of the counseling profession. Often times counselors advocate for their role within a particular context or for the overall profession (Erford, 2018). Other times counselors advocate for a specific cause related to their counseling domain.

The concept of healthcare reform has been around for several years and has become a focal topic in many recent political campaigns. Healthcare reform impacts the mental health community as changes to healthcare policy have the potential to shift who can access what types of mental healthcare. Serious mental illness including chronic psychosis, depression, anxiety, and substance use disorders presently account for the majority of disability claims worldwide. The cost of serious mental health care has risen exponentially and when left untreated leads to premature morality rates (Kilbourne, Keyser, & Pincus, 2010).

Under our present system, the cost of treating individuals without adequate healthcare is shifted to the general population by means of fees, service costs, and point of service charges. In 1991, it was estimated that the burden of healthcare for underinsured populations was more than $21 billion (Daschle, Cohen, & Rice, 1993). Multi-payer insurance providers form a patchwork system consisting of in network and out of network services which may shift depending on a client’s coverage package.

As a result, there is an increase in administrative costs allocated to managing the paperwork required to navigate the current healthcare system. Misallocation of funds has led to research in tertiary healthcare procedures while less glamorous areas of healthcare have been deemphasized. Additional aspects of a fee-for-services system has complicated immediate access to care and benefitted some organizations with internal referral systems where unnecessary services are provided (Daschle, Cohen, & Rice, 1993).

This has created what Kilbourne, Keyser, & Pincus (2010) call a cook-book method of treatment where organizations operate within silos rather than integrative treatment through collaborative efforts. Fee-for-service is often evaluated on 3 major domains; structure, process, and outcome with the rationale that mental healthcare resources and policies inform process used by clinicians. In practice, evaluation of fee-for-service systems have emphasized the characteristics of the treatment setting including infrastructure and staffing over quality of care.

The art of counseling relies heavily on the therapeutic relationship through the emphasis of person-centered approach. The core of person-centered counseling emphasizes unconditional positive regard, congruence, and accurate empathy that empowers a client to examine patterns of behavior and reflect on opportunities for personal growth and well-being (Cormeier, & Hackney, 2012). The quality of care provided becomes difficult to measure under a fee-for-service medical model where a client-therapist fit should take precidence.

Under a single payer system, a single publicly financed insurance fund would cover all Americans evenly while ensuring access to comprehensive mental healthcare despite income, employment, or that ability to cover out of pocket expenses (Hsiao, Kinght, Kappel, & Done, 2011). Several single-payer proposals exist that illustrate more subtle nuances such as funding at the federal or state level (Daschle, Cohen, & Rice, 1993) and implementation strategy. Programs similar to Medicaid/Medicare offer flexibility in coverage to include medical, psychological, and homeopathic treatments. This would allow flexibility in treatment approach for counselor to tailor their therapeutic methodology to fit each client on an individual level; emphasizing a client-centered, counselor-client fit.

Presently, there are several barriers preventing the implementation of a single-payer system. Advocacy against healthcare reform comes heavily from the for-profit insurance industry. Accessing information surrounding policy on healthcare reform is limited and often difficult to understand. I personally struggled to find free resources that outlined policy in an easy to digest manner and much of my understanding has come from previously reading Senate Bill 1129 introduced to the 116th Congress this past May. I feel it is safe to assume that many counselors and mental health practitioners may not fully understand the implementation of healthcare reform on their personal practices and livelihoods. Advocacy serves as an avenue to break down complex congressional legislature into digestible articles that can be read and understood easily.

References

Cormier, S., & Hackney, H. (2012). Counseling Strategies and Interventions (8th ed.). Pearson. ISBN 10: 0-13-707018-7

Daschle, T. A., Cohen, R. J., & Rice, C. L. (1993). Health-care reform: Single-payer models. American Psychologist, 48(3), 265–269. https://doi-org.library.capella.edu/10.1037/0003-066X.48.3.265

Erford, B. T. (2018). Orientation to the counseling profession: Advocacy, ethics, and essential professional foundations (3rd ed.). New York, NY: Pearson.

Hsiao, W.C., Kinght, A.G., Kappel, S., & Done, N., (2011). What Other States Can Learn From Vermont’s Bold Experiment: Embracing A Single-Payer Health Care Financing System. Health Affairs. Retrieved from
https://doi.org/10.1377/hlthaff.2011.0515

Kilbourne, A. M., Keyser, D., & Pincus, H. A. (2010). Challenges and Opportunities in Measuring the Quality of Mental Health Care. The Canadian Journal of Psychiatry, 55(9), 549–557. https://doi.org/10.1177/070674371005500903

Sanders, Baldwin, Blumenthal, Booker, Gillebrand, Harris, Leahy, Markey, Merkley, Schats, Udall, Warren, Whitehouse, Hirono, & Heinrich. (2019) Senate Bill 1129. 116th Congress. 1st Session. Medicare for All Act of 2019. Retrieved from https://www.congress.gov/bill/116th-congress/senate-bill/1129/text

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Latino/a Interpersonal Connections in Therapy

| Jen L'Insalata

by Jen L’Insalata

The term Latino/a refers to anyone with ancestry from Mexico, Puerto Rico, Cuba, the Dominican Republic and other Spanish speaking countries in Central and South America. Phenotypes of individuals of Latino/a descent show great variation due to historical mixing of European, African, and Asian Ancestry. Individuals often identify with their country of origin, as “Hispanic”, and as “American”. Identifying as American is most common among third generation youth. As a result, Latino/a culture demonstrates multiple dimensions of between-group and within-group variation (Sue, &Sue, 2016).

In general, Latino/a culture places a high degree of emphasis on the development and maintenance of interpersonal relationships. Cultural traditions demonstrate a deep tradition of unity, respect, and affection between communities, families, and extended families from which the term familismo originates.  Latino/a culture embodies a sense of collectivism in which interdependence forms the concept of familismo (Campos & Kim, 2017, & Sue, & Sue, 2016). Interpersonal relationships form the core of societal wellbeing and establish a harmony among community and family members.

Culture is recognized by psychologist as a driving force in all human behavior and relationships, as it influences social life. Recognizing the deep understanding of culture on interpersonal relationships provides a framework for how such relations impact mental health. Expectations of one’s self and their role in relation to other’s is influenced the collectivistic nature of Latino/a culture (Campos & Kim, 2017) and provides a framework for evaluation and treatment of psychological distress.

Research suggests that despite the socioeconomic disadvantages facing Latino/a communities in America, there is a statistically low prevalence of negative health related outcomes compared to white counterparts. This has become known as the Latino Paradox in which close interdependent relationships provides a protective factor. However; when traditional Latino/a values surrounding interpersonal relationships conflict with western individualism, the practice cultural norms break down. This breakdown leads to feelings of loneliness and increased rates of depression, anxiety, substance abuse, and suicide (Gallegos & Segrin, 2019). Individuals loose the cultural protective factor of connection which increases and compounds psychological distress.  

When treating members of the Latino/a community it is important to understand the bond established between family, extended family, and friendships. Often members of this community rely on one another to help in decision making processes surrounding life, finances, and day to day function. It is also important to be aware of a Latino/a reciprocal obligations to their familismo (Sue & Sue, 2017). It may be beneficial to the therapeutic alliance to incorporate extended family and community in the treatment process to encourage the reestablishment of connection to others.

Reference

Campos, B., & Kim, H. S. (2017). Incorporating the cultural diversity of family and close relationships into the study of health. American Psychologist, 72(6), 543–554. https://doi-org.library.capella.edu/10.1037/amp0000122

Gallegos, M. L., & Segrin, C. (2019). Exploring the mediating role of loneliness in the relationship between spirituality and health: Implications for the Latino health paradox. Psychology of Religion and Spirituality, 11(3), 308–318. https://doi-org.library.capella.edu/10.1037/rel0000180

Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and practice (7th ed.). Hoboken, NJ: Wiley. ISBN: 9781119084303

Treating Diverse Populations

| Jen L'Insalata
diversityby Jen L’Insalata

When working with a diverse client population it is important to acknowledge varying ideological concepts between demographic groups. In other words, a diverse population of clients requires a therapist to utilize a diverse repertoire of treatment approaches. Elements such as race, gender, age, religion, and sexual orientation impact the client’s response to particular therapeutic approaches. A therapist must recognize and utilize the best fit and appropriate approach for each individual client. Often when working with diverse population, it becomes necessary to integrate elements from varying psychotherapeutic approaches. Such integration allows for the necessary flexibility in clinical treatment that yields evidence based best practice results.

Methods of Integrating Psychotherapies

The integration of psychotherapeutic treatments can be as diverse as the theories themselves. However integration often takes the form of one of four main pathways. Each pathway allows a therapist to customize and blend psychotherapeutic treatments and modalities to best fit a particular client’s receptiveness and needs (Wedding, & Corsini, 2014).

Technical eclecticism is a research specific approach to integrating psychotherapeutic theories.  This integration style allows unrelated concepts of varying therapeutic theories to be integrates and combined. Technical eclecticism draws on research which compares effective treatments to particular problems and client characteristics and utilizes concepts and techniques from varying theories (Wedding, & Corsini, 2014).

Theoretical integration includes multiple therapies which are combined to achieve the best result. The overarching concept blends together multiple theoretical approaches in order to create a more effective conceptual framework for treatment. Integration of psychodynamic and interpersonal, cognitive and behavioral, or systems, and humanistic are most widely used in combination (Wedding, & Corsini, 2014).

Combining treatments based on common factors is an integrative approach that identifies core similarities of varying treatment modalities. Treatment techniques are then developed based on key combinations of commonalities. Combining common factors focuses on the effective commonalities in theoretical concepts of treatment processes rather than the individual theoretical differences (Wedding, & Corsini, 2014).

Assimilative integration is an integrative technique that utilizes one primary therapeutic theory as a foundation. It then selects specific elements of other theoretical approaches to assimilate into a single treatment modality. This combinations allows a foundation in one coherent system of treatment with the ability to interject a broader range of treatment techniques (Wedding, & Corsini, 2014).

Research

Empirical and evidence based research shows that the integration of theoretical approaches provides advantages from a variety of therapeutic modalities. Integrative therapies tend to focus on the clients individual circumstance and experiences rather than an overarching or abstruse theory (Ponterotto, 2013). Studies show that by integrating psychotherapeutic modalities for individual clients, the client attains the best possible outcome.

It is possible to conduct quantitative research without understanding epistemology however qualitative research relies on awareness of philosophical perspectives among client sub cultures. Qualitative research recognizes the sociocultural compounds of expression and experiences within a various populations and accounts for their voice or cultural input in the effectiveness. Qualitative research accounts for social, cultural, and economic realities for clients that impacts the structure and relationship of the therapeutic process (Ponterotto, 2013).

Mahrer’s 1989 Study

The Mahrer’1989 study investigated the integration of various psychotherapeutic techniques with concrete operating procedures. Mahrer utilized videotapes and transcripts to identify therapist’s behaviors that promoted client change. He believed that particular behaviors could be utilized and integrated into a range of options to achieve therapeutic goals. (Richert, 2007).

Concrete operations is describes as a set of ordered behaviors that a therapist would perform in sequence in order to elicit particular behaviors from a client. A therapist would utilize activities such as s Socratic questioning, teaching disputation, and the recording of automatic thoughts to implement a broader range of cognitive problem solving. Four specific theoretical orientations were selected for the integration into concrete operations procedures; humanistic and existential, cognitive and constructivist, analytic and dynamic, and interpersonal. (Richert, 2007).

According to Mahrer’s study, a constructivist therapeutic approach integrated most effectively with concrete operational procedures. Constructivist approach integrates unconditional positive regard, transference-counter transference while utilizing empathic reflections, two-chair dialog exercises, metacommunication or therapist self-disclosure, and dream work. Mahrer believed that a constructivist approaches proved favorable for integration due to emphasizing meaning-based practice, disputing irrational beliefs and self-monitoring procedure adapted from REBT and CBT (Richert, 2007).

Conclusion

Changing demographics in the United States calls for the continued development and integration of psychotherapy approaches. The ethnic and cultural diversity in which a clinician sees in their clients is increasing. More people from ethnicities who previously did not seek treatment are turning to therapist and clinicians with traumatic histories. Often these immigrant populations are underserved, under insureds, and receive treatment that is ineffective (Cook, & Tedeschi, 2007).

It is important to remember that when working with culturally diverse clients a therapist enters and experiences a foreign world and mindset. Empathy, respect and understanding of differences is imperative. A therapist must be able to suspend any preconceived concepts or stereotypes surrounding a particular population. (Ponterotto, 2013).

Blended elements from varying psychotherapeutic theories are effective when working with diverse populations. It is important for the therapist to keep an open mind about integrating treatments in the same manner as the must to toward each individual client. An effective integrative therapist recognizes the individual needs and limitations to therapy and creates a personalized therapeutic plan for each individual.

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References

Wedding, D., & Corsini, R. J. (Eds.). (2014). Current psychotherapies (10th ed.). Belmont, CA: Brooks/Cole. ISBN: 9781285083711.

Ponterotto, J. G. (2013). Qualitative research in multicultural psychology: Philosophical underpinnings, popular approaches, and ethical considerations. Qualitative Psychology, 1(S), 19-32. doi:10.1037/2326-3598.1.S.19

Richert, A. J. (2007). Concepts, processes and procedures: An introduction to the special issue on integration of concrete operating procedures. Journal Of Psychotherapy Integration, 17(1), 1-9. doi:10.1037/1053-0479.17.1.1

Cook, J. R., & Tedeschi, R. G. (2007). Systems of care and the integrative clinician: A look into the future of psychotherapy.Journal Of Psychotherapy Integration, 17(2), 139-158. doi:10.1037/1053-0479.17.2.139

CBT: Cognitive Behavioral Therapy

| Jen L'Insalata
woodbrainby Jen L’Insalata

In most psychotherapeutic environments the term CBT is tossed around all the time. CBT in research; my insurance providers prefer CBT; CBT; CBT; CBT. So what is this CBT stuff? CBT is short for cognitive behavioral therapy and essentially addresses both thoughts and the underlying emotions that influence behavior. This is achieved by bringing together components of both cognitive therapy and behavioral therapy is a direct and effective manner.

Behavior Therapy

Behavior therapy is centered on the concept that human behavior serves a function and results from stimuli within the individual’s environment. Behaviors result in response to environmental stimuli and behavioral patterns result from the reinforcement or punishment received from the interaction between the individual and their particular environment. The psychosociocultural viewpoint encompasses a wide range of therapeutic strategies that aim to change the environmental factors that stimulate maladaptive behaviors (Wedding, & Corsini, 2014).

Cognitive Therapy

Cognitive theory is a theory of personality in which individuals respond to life events cognitively, motivationally, and behaviorally. An individual perceives, interoperates, and assigns meaning to particular life events. Maladaptive behaviors and affects are caused due to the misinterpretation of stimuli, situations, and events. Cognitive therapy aims to adjust the way the individual processes incoming information by examining the individual’s belief about their self, the world, and others (Wedding, & Corsini, 2014).

Five Concepts That Add Dimension

Both behavior and cognitive therapy recognize that personality is consistent and an individual’s response to environmental stimuli can be predicted. Behavior therapy acknowledges five core domains from which personality can be assessed. Behavior therapy teaches flexibility within an individual’s personality domains and introduces healthy coping mechanisms and responses for environmental stimuli (Wedding, & Corsini, 2014).

Cognitive therapy recognizes schemas to explain and predict responses to environmental stimuli and situational cues.  A network of affective, motivational, and behavioral schemas known as modes asses and interoperate situations. Some modes are rooted in instinct and are referred to as primal modes. Primal modes are often ridged, automatic, and absolute. Primal thinking leads to maladaptive behavior. Cognitive therapy teaches a client to consciously override primal modes through means of deliberate thinking and problem solving (Wedding, & Corsini, 2014).

Behavior therapy focuses on the behaviors and actions that are conditioned responses to external stimuli. Cognitive therapy focuses on the affect and mental interpretation of a particular stimuli (Zaretsky, Segal, & Fefergrad, 2007). Due to similarities, behavior therapy and cognitive therapy are often combined in a treatment known as cognitive behavioral therapy. CBT targets the bias mental interpretations acknowledged in cognitive therapy and teaches the client to regulate emotions causing maladaptive behaviors (Harvey, Bélanger, Talbot, Eidelman, Beaulieu-Bonneau, Fortier-Brochu, & … Morin, 2014).

CBT is often used as a primary treatment for depression and mood disorders.  By leveraging a client’s awareness of the changes in their cognition, (Zaretsky, Segal, & Fefergrad, 2007) treatment techniques encompassing mindfulness, relaxation, meditation, exposure, (Wedding, & Corsini, 2014) and modeling teach the client ways to regulate their affect and reduce symptoms (Zaretsky, Segal, & Fefergrad, 2007).

When addressing depression, cognitive therapy addresses the client’s negative views of one’s self, their experiences, and future. A client’s interpretation of their environment is often bleak and the client maintains a pessimistic bias toward themselves and their future. Motivational symptoms appear such as a lack of energy and sometimes paralysis that inhibits the completion of everyday life tasks. Increasing activity and social exposure combined with combating negative interpretations of situations are used to alleviate the cognitive components of depression (Wedding, & Corsini, 2014).

Behavior therapy addresses the conditioned response to stimuli. Behaviors increase due to reinforcement (Wedding, & Corsini, 2014). Maladaptive coping strategies and behaviors continue to reinforce depressive behaviors. Treatments focused on positive social exposure and activity work to reinforce positive experiences for the depressed individual and reduce exposure to negative experiences such as isolation. Exposure to positive stimuli aids in reinforcing non-depressive behaviors (Ryba, Lejuez, & Hopko, 2014).

Modeling behaviors occurs when an individual observers others in a sociocultural environment. Anxiety or phobias are maladaptive behaviors that can be learned through modeling abuse (Wedding, & Corsini, 2014). If an individual observes a social fear or anxiety about a particular situation, it is likely to be interoperated as a truth. An individual may model the anxious or phobic behavior learned from observation.

Behavior therapy addresses the hyperarousal brought on by anxiety and phobia by combining exposure and relaxation training. Practicing relaxation techniques while exposed to environmental stimuli helps alleviate the physical stress and tension associated with phobia and anxiety. Cognitive therapy teaches an individual to reevaluate the particular stimuli and interoperate it as less threatening (Wedding, & Corsini, 2014).

Substance abuse is often coupled with depression and anxiety. The recognition of psychosocial factors maintain the maladaptive belief and subsequent behaviors are addressed by combining cognitive and behavioral therapies (Harvey, Bélanger, Talbot, Eidelman, Beaulieu-Bonneau, Fortier-Brochu, & … Morin, 2014). Substance abuse may begin as a molded socioenvironmental behavior and become reinforced through positive social experiences. Reinforcement of addictive behaviors may be reinforced when a client engages in self-medication to alleviate depression and anxiety symptoms.

Stimulus control is a behavioral technique that can be used to help individuals with substance abuse issues and addiction. Principles of classical conditioning state that conditioned cues illicit behavioral responses.  Stimulus control aims to correct the problems associated with a particular stimuli (Wedding, & Corsini, 2014). For example, a client may associate a place or event with the acquisition and consumption of substances. Clients are encouraged to avoid places and situations which are cues for their addiction.

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References

Wedding, D., & Corsini, R. J. (Eds.). (2014). Current psychotherapies (10th ed.). Belmont, CA: Brooks/Cole. ISBN: 9781285083711.

Zaretsky, A., Segal, Z., & Fefergrad, M. (2007). New developments in cognitive-behavioural therapy for mood disorders.Canadian Journal of Psychiatry, 52(1), 3-4. Retrieved from http://search.proquest.com.library.capella.edu/docview/222807541?accountid=27965

Harvey, A. G., Bélanger, L., Talbot, L., Eidelman, P., Beaulieu-Bonneau, S., Fortier-Brochu, É., & … Morin, C. M. (2014). Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: A randomized controlled trial. Journal Of Consulting And Clinical Psychology, 82(4), 670-683. doi:10.1037/a0036606

Ryba, M. M., Lejuez, C. W., & Hopko, D. R. (2014). Behavioral activation for depressed breast cancer patients: The impact of therapeutic compliance and quantity of activities completed on symptom reduction. Journal Of Consulting And Clinical Psychology, 82(2), 325-335. doi:10.1037/a0035363