THE ABSENCE OF RESPONSIBILITY IN PSYCHOTHERAPY
By Mickey Skidmore, ACSW, LCSW
Professionally, I first became aware of the importance of labels during the neo-twelve step movement — specifically, Adult Children of Alcoholics, et al. As it was explained to me, there was enormous relief from feeling like they were not “crazy”, and tremendous power in being able to identify some specific parameters which characterized their dysfunctional behaviors. For years I was unsatisfied and even troubled with this explanation, and eventually I discovered why — it only addresses half of the issue.
Justifications such as: “I treat the people who I love like crap because I’m an adult child of an alcoholic parent” just do not wash with me. Recently, a popular TV sitcom addressed this issue as well. One of the main characters was approached by a recovering alcoholic from her past asking for forgiveness for a horrible transgression long ago. Not feeling his gesture was heartfelt, she replied “so I have to forgive him just because he’s an alcoholic?”
The other part of this issue obviously has to do with responsibility. Using a label to better understand what you are dealing with is one thing. Certainly a good beginning point. But to stop there (as if developmentally arrested), and use the label to exonerate one’s behaviors is nothing short of manipulation and avoidance to say the least.
Unfortunately, the twelve-step community does not own the market on hiding behind and using labels to manipulate the situation or people to their advantage. The increasingly popular medicalized view of the mental health field lends itself well to labeling. And it did not take very much for managed care companies and even patients themselves to jump on this band wagon.
For example, at a national conference I recently attended, one of the presenters related that his son went to the doctor because of an unusual infection under the skin of one of his toes. Upon examination by the physician, he was diagnosed with “subdural anomaly.” (Lankton, 2001). Or maybe you know someone diagnosed with arthritis, which is yet another fancy label which vaguely describes a patients symptoms (and by the way means “joint inflammation causing pain”). Each edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is a growing exercise in pathologizing a wider and wider range of human behaviors for reimbursement of practitioners. Consider the following clinical case example which illustrates the adverse affects and potential dangers of labeling:
Kelly at age five turned on a lighter looking for a kitten under a couch and set the house on fire. It was clearly neglect on the part of the parents, yet she was labeled a fire setter and placed in a foster home. One day she was alone by a swimming pool, playing with a puppy and she put it in the water to see if it could swim. The puppy drown, and she was labeled an animal torturer. Clearly the foster parents had been seriously neglectful by leaving a five year old alone by a swimming pool, but by labeling the child they were exonerated of responsibility. Kelly was placed in the institution where she has been for three years. In the meantime, her mother remarried and has two children who are well taken care of. She wants Kelly back, but the staff thinks Kelly might still be a fire setter and animal torturer. The mother brought two puppies to prove that when Kelly visits she doesn’t hurt them, but that hasn’t helped. Just recently the mother and her family decided to move to California and desperately wanted to take Kelly with them, but it was refused because they were driving and they would have the puppies in the car. It was decided instead that Kelly would be placed in a foster home and then eventually flown by herself to California. This is total madness. Kelly now has to adapt to a strange foster family and then fly by herself across the country, instead of flying the puppies and sending Kelly in the car with the family. (Madanes, 2001).
Lankton went on to observe that interesting things occur when we view people through the lens of a label. For example, if you were to discover that your friend Joe had been labeled a “juvenile delinquent,” then almost without exception we become curious. “Maybe that explains why he drinks so much.” “It’s no wonder he treats women so badly.” “Perhaps that’s why he was so cruel to animals when he was a teenager.” It is uncanny how we reflect on this person’s history through the prism of this newly discovered label.
Perhaps the most alarming thing about this is the disservice that results for patients. Mental health patients are unlike any medical patient in this regard – when something is terribly wrong, impacting their lives in adverse ways, they seek understanding – often a label (diagnosis), which provides some type of hope for treatment to resolve or improve their condition. In my encounters with hospitalized psychiatric patients during the past decade, I have heard some version of the following exchange thousands of times: “my doctor says I have a chemical imbalance of the brain.” This message undermines the entire behavioral mental health treatment process. It encourages patients to not take any personal responsibility for change. Furthermore, it is disrespectful to clients in that it disregards their internal, social and spiritual resources that often are as important as any chemical prescribed to assist them. Persons with mental afflictions deserve to be more completely informed about their condition and their treatment options rather than be told a partial truth. As vastly complex as the human mind and body is, with few exceptions, it is simply unreasonable to conclude there is one single determinant to explain the complexities of a mental illness. In short, it is an approach that is non-wholistic in nature – one which fragments the human essence. (Skidmore, 2001).
Despite the fact that research has shown that those who personally invest in their mental health treatment achieve greater results, psychotherapy as a profession is clearly on the decline. There are many reasons for this. Insurance and managed care companies have successfully conditioned our society to think that any needed treatment will be covered by “insurance.” Yet mental health treatment is perhaps the least covered of all benefits in the healthcare industry. And while there has never been a greater recognition for the need for psychotherapy and mental health treatment, the prevailing attitude is: “if insurance (or medicaid) doesn’t cover it, then I’ll do without .” And they have gone to great lengths to scare the public into the belief that psychotherapy is beyond the reach of most people.
Contrary to popular misconception and misinformation, psychotherapy is affordable and indeed preferable to many people. Private pay arrangements offer many advantages (confidentiality; avoidance of labeling; client control over treatment, etc.) over insurance-based and/or managed care approaches — which relies heavily on the use of labeling, and conveys to consumers the strong message that they are exonerated of taking personal financial responsibility for their mental health treatment. The absence of such responsibility may become the ultimate demise to the art and practice of psychotherapy — and perhaps to mental health treatment overall.
1) Lankton, Steven. THE EIGHTH INTERNATIONAL CONGRESS on Ericksonian Approaches to Hypnosis and Psychotherapy. Phoenix, AZ. December 5-9, 2001.
2) Madaness, PhD, Cloe. THE EIGHTH INTERNATIONAL CONGRESS on Ericksonian Approaches to Hypnosis and Psychotherapy. Phoenix, AZ. December 5-9, 2001.
3) Skidmore, Mickey. “The 1990’s: Decade of the Brain?” (February 2000), http://www.turning-points.com.au/2017/09/05/february-2000/.