Individual and Couple Therapy
in Tacoma and Seattle

Tacoma Office near Proctor District

35th & N. Cheyenne St

Ample Free Parking

Tacoma Detailed Directions


Seattle Office on Greenlake

Greenlake Wellness Group

7900 East Green Lake Drive North, Suite 202

Free Convenient Parking

Greenlake Office Detailed Directions


(253) 304-1411

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The future of psychotherapy

Scott Miller delivers the most important message in the field of psychotherapy that concerns its future in this video:


Strange Bedfellows, Level 2

This post continues where the previous post left off. I have just argued that medical issues usually have a clearly defined and well understood organic cause and psychological distress rarely does. The only cases I can think of where psychological distress has such an organic cause involve traumatic head injuries, substance abuse, or exposure to other toxins.

If we are to insist on a distinction between medical and psychological issues, which is precisely what I would like to do, then we should acknowledge that these two categories are at least somewhat overlapping. For instance, many types of physical injury or illness will have psychological impacts. A diagnosis of cancer, for example, often induces a depressive or anxious episode; or the amputation of a limb often results in depression.

So let us propose a clear distinction that allows for such overlaps. To the extent that organic injury, disease, or developmental anomaly results in a dysregulation of mental processes, the problem may be understood as medical and, to that extent, it should be treated medically. To the extent that any dysregulation of mental processes cannot be attributed to such organic causes, the problem may be understood as psychological and should be treated psychotherapeutically.

To give this distinction a quick test drive, let us imagine a case of traumatic head injury resulting in severe depression. The psychological distress involves a profound dysregulation of mood. To the extent that the patient's mood is affected by damage to the parts of the brain involved in emotional regulation, it may be regarded as a medical issue to be controlled by medications or possibly surgical interventions. But to the extent that the depression is about loss--loss of the client's capacity for a full life as a result of the injury--this aspect of his depression may best be treated psychotherapeutically.

This distinction may help clarify the tricky issue of, for example, antidepressant medications. Are they a medical intervention or a psychological one? I would argue that, when they prove useful, antidepressants are showing themselves to be medically appropriate in a given case. So, in the case of SSRIs (Selective Serotonin Reuptake Inhibitors), the depression involves a chemical imbalance in the brain that is remedied by more serotonin floating around the synaptic clefts. In a medical sense, the severity of the depression can be explained, at least to some extent, as an organic problem of too little serotonin in the synaptic clefts of the brain. But it may also be true--and I would argue it most often is--that a deeper psychological cause explains the client's tendency to move toward depression in the first place. This aspect of the client's presentation calls for a psychological treatment, namely psychotherapy.

So far I have glossed over a rather tricky problem, which will require a post all to itself. Many would argue, myself included, that all psychological states (functional and dysfunctional) have physical correlates at the neurobiological level. SSRIs point to that issue: can not every psychological state be regarded as a specific organic state which is to be remedied organically in the end? And, if this is true, does that not eviscerate the distinction I am trying to make between the medical and the psychological? I think this is a very good question, but I still hold that the distinction remains valid. I promise to address this problem in a future post.

Of greater importance than this nit-picky philosophical snare, is the issue of classes of causes. Medicine is interested exclusively in organic causes. Psychotherapy, I would argue, is interested in social-emotional causes--that is, impacts that occur in the intersubjective space between people. Similarly, medicine deals exclusively in interventions that act directly on physiology whereas psychotherapy focuses on interventions that occur within, and act upon, the intersubjective field.

I will continue to argue as this series continues that psychotherapy represents the most effective and efficient approach to alleviating suffering of its native kind--that is, suffering felt by one person in the context of others.


Psychotherapy Versus the Medical Model

This page is a table of contents for posts about the general theme of psychotherapy in relation to the medical model, insurance reimbursement, and the Affordable Care Act. This page will be updated as new posts are added.

1. Is Psychotherapy a Medical Procedure?

2. Psychotherapy and the Emerging World Order

3. Strange Bedfellows, Level 1

4. Strange Bedfellows, Level 2

5. The Future of Psychotherapy


Strange Bedfellows, Level 1

In my continuing series on the mismatch between the medical model and psychotherapy, I offer here a shallow view of the problem. In projected future posts I plan to tackle successively deeper layers. My hope is to make a nuanced and credible case for why the American mental health system and, specifically, its diagnostic manual, the DSM, has woefully (and willfully) misunderstood the assessment and treatment of psychological distress. In this post I will make the most obvious case, but I admit that the nuances are a bit tricky and will require more careful treatment, which I hope to provide in future posts.

The problem, in brief, is that psychological distress is understood as a medical problem when it is not. Here's how this mistake occurs: If we think of psychological distress, such as depression or anxiety, as a kind of ill-health, then it's easy to think of its diagnosis and treatment as a kind of medical procedure. Both concern "health," and both involve "healing." But, in reality, this is only a kind of analogy--and not a particularly apt one at that. We might, for example, consider hunger as a kind of illness and eating its remedy. The analogy seems to work: we experience physical discomfort, just like other kinds of illness, and if we do not cure the hunger we will eventually die. But few would suggest that hunger is really a kind of illness or that eating is a medical procedure. I would argue that the analogy of physical illness with psychological distress is almost as weak.

Let's look at an important failure of the analogy which happens to bear directly on the Diagnostic and Statistical Manual of Mental Disorders (DSM). Let's say you have a broken leg. You may not know your leg is broken. You may only know that it hurts intensely to put pressure on your leg, and that there is a lot of swelling. The pain and the swelling are known as the symptoms. But the medical doctor requires a cause of those symptoms in order to make a proper diagnosis. Indeed, the diagnosis is a statement of the organic cause of the symptoms. So, the doctor does an x-ray of your leg. If the x-ray shows a fracture, then the doctor will diagnosis you with a broken leg and will treat it accordingly: set the leg, put it into a cast, and so on. If the x-ray does not show a fracture, but evidence is found of a severe bruise, then the diagnosis and treatment will differ.

Thus we can say that, in principle, medical treatment addresses the organic cause which, in turn, ameliorates the symptoms. Although taking ibuprofen may help with the pain and swelling of the leg, it will do nothing to heal the organic cause of those symptoms, namely the fracture. A proper medical treatment does not focus on the symptoms per se, but on the organic cause of those symptoms. (It's true that sometimes medical treatments focus on symptoms, but this is a special case that I will deal with in a future post.)

Now let's look at a case involving psychological distress. Let's consider one of the more common cases. A person reports the following symptoms: trouble getting out of bed in the morning, feeling foggy-headed, loss of interest in all activities, performing poorly at work, and sometimes thoughts of suicide. According to the DSM, these symptoms constitute a diagnosis of major depression. The diagnoses given in the DSM are simply collections of symptoms occurring under certain circumstances. The assessment of psychological distress does not involve the identification of an organic cause or, for that matter, any other kind of cause for the given symptoms. Consequently, treatment is not addressed to the cause (which remains totally invisible) but strictly to the symptoms. Cognitive-Behavioral Therapy (CBT) or antidepressants are considered treatments not because they address causes in any well-understood way, but strictly because they ameliorate symptoms.

The APA has spent more than 50 years pursuing the hypothesis that mental disorders have an organic cause equivalent to physical injury or disease, but they have never succeeded in finding a definitive organic cause for any category of psychological distress. In medical cases (at least the simplest ones), there is a correlation of 1.00 between organic cause and diagnosis: every broken leg involves a fracture of a bone of the leg; and every fracture of a bone of the leg is diagnosed as a broken leg. No equivalent proposition can be made for ANY class of mental disorder. Schizophrenia, for example, has been associated with certain anomalies in brain structure. But not all schizophrenics have this anomaly, and not all people with this anomaly have schizophrenia.

But surely psychological distress in any given case does have some cause, and any effective treatment of that distress would need to address itself to that cause. Psychotherapy purports to do just this. But the cause may not be organic--that is, the body may not be injured or faulty in some way, but rather we may have learned to process certain experiences in a way that trends toward depression, say, or anxiety. So psychotherapy addresses itself to that cause: how can we help our client process certain types of experiences in a way that does not lead to suicidal ideation or general malaise?

Given that the cause is not essentially organic but social-emotional, the treatment is similarly not medical but interpersonal. And now we are miles away from the medical model, and entirely outside the limited scope of insurance companies, their tidy treatment plans, and their very limited numbers of sessions. I will say more about this in future posts. For now, I hope I have given sufficient grounds to begin to wonder if the medical model makes any sense at all in cases of psychological distress.


Psychotherapy and the Emerging World Order

What is the future of private psychotherapy in the emerging world of the Affordable Care Act? No one knows, and speculation runs the gamut from little concern to full alarm. Toward the latter end of the spectrum is a piece that appeared in the Psychotherapy Networker, Psychotherapy and the Affordable Care Act. In it, the authors anticpate that:

The increased demand for demonstrating positive outcomes will require more collaboration and technical infrastructure, including the increasing use of sophisticated (and expensive) electronic medical records systems.

While the authors acknowledge a range of opinions about how this might affect the delivery of psychotherapy, they give significant column space to one particularly alarming view:

According to Nick Cummings, a former president of the APA [American Psychological Association] noted for his prescience in anticipating the advent of managed care and other practice trends, “It won’t happen right away, but private practice will essentially be a thing of the past, as 95 percent of practitioners will be on salary, either working in government-sponsored systems or large healthcare companies.” He says the remaining private practitioners will probably be based within concierge plans, which are typically expensive and accessible only to high-income patients. He believes that because of the glut of psychotherapists—about 700,000 therapists in the United States alone, twice as many as needed, he says—the prospects for therapists’ incomes aren’t bright.

I have no better idea what to expect than anyone else, but it seems entirely possible that Cummings will prove more or less correct; few have more credibility to make such a guess about the future. If his predictions turn out to be accurate, I would regard this a disaster for society--much more than it would be a disaster for me personally.

It's a disaster because it goes much further than we have already gone toward the medicalization of psychotherapy. As I have argued elsewhere on this blog, psychotherapy cannot credibly be described as a medical procedure, and it serves us badly to pretend that it can. To quarantine psychotherapy within medical offices, based strictly on whatever medical rationale exists for it, would only exaggerate the absurdity of the situation.

If Cummings' predictions come true, it would make an already bad situation much worse. The thousands of people who currently use therapy not for medical purposes (such as couple therapy where neither partner suffers from a clinical disorder) would be shut out from access to professional psychotherapy. And the millions who would benefit from such access, most of whom cannot afford it under current conditions, would have even less of a chance to get the kind of care that might transform their lives to the good.

So much is at stake here, I believe the profession must begin to advocate for what it believes is best for its clients. We have played along with the insurance industry and its medical model for too long. We need to articulate a vision of our profession that is more forthright and honest. We are not medical providers. What we do can be scientifically validated--not because it's medical, but because it works. It works to help people recover from attachment injuries, emotional trauma, and other psychological struggles that come with being human.

People have the right of access to such healing. Society has an obligation to do what it can to facilitate that right, even if this is limited. Moreover, the social cost of failing its members in this respect is almost certainly far greater than the cost of providing for it. We should not be limiting access because it is in the interest of insurance companies to do so, and we should not be cutting healthcare costs by squeezing private psychotherapists when other costs are outrageously out of control, such as drugs and specialty medical procedures.

We do ourselves and our clients a disservice by winking and nodding at the insurance industry because we want their reimbursements. The whole system is ill conceived and dishonest, and will likely become more so as the ACA and its sequelae take shape. It's time to take a courageous stand.


Apparently, according to Cummings, there are twice as many therapists in the United States as are "needed." Needed for what? Is Cummings suggesting that everyone who would benefit from psychotherapy currently has access to a therapist, and then some? I highly doubt it.

Let's do some math. Let's say that the average psychotherapist has 50 clients (this is a very high estimate for private practitioners but probably low for agency workers). That would mean that the 700,000 therapists could have 35 million clients at any given time. The population of the U.S. is now in excess of 315 million. Studies have shown that, in a given year, about 25% of the population suffers from a clinically diagnosable mental health disorder. If we assume conservatively that half of those would benefit from psychotherapy, that would mean 39 million Americans need therapy in a given year, more than current capacity can accomodate.

Even this, however, woefully underestimates the number of client hours that would be most beneficial to society. The evidence suggests that psychotherapy is indicated for very close to all diagnosable mental health disorders, driving our annual number of potential clients upwards of 70 million, close to double current capacity. Moreover, what of the great number of Americans who are suffering emotional distress but do not meet the criteria for mental illness under the DSM? Or couples that are struggling, not because either partner suffers from mental illness? What do we make of the common statistic that as many as 35% to 45% of the population is "insecurely attached" as measured by the Adult Attachment Interview? Therapy can be helpful in all these cases and, if it were available, could alleviate a great deal more suffering than currently possible.