{"id":110183,"date":"2018-04-30T12:00:03","date_gmt":"2018-04-30T11:00:03","guid":{"rendered":"https:\/\/www.transcend.org\/tms\/?p=110183"},"modified":"2018-04-29T16:56:09","modified_gmt":"2018-04-29T15:56:09","slug":"homogenization-of-psychotherapy-and-counseling-scientific-professional-ethical-moral-issues-risks-and-directions","status":"publish","type":"post","link":"https:\/\/www.transcend.org\/tms\/2018\/04\/homogenization-of-psychotherapy-and-counseling-scientific-professional-ethical-moral-issues-risks-and-directions\/","title":{"rendered":"Homogenization of Psychotherapy and Counseling: Scientific, Professional, Ethical\/Moral Issues, Risks, and Directions"},"content":{"rendered":"

Homogenization: Efforts Pursuing Standardization, Control, Domination, Oppression!<\/em><\/p><\/blockquote>\n

28 Apr 2018 – <\/em>I am gravely concerned and fearful by the widespread pursuit and endorsement of homogenization in many sectors of our life.\u00a0 I am particularly concerned about the consequences homogenization may have for \u201crobotic-like\u201d existence for human beings, limiting \u00a0opportunity, and diversity.<\/p>\n

Trade-Offs <\/strong><\/h2>\n

Homogenization is rooted in \u201cstandardization!\u201d \u201cStandardization\u201d offers certain protections against extremes in variation capable of harming individuals and groups.\u00a0\u00a0 At the same time, \u201cstandardization\u201d results in dominance, control, and oppression. \u201cStandardization\u201d resists variations associated with growth, change, diversity. \u00a0Some say, standardization is a \u201ctrade-off;\u201d and this is difficult to deny. But, there are risks. The caveat may reside in recognizing the \u201ctrade-offs,\u201d and identifying the risk-benefit tradeoff.<\/p>\n

For example, homogenization in education often fails to acknowledge individual or group variations, not only in abilities and talents, but also the contributions of gender, ethnocultural, and racial differences. At this point it is a win-lose situation. \u201cStandardization,\u201d with pressures for uniformity in education goals, methods, and outcomes, risks losing lives by the very institution designed to develop and nurture individual and group potential.<\/p>\n

Clearly, there are areas in which standardization has utility and value, including certain medical surgical procedures, airline pilot training, equipment, training, and related performance-based technologies.\u00a0 Even in these examples, however, we must question the tendency for contentment with specified goals and procedures, and while resisting other options. There must be, in my opinion, a tolerance for change, rooted in a constant evaluation of consequences.<\/p>\n

Acculturation is Omnipresent<\/strong><\/h2>\n

I believe we must maintain a commitment to diversity, (i.e., \u201cLife is Diversity\u201d), and recognize homogenization presents problems stifling creativity and innovation in favor of accepted standards. \u00a0Too often, an existing power structure (group, cabal, cartel) retains control by reducing or eliminating contrary view or positions.<\/p>\n

I grew up and was socialized in a traditional Sicilian immigrant household; I as I went to school, I was caught between two worlds.\u00a0 Some resolution occurred as I discovered: selective detachment!<\/em> \u00a0I did not have to buy into the entire ways-of-life. I could choose based on situations and perceived consequences. Freedom! I must add however, resolution requires compromise, and compromise can be traced to existing power distribution. Should Amazon tribes acculturate? Should spouses acculturate?<\/p>\n

Evidence-Based Homogenization of Therapies and Counseling<\/strong><\/h2>\n

Energetic efforts are in progress to develop and canonize a recommended \u201cmenu\u201d of evidence\u2013based therapies acceptable for application and implementation.<\/p>\n

A major issue is: acceptable and implementation for who? Under the guise of \u201cscientific\u201d evaluation standards, the recommended \u201cmenu\u201d poses serious risks and problems for both patient and therapist.<\/p>\n

    \n
  1. Legal Issues: <\/strong><\/li>\n<\/ol>\n

    Both insurance systems and conventional professional organizations support these efforts. Insurance systems are seeking a \u201clegal\u201d basis for reimbursement of psychotherapy and counseling services which would help them approve and disapprove petitions for reimbursement.<\/p>\n

      \n
    1. Financial Issues:<\/strong><\/li>\n<\/ol>\n

      Clearly, as cries for mental health services increase in the wake of mass violence and deaths related to societal and cultural collapse, innocent victims are increasing.\u00a0 In addition, financial costs for mental health interventions therapy are experiencing an alarming rise, and serious limitations in quality of care. For insurance systems, private and public, the costs pose a challenge for profits.<\/p>\n

        \n
      1. Professional-Cabal Interests<\/strong><\/li>\n<\/ol>\n

        \u00a0<\/strong>In addition to insurance systems, conventional professional mental health-related organizations and providers are seeking to legitimize practices under the rubric of \u201cevidence-based\u201d standards. Existing professional groups favoriting certain procedures, and codifying them in journals, programs, funding sources also represent a source of problems.<\/p>\n

        Some groups currently dominating \u201cacceptable\u201d conventional views favor specific histories, assumptions, methods, procedures, and outcome data. These groups may control journal research methods, and book publications, often times based on an \u201cempirical\u201d foundation for preferred teaching, research, and applications.<\/p>\n

        \u201cScience\u201d as Arbiter<\/strong><\/h2>\n

        Here we must also remember \u201cempiricism\u201d does not mean \u201cscientific,\u201d and \u201cscientific\u201d does not mean bias-free. Most professionals are aware \u201cpower, position, and person often determine canon.\u00a0 This is true in medicine, physics, economics, and education; it is also true in mental health. I shudder as I hear politicians seeking approval call for increases in mental health services without recognizing the numerous limitations and issues in mental health care.<\/p>\n

        Let me be clear in my purposes: I am not speaking against inquiry, nor research of any ilk, for exploring the \u201csuccesses\u201d or \u201ccures\u201d in psychotherapy and counseling. \u00a0I am, however, critical of efforts after homogenization and uniformity in an area begging for recognition of variability and resisting imposition of set standards under the risk of financial and ethical violations for non-compliance.<\/p>\n

        The fact of the matter is conventional mental health institutions and practices have strong ideological attachment supported by uniformity, conformity, and compliance with certain assumption and procedures.\u00a0 In a world now dominated by surveillance, monitoring, and archiving of virtually every aspect of our lives for purposes of \u201ccommercial\u201d and \u201cnational\u201d security, efforts after yet more \u201cstandardization\u201d related to cures and healing assume our knowledge is accurate.<\/p>\n

        Homogenization brings uniformity, and uniformity brings compliance, and compliance brings control.\u00a0 It is an issue of \u201cEn Loco Parentis.\u201d<\/strong>\u00a0\u00a0 Further, a have come to believe one task of psychotherapy and counseling may be to introduce an understanding of how power and authority in lives are problems sources! Liberation therapy?<\/p>\n

        To all of these ends, I wish to discuss critiques and knowledge-information material for consideration: (1) Mental Health; (2) Mental Health Industry; (3) Outcome Uniformity Equation; (4) Non-Western Therapies; (5) Healing Principles; (6) Quo Vadis<\/em>?<\/p>\n

        Mental Health: Issues<\/strong><\/h2>\n
          \n
        1. Mental Health Industry<\/strong><\/li>\n<\/ol>\n

          There is a vast mental health industrial complex exacting control over \u00a0\u00a0\u00a0 definitions of mental health and the legitimacy of practices ranging \u00a0\u00a0 from diagnosis\/classification to therapies and prevention.<\/p>\n

          I wonder if most are aware of the industry nature of the field. Table 1 \u00a0\u00a0\u00a0\u00a0 lists members of the mental health industry complex:<\/p>\n

          Table 1: <\/strong>Mental Health Professions, Professionals and \u00a0Technical-Support Services (Marsella, 2016)<\/strong><\/p>\n

            \n
          • Clinical Nurse Specialist (MSN)<\/li>\n
          • Clinical Psychologist (Ph.D. or D.Psy.)<\/li>\n
          • Counseling Psychologist (D.Ed., Ph.D., D.Psy.)<\/li>\n
          • Drug Counselor (Varies)<\/li>\n
          • Family Advocacy Groups<\/li>\n
          • Licensed Psychologist (Ph.D. Non-clinical)<\/li>\n
          • Licensed Practical Nurse (LPN)<\/li>\n
          • Marriage and Family Therapists (MFT)<\/li>\n
          • Medical Intern (M.D.)<\/li>\n
          • Mental Health Aide (Certificate or Diploma)<\/li>\n
          • Occupational Therapist (O.T. Degree, License, Certificate)<\/li>\n
          • Pastoral Counselor (Varies)<\/li>\n
          • Physician (M.D. or O.D. + Internship and Medical Residency)<\/li>\n
          • Psychiatrist (M.D. or O.D. + Psychiatric Residency)<\/li>\n
          • Psychiatric Nurse (LPN, BSN)<\/li>\n
          • Psychiatric Resident (M.D.)<\/li>\n
          • Psychiatric Social Worker (BSW, MSW, DSW)<\/li>\n
          • Psychometrist (M.A., M.Ed.)<\/li>\n
          • Psychotherapist (Varies)<\/li>\n
          • Recreational Therapist (A.D. or B.A.\/B.S.)<\/li>\n
          • Rehabilitation Counselor (Varies)<\/li>\n
          • Others: Alternative Medical Systems (Acupuncture, Chiropractor, Indigenous Healers, Naturopath, Shiatsu)<\/li>\n<\/ul>\n
              \n
            1. The Ties that Bind<\/strong><\/li>\n<\/ol>\n

              The mental health field is a web of inter-connected personal and professional relationships, ties, and obligations. Member critiques of each other risk condemnation and isolation.<\/p>\n

              Figure 1 displays the web of relationships. Does this web itself not become a source of problems for care facilitating preferred \u201cevidence-based\u201d approaches in mental health.<\/p>\n

              Figure 1:\u00a0 Web of MH Care-Systems Forces and Influences<\/strong><\/p>\n

              \"\"<\/p>\n

                \n
              1. Reliance on a Flawed and Invalid Diagnostic and<\/strong> Classification System<\/strong><\/li>\n<\/ol>\n

                It is now widely accepted, even among its supporters, that DSM systems from DSM I to DSM V is an anachronistic system traceable to historic and cultural forces and individual positions of power and influence. The subsequent emergence and empowerment of the DSM systems represent examples of the abuses of power and influence of conventional professions, individuals, groups, and, ultimately, government sanctioned (NIMH) and authority-figure assertions.<\/p>\n

                Figure 2<\/strong> Displays \u201cD\u201d<\/strong> Word Alternatives Relative to Mental Health. The sheer variation and nuances of each category speaks to the awesome task of trying to arrive at reliable and valid diagnoses for purposes of therapy and counseling. What occurs is an informal or formal acceptance of various \u201cD\u201d<\/strong> words for purposes of work.<\/p>\n

                Figure 2: \u201cD\u201d Words and Mental Health (Marsella,2016) <\/strong><\/p>\n

                \"\"<\/p>\n

                Consider this fact: Any of the \u201cD\u201d<\/strong> words constitute a dynamic patient state, subject to changes ranging from descriptors of their existence to subsequent interventions including precipitating factors, exacerbating factors, and maintaining factors. The idea of a static problem subject to distinct interventions does not exist.<\/p>\n

                The harsh reality is assignment to any \u201cD\u201d word category or diagnosis associated with a DSM system does not indicate: (1) Cause, (2) Symptom\/Sign Display, (3) Site\/Source of Pathology, (4) Course, (4) Outcome), (5) Treatment, or (6) Prevention<\/strong>. \u00a0There are historic reasons for our continued use of the DSM, even as past adherents are seeking alternatives.<\/p>\n

                Compassion for mental health industrial-complex members is warranted; I nod my head amid the daily tasks before them.\u00a0 They are caught in a medical-political-economic-moral bind.\u00a0 Fixing the problem is beyond them, yet they are compelled to function amid the conventional system within which they work.\u00a0 I was there and made regret mistakes. My regret is no consolation for patients hurt by my decisions.<\/p>\n

                Concerns, Problems, Issues: Evidence-Based . . . <\/strong><\/h2>\n

                The primary problem, in my opinion, faced by evidence-based efforts is the failure to recognize the serious limitations in homogenized and standardize approaches and methods, and risks for care and healing.<\/p>\n

                Scientific and professional preferences for a canon fail to acknowledge the profound variations across each client, each therapist, each disorder(s), and each therapy and healing approach and method. There is an implicit insistence on uniformity at the expense of diversity and variation. This perpetuates myths of therapist, patient, therapy, and disorder in favor scientific and professional interests and concerns. This equation is displayed in Figure 2.<\/p>\n

                Figure 2: <\/strong>Equation of Determinants of Outcome for Psychotherapy and Counseling <\/strong><\/p>\n

                Outcome = f constant x patient variability x therapist variability x disorder(s) x therapy methods x time x costs.<\/strong><\/em><\/p><\/blockquote>\n

                In addition, therapy and therapist availability, accessibility, and acceptability must be considered.\u00a0 The point being, homogenization of therapy is subject to considerable uniformity influences which deny variation.<\/p>\n

                Decades ago, Charles A. Kiesler, an eminent psychologist and university administrator, pointed out the myths of uniformity. He noted professional psychotherapy efforts fail to acknowledge ubiquitous variations in each of patients, therapists, methods, disorders (e.g., Kiesler, 1999).<\/p>\n

                The assertion of \u201cempirically validated\u201d therapies as the arbiter for implementation for \u201csuccess,\u201d \u201cinsurance,\u201d and \u201cconventional\u201d acceptance is a serious challenge for therapists and healers of all identities.<\/p>\n

                Much of the assertion is based on clinical studies comparing therapies with controls. There are numerous problems with this strategy, and in my opinion, does not constitute a useful approach.<\/p>\n

                Among the typical problems from the point of view of valid and reliable research approaches are the following: (1)<\/strong> uniformity of patient samples; (2)<\/strong> fidelity of therapist interventions; (3)<\/strong> ethnocultural and racial identities of therapist and patient; (4)<\/strong> variations in disorders, dysfunctions, and deviancies; (5)<\/strong> confounding by past patient history including medical histories, diagnostic assignment using the problematic DSMIV and DSMV; (6)<\/strong> outcome measure limitations relying on simple ratings of scales by therapist or patient; (7<\/strong>) failure to consider ethnocultural variations in communication styles, appearance, language, and perceptions.<\/p>\n

                All of these considerations create extensive \u201cerror variance\u201d<\/strong> which cannot be dismissed or processed via statistical procedures to highlight effects. Uses of different statistical methods can yield different results. Sample size may limit error, but it does not support minimal effects.<\/p>\n

                Outcome measures for evidence-based research too often fail to consider the spectrum of sources of patient reports including: (1)<\/strong> patient self-report (2)<\/strong> therapist evaluations; (3)<\/strong> family evaluations; (4)<\/strong> \u201cobjective\u201d indicators of status; (5)<\/strong> institutional pressures for cure rates.<\/p>\n

                Existing conventional \u2018in-group\u201d advocates and supporters aligned with professional (APA) and scientific groups, are inclined to support notions of science associated with empiricism without considering the limitations of empiricism, especially inherent assumptions and preferred methods found among certain culturally-endorsed approaches (Marsella, 2009).<\/p>\n

                This speaks to the issues of \u201cpower\u201d in professional and scientific groups, rather than doubt and contestation. There is a need here for reflexivity!\u00a0 \u201cPower\u201d in position does not yield easily; there is safety in convention. Cliques form in defense of particular theories, methods, and approaches claiming superiority (e.g., cognitive behavioral, psychodynamic, humanistic, behavioral).<\/p>\n

                Assuming a single therapy approach (e.g., Cognitive Behavior Therapy is current favorite) denies individual and cultural diversity and assumes application of the therapy method will be uniform across therapists. In addition, variations in the ethnocultural identity of therapist and client leads to considerable verbal and nonverbal communication problems.<\/p>\n

                Therapy outcome is a complex function of factors including the unique configuration of therapist, patient, disorder, therapy, time, cost, and healing principles.<\/p>\n

                As I studied, and applied different \u201cWestern\u201d and \u201cnon-Western\u201d therapies and counseling systems throughout my career, I concluded \u00a0a number of \u201chealing\u201d principles exist; each is effective depending upon the uniqueness of each case, including the client characteristics, particular time in therapy cycle, situational considerations. Among these are the following:<\/p>\n