People can Change

Carl Roger believed that, “the therapist must be willing to be real in the relationship with clients. By being congruent, accepting, and empathic, the therapist is a catalyst for change” (Corey, p. 171). The text points out that the therapist does not take on the normal role of a therapist, because they do not ask normal “Intake” questions or probe into the client’s life. The therapist is there for the client at that given moment, and their role is to be “without roles.”

            Roger’s believed that people, clients, have their own empowerment and that they can change without intervention. They can do this with the help of the therapist; the therapist is a spring board that they bounce ideas off of. The therapist will then pay attention to the client’s frame of mind and references. The client will more than likely show “themes” and these “themes” can be discussed in sessions. Rogers’s theory “rest on the assumption that clients can understand the factors in their lives that are causing them to be unhappy” (p.187). This approach allows the client to take responsibility for the changes that they make or the lack of changes that they make based on what they do: their actions.

Corey, G. Theories and Practice of Counseling and Psychotherapy. (8th Ed.). Belmont, CA: Brooks/Cole  

 

Psychodynamic Approaches versus Experiential and Relationship Oriented Therapies

While learning about counseling, counselors have to develop their own counseling style. This requires the counselors to not only know about the theories, but they must also know how to apply them in their patient’s life. The theories can be grouped into “five categories” according to Gerald Corey in the text Theories and Practice of Counseling and Psychotherapy; “1) Psychodynamic approaches, 2) Experiential and relationship oriented therapies, 3) The action therapies, 4) General approach, and 5) Post modern approaches” (2009, p. 8-10). This paper will compare and contrast the first two approaches (theories).

Psychodynamic approaches include the Psychoanalytic therapy and the Adlerian therapy; both of these approaches can be considered “Analytical approaches” with the exception that the Adlerian therapy does not focus on the unconscious aspects of the individual (p. 8). According to Corey it could be argued that, “Perhaps Freud’s greatest contributions are his concepts of the unconscious and of the levels of consciousness, which are keys to understanding behavior and the problems of personality” (p. 62). The two approaches differ in the importance that the unconscious mind plays, but Alder stresses that “people are in control of their fate, not victims of it” and Freud believes the unconscious controls the conscious behaviors (p. 98). There are some other differences with these approaches, but the author felt it was important for these two approaches to be grouped into the same category.

The Experiential and relationship oriented therapies include the Existential therapy, the Person-centered therapy, and the Gestalt therapy. These approaches stress “what it means to be fully human” and the importance of the client-therapist relationship (p. 8). The relationship that is built between the therapies will encourage the client and the therapist to work together through life’s problems. For example, the therapist is a spring board for the client and he/she can bounce ideas off of the therapist. The therapist will use the information provided to help them understand the client’s frame of mind and references, so that they can help the client to become aware of themselves. These theories encourage the therapists to help the client look at their life, and to become self determined to make change; this takes action on the clients part. 

The therapist’s function and role in the therapeutic relationship between the first set of theories and the second differ greatly. “Classical Psychoanalysis assume an anonymous stance;” whereas more modern/current psychoanalysis portrays the therapist as helping the client to interact “in the here and now” of their life (p. 70-71).  The therapeutic relationship and the treatment process of this approach require a great deal of time, effort, and expense because it focuses the clients attention on personal “insight” and reflection of maladaptive behaviors and anxiety (p. 72-4). The Adlerian Therapy has goals as well. They provide the client with an environment that is conducive to meeting the goals and developing socially useful goals (p. 100-104). Corey explains that the Adlerian therapist “assists clients in better understanding, challenging, and changing their life story” (p. 105).  

Founder Carl Roger, of the Person-centered therapy, believed that, “the therapist must be willing to be real in the relationship with clients: by being congruent, accepting, and empathic, the therapist is a catalyst for change” (Corey, p. 171). The text points out that the therapist does not take on the normal role of a therapist, because they do not ask normal “Intake” questions or probe into the client’s life. The therapist is there for the client at that given moment, and their role is to be “without roles.” Viktor Frankl, Rollo May, and Irvin Yalom were the key figures in the Existential therapy and their view was that people “are capable of self-awareness, which is the distinct capacity that allows us to reflect and to decide” (p. 138) In fact, it is the ability to be aware of our wants, needs, and desires that make us unique from other animals (mammals). However, along with the capacity to be self-aware comes questions and concerns; such as, “Who am I? What can I know? What ought I to do? What can I hope for Where am I going” (Corey, p. 139).

Freud drew attention to the “Ego-Defense Mechanisms:” which are the “motivations” for the behaviors that patients display when they are “overwhelmed” and unable to cope with anxiety (p. 63); in turn, the person-centered approach allows the therapist to work on themes that the client portrays (their words and deeds). Roger’s believed that people, clients, have their own empowerment and that they can change without intervention. They can do this with the help of the therapist; the client will more than likely show “themes” and these “themes” can be discussed in sessions.  

When “devising a treatment program” therapists need to ask: “What works for whom under which particular circumstance? Why are some procedures helpful and others unhelpful?” (p.458). For example, Gestalt therapy “leads to intense emotional expression; if these feelings are not explored and if cognitive work is not done, clients are likely to be left unfinished and will not have a sense of integration of their learning” (p. 474).  

Treatment plans are unique to the client; even though a therapist might use the same techniques or similar ones, the approach needs to fit the client’s needs. Therapists need to know when to be assertive and when to be less assertive. The way the therapists speak and acts should be adaptable: adaptable in that they don’t push a client’s buttons because they can. They develop a working therapeutic relationship.

The theories discussed do not have a so called “integrated perspective” when dealing with clients, so for some counselors there is a challenge in developing an “integrated plan” (p. 454). Therefore therapist will want to make sure that they are not trying to integrate approaches; in such a way, that they are confusing their clients or not being realistic about the progress clients are (are not) making. This writer feels that some form of therapy, insight, and knowledge it better than none. However, “A summary of the research data shows that the various treatment approaches achieve roughly equivalent results” (p. 476). Researchers have found that their our “four factors accounting for change in therapy: client factors (40%), alliance factors (the therapeutic relationship: 30%), expectancy factors (hope and allegiance: 15%), and theoretical models and techniques (15%)  (p. 476). The evidence is clear that therapy works although some would argue about what techniques work better.

All of the theories have applications; meaning that they have been proven to work (show that change can take place). I believe that the theories are not a one size fits all approach. The therapist has to decide where the patient is, what/if there is a diagnosis, and if the patient is prepared to accept what they are being told. Then, the therapist can go from the spot where the patient is and the therapist can determine what approach they would use. If an approach does not work then the therapist should reevaluate what is going on. For me, I appreciated the fact that the therapist answered any questions I had with tangible materials (handouts), and that she listened to me when I said I didn’t like something, so we focused on the things that I was willing to try (notice I don’t say that I liked). Talking through what I was thinking and feeling allowed me to hear myself and to process the information. Being in therapy allowed me the chance to speak my mind without repercussions; I felt safe. The psychologist that worked with me on my PTSD was very different from my therapist. The first day she laid out a plan for the rapid eye movement treatment, and she explained to clear the entire day because I would be exhausted afterwards. I saw her for twelve weeks, and my body doesn’t respond the way it used to. The point is that as a therapist we need to know when to refer someone. Once my treatment was completed, I wasn’t left alone I stayed in therapy for a little while longer just to make sure things were okay and I was good.

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Results of Life in Recovery

 If you’d like to improve your health you might stop smoking, but if you want to transform your life you need to adjust your thinking (mental inclination, attitude, and power of reason). This type of transformation doesn’t happen overnight. It comes about through phases. While the mental health system, services and supports, are transforming, this type of system-wide change will take time. SAMSHA (2012) has supplied consumers, families, and mental health professionals with four dimensions to support recovery, ten guiding principles of recovery, and a current working definition of recovery; which is, “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” Therefore, when individuals go through the process of change the positive benefits that they experience to their mental, physical, and social health is their recovery. In this current review of the literature, 103 sources were reviewed for information on recovery systems for individuals with a neurobiological disorder.

            First, the analysis revealed that there is not adequate funding for individuals with a neurobiological disorder. The United States spends $113 billion on mental health treatment (6% of their health care costs), but the indirect cost (loss of productivity) of mental illnesses is estimated to be $79 billion. Individuals with a neurobiological disorder need employment and income to support themselves. If mental health outcomes can be improved, then there is a possibility that the loss of productivity will decrease. There are many gaps in between mental health care needs and actual services that are delivered; as a result, most communities lack sufficient infrastructure, adequate facilities, and trained professionals to provide care to individuals with a neurobiological disorder. It is possible to measure recovery and justify an increase in financial resources; thereby, making it possible to improve the infrastructure, provide adequate facilities and trained mental health professionals.

            Research indicates that early identification and intervention can greatly improve outcomes for individuals with a neurobiological diagnosis. It will take strong leadership to develop and sustain a successful mental health system. While there has been legislation changes to increase access to community-based mental health services, it will take time and perseverance to see these changes implement. Once the changes have been implemented, then it will be possible to measure the effectiveness of the changes. If the changes help to remove some of the barriers to mental health care, then studies show that the policies will enhance the health and wellness for individuals with a neurobiological disorder and impact the community by providing a healthier environment. In the meantime, it important for researchers to continue to study the mental health care system, and to offer quality improvement mechanisms to improve treatment access and retention.

            Second, the United States needs to increase education and training for individuals with a neurobiological disorder. Neurobiological disorders are legitimate medical illnesses, like cancer, diabetes, heart disease, and so on so forth. Research shows that there are genetic and biological causes for psychiatric disorders; hence, the use of the term neurobiological disorders in this paper. Neurobiological disorders can be treated effectively. The recovery model has multiple facets and it is a nonlinear process; therefore, it would benefit consumers and families to know about the service options that are available at each stage, so that they can have a meaningful share in the opportunities available to them. By providing education and training to the consumer on their specific diagnosis it provides them with the opportunity to increase their knowledge and skills. However, recovery involves more than treating the diagnosis and symptoms because it is a multifaceted process that takes time.

            In order to attract the two-thirds of people with neurobiological symptoms that don’t seek care, the United States needs to remove common barriers that hinder people from seeking treatment. For instance, there are mountains of rules and regulations that consumers have to climb through to receive mental health services, because the mental health care system is not designed to be user friendly. The United States needs to increase recovery model education and training for mental health professionals, so they use the components of recovery to empower individuals with a neurobiological disorder to learn about their diagnosis, the system, resources, and to advocate for themselves. Most professionals have been introduced to recovery concepts and principles through federal program requirements or their agency’s administration policy; as a result, they should be held accountable when they do not promote recovery and follow the evidence based practices set forth by SAMSHA.

            Third, the United States needs to reduce the stigma and fear that surrounds a neurobiological disorder. Reducing stigma and improving mental health knowledge have the potential to enhance the mental health outcomes for individuals with a neurobiological disorder. By creating anti-stigma ads, it is possible to dispel inaccurate stereotypes and discourage the spread of myths, so that the public has a balanced view about mental health and treatment.

             There are shortcomings to this study; for instance, there are criticisms of Maslow’s hierarchy of needs that were not discussed (his theory is difficult to test scientifically), and the effects of medication on individuals with a neurobiological disorder were not looked at. There is limited research on the implementation and outcomes of recovery-oriented services and the mental health systems, since the changes in legislation and the SAMSHA working definition of recovery was released. More scientific research is needed to confirm or deny the changes to the quality of life for individuals; as well as, the long term effects to the individual, family, and community.

Conclusion

            In closing, neurobiological disorders are common all over the world. They can affect any person of any age, race, or socioeconomic status. While some obstacles have been removed from the mental health care system, there are still obstacles and challenges that are impeding the systems development, like the inadequate facilities and workforce. The components of recovery help to empower individuals with a neurobiological disorder to learn about their diagnosis, the system, resources, and to advocate for themselves. Since, it is estimated that approximately twenty-six percent of Americans, 57.7 million people or one in four adults, age 18 and older, suffer from a diagnosable neurological disorder in a given year it is important to continue understanding and researching all facets of neurobiological disorders.

            It is clear that much more research is needed; for example, the Affordable Care Act (ACA) will need to be evaluated to determine the effectiveness and the cost-effectiveness of the policy, after the policy has rolled out and some time is allotted for people to utilize the services; the Recovery Oriented Systems of Care (ROSC) model will need to be evaluated to determine the effectiveness (benefits) to the individual, the family, and the community; the ROSC model will need to be evaluated to determine the cost-effectiveness; and there is minimal research on the use and benefit of alternative medicine, just to name a few.

Recovery Transformation

SAMSHA (2012) redefined its definition of recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential;” therefore, when individuals change the overall positive benefits to their mental, physical, and social health is their recovery. SAMSHA (2012) realized that recovery is multifaceted, so along with this definition they came up with the four dimensions that support recovery and the ten guiding principles of recovery. Consequently, the four major dimensions that support a life in recovery are: (1) taking care of one’s emotional and physical health; (2) a safe home or place to live; (3) a purpose to life through meaningful activities; and (4) community supports that create relationships and social networks (SAMSHA, 2012). In the article Working Definition of Recovery, SAMSHA (2012) defines the ten guiding principles of recovery as:

Recovery emerges from hope:  The belief that recovery is real provides the essential and motivating message of a better future – that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them. Recovery is person-driven:  Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s). Recovery occurs via many pathways:  Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds- including trauma experiences - that affect and determine their pathway(s) to recovery. Abstinence is the safest approach for those with substance use disorders. Recovery is holistic:  Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. The array of services and supports available should be integrated and coordinated. Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Recovery is supported through relationship and social networks:  An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change.  Recovery is culturally-based and influenced: Culture and cultural background in all of its diverse representations - including values, traditions, and beliefs - are keys in determining a person’s journey and unique pathway to recovery. Recovery is supported by addressing trauma: Services and supports should be trauma-informed to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and collaboration. Recovery involves individual, family, and community strengths and responsibility:  Individuals, families, and communities have strengths and resources that serve as a foundation for recovery.  Recovery is based on respect:  Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems – including protecting their rights and eliminating discrimination – are crucial in achieving recovery (p.1-2). 

 

            Research suggests that as people progress through the recovery process their goals will change as their basic needs are met. According to humanist psychologist Abraham Maslow basic needs are vital for survival; for example, ‘physiological needs’ are water, food, and sleep; therefore, once these needs are met the individual would move onto meeting their ‘security needs’: safety, shelter, employment, and health care (1987). When setting goals it is important for consumers to have an understanding of the recovery process, because if they believe that recovery means a ‘cure’ to all their symptoms, then it might make recovery seem unreachable and be disheartening (Svanberg, Gumley, & Wilson, 2010). It is important to set appropriate and effective goals for each individual with a neurobiological disorder. If an appropriate and effective goal is set, then the individual will have a better chance of impacting their whole life (Clarke, 2012). Clarke, Oades, & Crowe (2012) explain that there are different stages of recovery goals; for example, “Avoidance goals aim to move or stay away from a negative or undesirable outcome (e.g. ‘to stop hearing voices’) whereas, approach goals aim to move towards or maintain a positive or desirable outcome (‘buy a car’) (p.298). Therefore, it is important to build on the individuals strengths when setting goals, and to acknowledge that “Individuals often experience setbacks within recovery which can lead to a few steps back before progressing again” and that is ok (Clark, p.303).            These recovery-oriented concepts are transforming the mental health care system (Clarke, 2012; Gehart, 2012; Onken et al., 2007; Pilgrim, 2009; Segal, Silverman, & Tempkin, 2010; Svanberg, Gumley, & Wilson, 2010).  

            This study is an analysis of the recovery system for individuals with a “neurobiological disorder,” [1] and it reveals that (1) there is not adequate funding for individuals with a neurobiological disorder; (2) there needs to be more education and training for individuals with a neurobiological disorder and professionals; as well as, accountability for professionals that do not promote recovery and follow the evidence based practices; and (3) society needs to reduce the stigma and fear that surrounds a neurobiological disorder, because evidence shows that change is possible.  

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[1] In this paper, “Neurobiological disorder” refers to a diagnosis given to any person, who currently or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder that would meet diagnostic criteria specified in the Diagnostic and Statistical Manual for Mental Disorders Fifth Edition (DSM - V). This term is not meant to be derogatory or demeaning to people who are dealing with mental health challenges.

Synopsis of Changes

             The organizational structure of mental health services has changed over the last few decades by shifting from institutional treatment to community-based treatment that focuses on a recovery-oriented approach (Gehart, 2012; Kaplan, Salzer, & Brusilovskiy, 2012; Onken, Craig, Ridgway, Ralph, & Cook, 2007; Pilgrim, 2009). These changes within the organizational structure of mental health services have made it possible for more individuals with a neurobiological disorder to live in communities. The United States government passed legislation which halted large group health plans (51 or more employees) from imposing annual or lifetime dollar limits on mental health benefits, because discriminating health insurance practices placed limits on insurance coverage for mental health and addictions treatment (SAMSHA, 2013). This was known as the Mental Health Parity Act (MHPA) of 1996. Yet, many consumers continued to receive inadequate services and treatment, and most communities continued to have inadequate resources (Corrigan, 2004; Komiya, Good, & Sherrod, 2000; Vogel, Wade, & Haake, 2006).  

            Consumer is a term that is preferred to be used; rather than, ‘client’, ‘patient’, or ‘service recipient’ (Gehart, 2012, Part I, p.431; President’s New Freedom Commission on Mental Health, 2003, p.4). This term is not meant to be derogatory or demeaning to people who are dealing with mental health challenges. In fact, the consumerism movement is the joining together of any individual who has had or is experiencing emotional and mental health challenges in a movement to regain their rights; thereby, “ridding society of discrimination and prejudice” (Holter, Mowbray, Bellamy, MacFarlane, & Dukarski, 2004, p.51).

The U.S. Supreme Court heard the case Olmstead v. L.C. (1999), and the justices determined that the Americans with Disabilities Act of 1990 requires states to place individuals with a neurobiological disorder in community settings when it is determined that community placement is appropriate; for that reason, the Olmstead v. L.C. case is used as the basis for making determinations about placement of individuals with a neurobiological disorder. As a result of the Olmstead v. L.C. case and the Consumerism movement, the New Freedom Commission on Mental Health (2003) recommended a policy shift that would transform mental health services and supports towards a ‘recovery-oriented approach.’ The idea of this type of transformation was a move in the right direction. According to Gehart (2012), “this approach draws upon some of the field’s best practices to create an approach that harmonizes with and supports the principles and ethics identified in the consumer-based, mental health recovery movement” (Part II, p.443). But, recovery is a broad term and without a clear definition and understanding of the term there were many misunderstandings surrounding its use by professionals and consumers. Since the policy that was developed lacked a clear definition Pilgrim (2009) pointed out that there was “little consensus on what recovery means in relation to mental illness” (p.477).  In order for there to be more of a consensus between professionals and consumers there needed to be a better description of what recovery meant and how recovery could be attained.

            In 2005, the Substance Abuse and Mental Health Services Administration (SAMSHA) came out with a definition of recovery, and they defined recovery as “A journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.” Despite this definition of recovery there was still confusion surrounding the definition of recovery. Davidson and Roe (2007) tried to decrease the confusion that surrounded recovery by dividing recovery into two categories: ‘recovery from’ which involves an individual with a neurobiological disorder diagnosis becoming symptom free and not being admitted into a hospital or facility as a patient, and ‘recovery in’ which is when an individual with a neurobiological disorder endures their fluctuating symptoms as they change.

            SAMSHA was central to the transformation of the recovery system when they made the commitment that, “The Concept of recovery lies at the core of SAMSHA’s mission, and fostering the development of recovery-oriented systems of care (ROSC) is a SAMSHA priority” (Center for Substance Abuse Treatment, 2006, p.8). During this time period some other issues arose: sixty percent of consumers were leaving mental health and substance use disorders treatment before completion of their treatment (Substance Abuse and Mental Health Services Administration Office of Applied Studies Treatment Episode Data Set 2005, 2008); organizations were finding it difficult to measure the results of recovery and the government started feeling the pressure to reduce spending. As a result, the government started holding organizational programs, and professionals, accountable to provide measurable results.

It was apparent that the entire mental health system needed to be changed, so in 2009 SAMSHA started releasing recovery-oriented publications to provide direction in making efficient use of resources (Sheedy & Whitter, 2009; Gaumond & Whitter, 2009; Halvorson & Whitter, 2009; Laudet, 2009). Furthermore, SAMSHA created best practices and common terms that could be incorporated into the mental health and addictions field (Sheedy & Whitter, 2009; Gaumond & Whitter, 2009; Halvorson & Whitter, 2009; Laudet, 2009). The United States government realized that there were millions of Americans with neurobiological and/or substance disorders that were not receiving the same level of care as Americans with other general medical conditions; as a result, the U.S. passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 (Humphreys & McLellan, 2010). Then, SAMSHA (2010) released a three phase plan entitled Access To Recovery (ATR) Implementation Toolkit which was intended to help organizations receiving ATR grants to understand how to plan and implement recovery-oriented changes within their organization.

The MHPAEA's legislation was helping some Americans, but it was leaving millions of Americans without the needed medical insurance to get mental health services. Consequently, the U.S passed the Affordable Care Act (ACA) of 2010 (SAMSHA, 2013). However, there are challenges when implementing organizational changes. For example, some studies point to funding, administrative, and infrastructure challenges when implementing organizational changes (Halvorson & Whitter, 2009, p. 21). Halvorson & Whitter (2009) point out that “it’s important for all parties to be flexible during the alterations of the current mental health system;” however, the changes would continue over the next few years with the biggest changes being implemented in 2012 when the recovery process was transformed (p.17).