We have an odd structure for training clinical psychologists in the US, and it's really clear to me the contrast since I'm now visiting Canada. In the United States, we've made it fairly easy to start training programs in psychotherapy, but we've made it exceedingly difficult for practitioners to get licensed and into practice. Sadly, as a result, many psychotherapists are demoralized and fairly exhausted by the demands of training before they've ever been able to get into full practice. It's odd, when you think about it, because the very idea of a profession involves the public expectation that practitioners will be uniformly trained in a technical subject. In psychology, we've been talking for years about wanting a diversity of training models, but this makes it hard to achieve uniformity. To a consumer, the array of options must be bewildering. You can see a master's level practitioner (Marriage and Family Therapist, Master in Social Work) or a doctoral level practitioner (psychiatrist, Ph.D., Psy.D., or Ed.D.) or even a pastoral counselor or psychiatric nurse. Your therapist may have gone to a University, which also trains people in lots of other disciplines and professions, or they may have gone to a school that is very small and only exists to train psychotherapists.
In Canada, the idea of a for-profit educational institution is controversial. While therapists in the 1970's learned that they could make a living by starting schools to train others (especially in California), and there was indeed a terrible shortage of mental health practitioners, that has never been allowed on a large scale in Canada.
As a result, therapists in Canada are more uniformly trained, especially if they are doctoral level psychologists. All Ph.D.'s will have attended a University based program, and the University itself has no profit motive, so it can afford to be choosy and dismiss inappropriate students without a second thought. Whether that happens or not, I don't know.
On the other hand, clients don't have managed care plans, and the government rarely pays for therapy (outside of hospitalization, as I understand it). So Canada probably has better and more gifted therapists, on average, but their therapists are more expensive to see. Fortunately, people with good health insurance through their employers may have great access to a variety of practitioners, but people without such insurance may be out of luck.
The contrast reveals a fundamental problem in structuring health services. The needs of clients are antithetical to the desires of practitioners, and what is good for one tends to be bad for the other, at least in the fee-for-service market. If the cost of care comes down for clients, then the benefits of providing care come down for practitioners. You can then expect the best practitioners to feel demoralized, since they could usually make a better living elsewhere. Lest you think that psychotherapists are extravagantly paid, the average practitioner at a master's level makes about as much as, or less than, a schoolteacher, especially when benefits are included.
Having pondered this conundrum for years, I personally would recommend a system more similar to actuarial science, which has a series of 8 graded exams. People can stop after 4 and practice, or they can go for all 8. If you want the most stellar actuary out there, pick someone who has passed all 8 exams. If you want a less expensive choice, go for someone who just passed exam 4. Something like this, if implemented in a broad scale in psychotherapy, could help clients identify the best (most skilled) practitioner in their price range. It could be good for Canada, which shows signs of emulating the broken US system, as well as the US.
The existing system is endangered by widespread career dis-satisfaction. A substantial number of practitioners are considering leaving the field, and we may have a shortage in the distant future if we don't do something now to to make the field of practice fairer in its compensation given the extreme work and talent that go into training the best practitioners at top programs. We risk losing our brightest minds to business and government and research if we don't take action.
Tuesday, June 23, 2009
Tuesday, June 16, 2009
The Glory that is Canine
This week, I've been visiting an old friend on vacation, who has a lovely little black and white Havanese. In Toronto - a city run by dogs, who lead their owners around on leashes until they deliver the coup de grace and watch in delight as a fully grown human with plastic covered hands picks up their excrement - it became clearer and clearer what dogs do for us. A dog doesn't fret and stew and hold grudges. A dog doesn't sit up nights wondering if the market will come back. A dog just wants to love and be loved, to eat now and then, to run around, and once in a while to urinate on a park bench so its friends will know it was there. In short: a dog knows how to live.
And so, here in Toronto, it became clear to me what the dogs do for us. They are our teachers and guides. We learn from them to eat, to walk, to enjoy the smells and tastes and warm comforts of daily life, and to make friends and leave a little of ourselves after, so that others will know we lived well.
And so, here in Toronto, it became clear to me what the dogs do for us. They are our teachers and guides. We learn from them to eat, to walk, to enjoy the smells and tastes and warm comforts of daily life, and to make friends and leave a little of ourselves after, so that others will know we lived well.
Sunday, June 14, 2009
Quick Help for Anxiety
Check out the "Quick Help for Depression" post for general directions on using the question list.
What could you learn from this situation that would help you in other places in your life?
What is the reality of the upsetting situation? What is the threat? What is your goal? How can you best achieve it?
What is so terrible about this moment right now? Are you making yourself anxious un-necessarily?
What will this situation look like next year? What will it look like many years from now?
What stories have you been telling yourself about the upsetting situation? Can you think of a story that makes you feel less anxious?
Is there another side to the upsetting situation that makes you feel more calm?
What is the most pleasurable thing about this moment, right now?
Think about somebody you admire - someone who handles anxiety well. How might that person look at the situation that seems to be causing your anxiety? What might that person do to keep a level head and act effectively?
If a good friend of yours were in a similar situation, what might you say to help them through it?
What is the worst thing that is really likely to happen in this situation? If that happened, what good things could you still enjoy in life?
What can you do now to make the worst-case scenario less likely? How can you make it less threatening (if it does happen)?
Are you using anxiety to distract or energize yourself? What might you be thinking about if you weren't thinking about this? Would it make more sense to focus on that and deal with it now?
If you are using anxiety to energize yourself, what alternative would be healthier?
How much do you really care what other people think of you in this situation? How much of a difference would it make if you didn't have to worry about your reputation or how others view you? Are you sure you're not getting over-worried about their thoughts?
Are you rehearsing or replaying upsetting situations in your mind? Could you let go of that and focus on this moment now?
What advantages do you have in this upsetting situation that you would miss if you found yourself in another situation that looks preferable to you now?
What healthy things have you done to calm yourself before?
What could you learn from this situation that would help you in other places in your life?
What is the reality of the upsetting situation? What is the threat? What is your goal? How can you best achieve it?
What is so terrible about this moment right now? Are you making yourself anxious un-necessarily?
What will this situation look like next year? What will it look like many years from now?
What stories have you been telling yourself about the upsetting situation? Can you think of a story that makes you feel less anxious?
Is there another side to the upsetting situation that makes you feel more calm?
What is the most pleasurable thing about this moment, right now?
Think about somebody you admire - someone who handles anxiety well. How might that person look at the situation that seems to be causing your anxiety? What might that person do to keep a level head and act effectively?
If a good friend of yours were in a similar situation, what might you say to help them through it?
What is the worst thing that is really likely to happen in this situation? If that happened, what good things could you still enjoy in life?
What can you do now to make the worst-case scenario less likely? How can you make it less threatening (if it does happen)?
Are you using anxiety to distract or energize yourself? What might you be thinking about if you weren't thinking about this? Would it make more sense to focus on that and deal with it now?
If you are using anxiety to energize yourself, what alternative would be healthier?
How much do you really care what other people think of you in this situation? How much of a difference would it make if you didn't have to worry about your reputation or how others view you? Are you sure you're not getting over-worried about their thoughts?
Are you rehearsing or replaying upsetting situations in your mind? Could you let go of that and focus on this moment now?
What advantages do you have in this upsetting situation that you would miss if you found yourself in another situation that looks preferable to you now?
What healthy things have you done to calm yourself before?
Quick Help for Sadness
In 2001, I created a brief online tool that has proven fairly popular. I'm migrating it here.
How would you like to have a tool that would allow you to get out of a gloomy mood quickly and achieve an experience of confidence and calm?
Experienced therapists help clients do this by asking strategic questions at key moments in therapy. Based on years of work as a mental health professional, I have developed a list of the most effective questions therapists use to help clients find a way out of sad and depressed moods. These questions come out of my own clinical experience and informal study of masterful psychologists and what they do. I have used them to help many clients, and chances are good that they can help you as well.
You can try out the system yourself right now. If you would like to get the full benefits of using it, you should consult this list five times a day for at least three weeks. If merely reading the questions doesn't help, you might try writing out answers several times (in a spirit of cooperativeness) and seeing what happens.
To get started now, read over each question below, silently. After reading each question, take a deep breath, let it out, and then move on to the next question.
Sometimes a question will help you find a fresh perspective on whatever is making you sad.
Sometimes a question will be irrelevant. Occasionally a question may make you feel a little worse. Depending on your past experiences, reviewing the questions may be a little annoying. Applying yourself to them is likely to make that reaction go away and leave you with benefits.
However, for many people, at least one of the questions will be just the thing to help you turn your mood around.
Read each question below, and after your read each one, let it settle in the mind, think of an answer, and then move on.
What could you learn from this situation that would help you in other places in your life?
If things go well in the situation that is making you sad, what do you think this situation willlook like when you remember it next year? What will it look like many years from now?
What is the worst thing that is really likely to happen in this situation? If that happened, what good things would you still be able to enjoy?
What can you do now to make the worst case scenario less likely? What can you do now to make the worst case scenario less threatening?
What can you do now to take care of yourself - to make yourself feel calmer or more comfortable? How can you make sure to do those things?
What stories have you been telling yourself about the situation that is making you sad? Can you think of a more empowering or helpful story?
Should you put yourself first in this situation?
Have you been putting other people's needs and wants too far ahead of your own? If so, why do you think their needs and wants are more important than your own?
What is the most pleasurable thing about this moment right now?
Think of someone you admire. How might that person look at the situation that is making you sad? What would that person do?
What is your overall mission in life right now? What would that have you do? How are you doing lately in terms of your most important priorities?
Are you trying to do more than is reasonable in light of your resources? Can you allow yourself to set your aim a little more realistically?
What is the reality of this depressing situation? What is the real threat? What is your goal? How can you work toward it?
If a close friend of yours were in the situation that is making you sad, what would you say to help them get through it? What would you want to help your friend see? What would you want to help your friend do?
What is so terrible about this moment right now? Are you making yourself miserable un-necessarily, in anticipation of something unpleasant, or by holding on to something past?
What advantages do you have in this sad situation that you would not have in some other circumstance that looks better to you now?
What is the best thing that has happened to you in the past few days or weeks? Can you remember to hold on to some of the small joys of daily life, such as the smile of a happy child or the scent of a rose in bloom or the colors of sunrise or sunset?
What healthy things have you done to get through sad times before?
How would you like to have a tool that would allow you to get out of a gloomy mood quickly and achieve an experience of confidence and calm?
Experienced therapists help clients do this by asking strategic questions at key moments in therapy. Based on years of work as a mental health professional, I have developed a list of the most effective questions therapists use to help clients find a way out of sad and depressed moods. These questions come out of my own clinical experience and informal study of masterful psychologists and what they do. I have used them to help many clients, and chances are good that they can help you as well.
You can try out the system yourself right now. If you would like to get the full benefits of using it, you should consult this list five times a day for at least three weeks. If merely reading the questions doesn't help, you might try writing out answers several times (in a spirit of cooperativeness) and seeing what happens.
To get started now, read over each question below, silently. After reading each question, take a deep breath, let it out, and then move on to the next question.
Sometimes a question will help you find a fresh perspective on whatever is making you sad.
Sometimes a question will be irrelevant. Occasionally a question may make you feel a little worse. Depending on your past experiences, reviewing the questions may be a little annoying. Applying yourself to them is likely to make that reaction go away and leave you with benefits.
However, for many people, at least one of the questions will be just the thing to help you turn your mood around.
Read each question below, and after your read each one, let it settle in the mind, think of an answer, and then move on.
What could you learn from this situation that would help you in other places in your life?
If things go well in the situation that is making you sad, what do you think this situation willlook like when you remember it next year? What will it look like many years from now?
What is the worst thing that is really likely to happen in this situation? If that happened, what good things would you still be able to enjoy?
What can you do now to make the worst case scenario less likely? What can you do now to make the worst case scenario less threatening?
What can you do now to take care of yourself - to make yourself feel calmer or more comfortable? How can you make sure to do those things?
What stories have you been telling yourself about the situation that is making you sad? Can you think of a more empowering or helpful story?
Should you put yourself first in this situation?
Have you been putting other people's needs and wants too far ahead of your own? If so, why do you think their needs and wants are more important than your own?
What is the most pleasurable thing about this moment right now?
Think of someone you admire. How might that person look at the situation that is making you sad? What would that person do?
What is your overall mission in life right now? What would that have you do? How are you doing lately in terms of your most important priorities?
Are you trying to do more than is reasonable in light of your resources? Can you allow yourself to set your aim a little more realistically?
What is the reality of this depressing situation? What is the real threat? What is your goal? How can you work toward it?
If a close friend of yours were in the situation that is making you sad, what would you say to help them get through it? What would you want to help your friend see? What would you want to help your friend do?
What is so terrible about this moment right now? Are you making yourself miserable un-necessarily, in anticipation of something unpleasant, or by holding on to something past?
What advantages do you have in this sad situation that you would not have in some other circumstance that looks better to you now?
What is the best thing that has happened to you in the past few days or weeks? Can you remember to hold on to some of the small joys of daily life, such as the smile of a happy child or the scent of a rose in bloom or the colors of sunrise or sunset?
What healthy things have you done to get through sad times before?
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