M O'Hara Emancipatory therapeutic practice in a turbulent transmodern era: a work of retrieval

0000 There are at least three different kinds of responses to the fundamental questions currently coexisting within the mental health community. Gergen divided psychological discourse into modern objectivist, the modern romantic, and the postmodern constructivist responses (Gergen, 1994). Another designation might be biomedical modernists, the psycho-poetic depth psychologists who straddle the boundary between modern and postmodern, and the postmodern social-constructivists and integrationists.

0000 They frequently co-exist, it should be added, within the same individual psychotherapist.

0000 0000The Biomedical Majority
0000 The dominant position among members of the American Psychological Association (APA), the American Psychological Society (APS), and the American Psychiatric Association is firmly modernist. Even in psychology, the biomedical paradigm dominates enshrined in the Boulder model of clinical psychologist as natural scientist and behavioral practitioner. The metaphysic of main-stream psychology is causal and materialist. Reality, including mind itself, is made up of measurable quantities of matter that behave in predictable, law-like fashion. Its dominant epistemology is Cartesian or empiricist-objectivist. This position holds that valid knowledge is impersonal, gained only through strictly controlled experimental methods from which all sources of contextual contamination and observer subjective biases have been eliminated. As a logical consequence of these first two tenets, adherents to the modernist-objectivist position claim its truth to be precise, value-free, and generalizable.

0000The Psycho-Poetic Romantics
0000 The next most widely held position among American psychologists is the romantic-subjectivist or psycho-poetic, which places the unique, experiencing individual at the center of its metaphysics, epistemology, and moral theory. Stretching back to the earliest days of psychotherapy, the romantic view was part of the thinking of early psychoanalytic thinkers like Adler, Rank, Horney, and Jung. Its most widespread and popular manifestations, however, have been in the humanistic and transpersonal traditions, represented by members of the Association for Humanistic Psychology, the Association for Transpersonal Psychology, the American Academy of Psychotherapy, and members of the Division of Humanistic Psychology of APA, Division 82. Arising as a direct challenge to regarding psychological problems as diseases and to limiting the focus of psychological attention to questions of treatment and repair, the humanistic tradition refused the medical designation and instead, defined itself in growth, education, and wellness terms. This tradition reached back to the gentler, more tolerant, and inclusively humanistic visions of reality of pre-Cartesian Renaissance humanism. For the psycho-poetic therapist, the highest reality is transcendental reality--the whole that is greater than the sum of its material parts. Knowledge is personal knowledge, the most important and enduring answers to the eternal questions found deep within the individual subjective human being. Despite self-characterization as alternative or "Third" and "Fourth Force" movements within psychology, the modernist origins of a great deal of humanistic psychology are still clearly visible. Although arrived at through more personal or subjective processes of inquiry; continued emphasis on such Enlightenment universals as truth, freedom, and self reveal its (in my view, proud) modernist lineage.

0000The Constructivists
0000 The newest family in the psychological discourse neighborhood one that is clearly offspring and kin of both modernistobjectivists and subjectivist-romantics--is a heterogeneous assortment of practitioners and theoreticians who approach questions of reality, knowledge, and morality from pluralist, contextualist, or social-constructivist perspectives. These newer voices--often referred to as postmodern--speak in the frankly politicized accents of previously marginalized groups such as women and ethnic, sexual, and religious minorities. They interpret psychological pain contextually, as the result of cultural and political forces that have forced people on the margins of society to internalize self-injurious conceptual maps and narratives, which lead to restricted patterns of life.

0000 The postmodern discourse represents a conjunction of some recent extensions of both objectivist and subjectivist traditions. On the one hand, by casting an analytical and critical eye onto the processes of normal science itself, objectivist researchers have been able to show that when formerly tacit or invisible variables such as the values, investments, and interests of the investigators are put under scrutiny, claims about impersonal objectivity and moral neutrality prove unsustainable. On the other hand, by taking phenomenological, narrative, and interpretative research methods favored by romantic-subjectivists to their furthest extensions, they reveal psychological reality to be uniquely personal, as the romantics have long asserted, but at the same time coextensive with the cultural contexts--historical, class, gender, racial, ethnic, and linguistic--in which any individual develops consciousness. The post-modern discourse offers contemporary psychology the potential for reconciling and surpassing the limits of both objectivism and subjectivism. There are still important methodological, ethical, and developmental problems to be solved before a new postmodern psychotherapy can be satisfactorily described that is more than either of the psychologies it attempts to replace, but the postmodern discourse appears very promising (Neimeyer, 1996; Stricker, 1996).

. 0000A HOUSE DIVIDED
0000 Despite its enormous social influence in creating the 20th-century worldview, psychology is a house divided. The deep philosophical differences and ever-present threat of schism among the modernist-objectivist, subjectivist-romanticist, and postmodernist-contextual discourses within psychology have gone unresolved for over three decades. After a brief period of openness in the late 1960s and early 1970s, the. modernist Boulder model has come to dominate mainstream academic and government psychology. With a few remarkable exceptions (e.g., Duquesne University, Sonoma State University; and the State University of West Georgia), by the 1980s, in mainstream schools, humanistic and transpersonal approaches had been either banished to programs in counseling, marginalized within departments of psychology--which over the 1970s came to look and sound ever more like departments of zoology, biochemistry; or computer science or had struck out on their own into free standing alternative graduate schools like the Union Institute, Fielding Institute, Saybrook Institute, California Institute for Integral Studies, and the Center for Humanistic Studies.

0000 Outside the academy, and outside scholarly journals, however, the vast majority of private mental health practices across the country, service professionals, and the general public had until recently accommodated to the schism. Subjectivist-romanticist practitioners resolved their cognitive dissonance by convincing themselves they were "playing the insurance game"--giving medical diagnoses to insurance companies while avoiding them within their actual practices. Conversely, modernist-objectivists supplemented their scientist-practitioner graduate training with workshops, clinical training programs, and growth experiences of all sorts, which offered a rich diet of both romanticist and postmodern growth opportunities and therapeutic training. During the 70s and 80s, people favored gestalt therapy, self-psychology, client-centered therapy, Eriksonian hypnosis, Jungian psychology, and transpersonal psychology. The postmodernists, who go by such names as narrative, deconstructionist, constructivist, relational, and contextual therapists, have gained ground in the last decade. In many ways ideally suited to the need to play more than one game, the postmodernists have been particularly visible among marital and family, feminist, and ethnic therapists.

0000 Despite deep and seemingly irreconcilable theoretical contradictions, professional therapists have so far been remarkably adept at juggling the multiple discourses or paradigms that coexist within their field, speaking one language and idiom with their university professors, another with their clinical supervisors, another with the insurance companies, and yet another with their clients.

0000 But the ground is shifting once again and the cracks are beginning to show. The paradigm wars are heating up--not only on an academic or theoretical level but in the more concrete arena of the business of practice. The always-incoherent center of professional psychology threatens to finally fracture into separate discourses.

0000THE WIDENING CHASM
0000 As the cultural divisions within the psychotherapy community widen, some practitioners try to resist the disintegration of their world with a flurry of activity within their various professional organizations, apparently aimed at consolidation of the modernist position before it slips away.

0000 There are initiatives among practitioners within the APA to develop standardized treatment protocols for psychotherapists based on empirically validated treatments and to define standards of care in objective, operational terms. A Division 12 (clinical psychology) task force, for instance, recently proposed that APA create an authorized treatment manual that would endorse only those therapeutic approaches that had been subjected to randomly assigned, double-blind, symptom-specific outcome studies. Although the proposal was rejected by the majority within APA as overly restrictive, other attempts to establish therapeutic effectiveness on the basis of strict experimentalist and objectivist criteria are likely to follow in North America and worldwide. According to Auckenthaler, Psychotherapie im Wandel: Von der Konfession zur Profession (Psychotherapy in and Berauer (1994), has been very influential in movement within European psychotherapy toward the objectivist position and away from either the romantic or postmodern positions (Auckenthaler, July 4, 1996, personal communication). Recently, the APA voted to seek drug prescription-writing power for clinical psychologists, thereby moving even further along a biomedical path. As the managed care revolution in health care proceeds, demands for accountability in health care spending intensify. Shareholders and executives of the large for-profit health care entities begin to clamor for good returns on their money; and pressure is on psychotherapists to demonstrate therapeutic efficacy in terms that are acceptable to managed care executives and their corporate customers. Non-physician psychotherapists, wary of losing their piece of the health care pie, are scrambling to play catch-up with the psychiatrists. Clearly, they have decided to put their money on the modernist-objectivist horse.

0000 There are serious challenges to APA's attempts to fortify its modernist-objectivist grounding for its claims about the effectiveness of psychotherapy, some of them coming from within the modernist-objectivist camp itself. It has been long recognized that training and credentialing processes employed by APA-accredited graduate schools of psychology and state licensing boards cannot be shown to result in more positive treatment outcomes for clients (Dawes, 1994). Others point out that from within the objectivist story favored by dominant voices within APA, no strong, validated evidence exists that verifies that specific therapeutic techniques, beyond such nonspecific factors as warmth and a sympathetic ear, actually correlate significantly and favorably with treatment outcomes (Dawes, 1994; Eysenck, 1952, 1983; Jacobson, 1995; Miller, Hubble, & Duncan, 1995). Some researchers, although granting that people who consult psychotherapists do report benefits, nevertheless argue against considering such benefits therapeutic. Dawes, for instance, suggests that out-patient psychotherapy plays an educational or spiritual rather than therapeutic function in peoples' lives. He calls for the complete deregulation of outpatient psychotherapy and suggests that because it is not medicine, it be marketed on a caveat emptor basis like any other personal service or product. He argues that professional licenses should be required only by those therapists who work in institutional settings such as hospitals, prisons, and residential treatment programs, where inmates are relatively powerless and so need some kind of organized protection from abuse of psychiatric power. These debates over fundamentals within the modernist community are likely to become increasingly politicized.

0000 Meanwhile, from without there rages a vigorous postmodernist antitherapy critique (Wakefield, 1996). By revealing the embarrassing history of racism and misogyny that has informed psychology's views of women, people of color, strangers, nonconformists, and lesbians and gays, the postmodern critique argues that all theories of psychological life, systems of psychotherapy, strategies for change, values, and ethics are nothing more (or less) than shared traditions--myths or stories generated to protect the interests of particular dominant groups (Caplan, 1995). (Postmodernists have been slower to extend this analysis of interests to their own position.)

0000 Virtually ignored by both modernist-objectivists and deconstructivist. postmodernists are the very large numbers of practitioners and the dwindling numbers of academics who make up the ranks of the humanistic and transpersonal counselors, psychotherapists, psychologists, and organizational consultants. Unacknowledged, or when acknowledged, devalued or even disapproved of by APA-accredited clinical psychology programs, much of the actual clinical psychotherapy practice of the nearly 300,000 mental health practitioners across the United States, the majority of organizational-behavior practitioners, and virtually all of the practice within the self-help movement, is grounded in a romanticistsubjectivist language of humanistic psychology, often combined with the spiritual focus of transpersonal psychology. "Becoming your own person," "awareness," "trusting what is deepest within you," "listening to your unique inner self," seeking "authentic experience," building "empathic" and "accepting" "1-Thou" relationships with others, "realizing your true potential," embracing the freedom to be," experiential exercises, guided imagery that help people "get in touch with their deeper selves," and stress reduction meditation techniques are familiar touchstones of actual practice for the vast majority of American practitioners and their clients. Although frequently sliding back and forth across the fuzzy boundary between modernism and postmodernism, this broad folk-psychology clearly derives much of its language, meanings, and behavioral conventions from the romanticist tradition.

0000 The radical turmoil within the psychotherapy culture leaves a pervasive sense of pessimism and uncertainty among psychotherapists about their own futures in a profession that is in the process of being turned upside down. Bewildered and anxious, they buy books and newsletters and flock to conferences and seminars that offer to teach them managed-care-friendly, "magic bullet," short-term techniques and programs on how to make their livelihoods outside the health care "industry." But at the same time, a burgeoning therapeutic counter-culture of licensed and nonlicensed healers thrives in the widening cracks in the authorized mental health landscape--yet more evidence of centrifugal forces tearing the psychotherapeutic community apart (O'Hara, 1996).

0000CULTURE WARS
0000 The therapeutic community can no longer deny that not only does it house multiple theoretical positions about psychological development and the practice of psychotherapy, but it embraces multiple ways of investigating the existential questions--everything from positive science to myth. It also has multiple views on the multiplicity! There is no coherent and universally accepted meta-story that can make sense of the mental health field's pluralism and help clients make sense of it. Like the rest of society, mental health professionals find themselves caught up in contradictory and deeply divisive movements that become increasingly difficult to reconcile. In October 1996, the American Psychologist published a special issue on outcome assessment in psychotherapy that included 11 very different points of view about research about psychotherapy, ranging from vigorous defense of experimental treatment-focused methods to arguments favoring more contextual patient-focused approaches (VandenBos, 1996). In reviewing Hoshmand and Martin's book, Research as Praxis: Lessons From Programmatic Research in Therapeutic Psychology (1995), Claiborn expresses his astonishment at how much of discussions of therapeutic outcome end up being discussions about "methodology as distinct from findings" (Claiborn, 1996). Practitioners attempting to straddle more than one discourse community must come to terms with the dawning realization that the grounds for justification of any particular clinical approach, ethical consensus or choice of action, are in large part socially constructed. More confusingly, some are logically and ethically incommensurate one with another.

0000 When parallel but incommensurate logical, moral, and ethical systems collide, as they increasingly do within the mental health community, ensuing disagreements frequently become divisive, interminable and shrill (Maclntyre, 1981). The strain this puts on any community is enormous. In the absence of any universally respected final authority--science, God, Truth--if disagreements are to be resolved at all, it is frequently through the exercise of force--coercive or brute by the stronger over the weaker.

0000 There is a real danger of strong-arm methods being used within psychology, by modernist-objectivists who represent the powerful majority denying legitimacy to both subjectivists and postmodernists and forcing them beyond the margins of acceptability. Of the 20 or so clinical treatments initially endorsed by the APA Division 12 task force on practice guidelines, all but 1 were cognitive behaviorist approaches.

0000 To be included by the Division 12 task force as a proven effective treatment (in contrast to a treatment that is considered experimental or ineffective), a therapeutic process must pass muster when held to standards of evaluation derived from biological medicine and drug trials conducted under conditions that bear little or no relationship to the actual practice of psychotherapy. Only those therapies that have already been "manualized"--broken down into clearly delineated, replicable, and quantitatively measurable operational steps--are considered. These selection criteria are based on the proposition that only by comparing psychotherapy outcomes with different therapists, specific client populations who are randomly assigned to either no treatment control groups or test groups, and the therapy conducted under specified clinical conditions can outcome results be confidently evaluated and effectiveness claims justified (Barlow, 1996). Context, the experience or other personal dimensions of the therapist, or the unique life circumstances of the client have no place in this form of outcome assessment. They are "out of paradigm" (Bohart, O'Hara, & Lietner, in press). Such strict adherence to abstract standards of formal 'objectivity, long abandoned by biological and physical sciences, has been referred to by some critics as "the cult of empiricism" (Toulmin & Leary, 1994). Regardless of its validity in assessing the effectiveness of some kinds of behavioural interventions, this type of research protocol effectively eliminates a priori the work of researchers interested in the subjective particularities of individual cases and in specific client-therapist relationships.

0000 Humanistic, transpersonal, or constructivist approaches did not survive the Division 12 cut. Nor for that matter did any depth psychoanalytic, family process, or sociocultural approaches. Within the modernist-objectivist logic of the task force, such an exclusion is logically and ethically coherent. Exclusion is logically and ethically coherent

0000 Within the real world of psychotherapy--as the enterprise is actually experienced by clients--a far wider range of therapeutic approaches can be shown to have successful outcomes for participants than the Division 12 validity criteria would have recognised, this placing practitioners in a serious professional bind (Seligman 1995). Because the stated goal of such manualisation project is to identify those treatments that pass empirical muster from those that do not, and by doing so endorse one set of methods over others, it is quite clear that methods not on the list--regardless of the questionable validity of such exclusion--are likely to be seen as substandard. This would leave any practitioner who uses nonendorsed methods open to charges of ethical violations for providing substandard care and vulnerable to malpractice lawsuits.

0000 THE NEW HERESY HUNTERS
0000 The threat to psychotherapists is real--not just to those at the flaky fringe, but to all creative and innovative psychotherapists. Consider a recent case in California brought by the family of a client. The family accused a licensed marriage and family therapist of malpractice for performing what she referred to as shamanic healing. The case was settled in favour of the family. The therapist lost her license--and her livelihood. Her professional organisation did not support her use of shamanic techniques. In another case Thomas Szasz, a long time antipsychiatry voice, was sued successfully by the family of a deceased physician. He had consulted Szasz for depression after having given up treatment with a previous psychiatrist who had prescribed lithium. The physician was fully aware that Szasz was well known for his antimedication stance. Several months after he had stopped seeing Szasz, the physician killed himself The family won more than $600,000 in a malpractice settlement against Szasz for not insisting that the patient take medication.

0000 So far, nonphysician psychotherapists have not had to fear this particular kind of lawsuit, but if efforts to secure prescription writing power are successful, psychologists too will be expected to insist on medication, This is likely to create even more divisive pressures within the psychology community as prescription writers become differentiated from nonprescription-writing therapists in both training and worldview. At the 1995 annual convention of the APA, when JHP editor Tom Greening expressed his opposition to prescription authority for psychologists, a colleague active in promoting such authority told him he should resign from APA because "his type of opposition could undermine and split the organization, which should be united on this issue" (Greening, October 1996, personal communication). Similarly, in the August 1996 issue of the APA Monitor, Smason wrote,

0000 We've got PhDs, PsyDs, EdDs, clinical, counseling and school psychologists... some sociopaths and God know what out there as licensed clinicians......... let's establish one method of training, and one degree....... first. Then let's begin requiring adequate predoctoral training in psychopharmacological prescription for doctoral students in clinically oriented psychology.(1996)

0000 Clearly, this urgency to obtain prescription privileges threatens to narrow the field of clinical psychology and to close off dialogue and support for diversity and creative alternatives, especially those who do not follow medical models of treatment.

0000 Yet another battle is raging around the recovered memory question, and positivistic psychological researchers with bona fide credentials can be found on both sides of the debate. The debate has been very productive and has resulted in so-called false memory-syndrome advocates coming to accept that there is good evidence for amnesia for traumatic events (FMS Foundation Newsletter,(1993). At the same time, psychotherapists have become much more circumspect about the epistemic status of what their clients talk to them about. The fact that the debate has become so fiercely politicized, however, taking place in the popular press, in highly publicized court proceedings, and on TV talk-shows, is part and parcel of the psychological culture wars and has resulted in erosion of public confidence in both psychological research and in psychotherapy.

0000 In criminal cases, the role of mental health practitioners as expert witnesses is also hotly contested. Advocates for psychology as an exact and predictive science are frequently challenged by others who deny any such exactitude or objective reliability to psychological testimony.

0000 Nor can therapists turn to the seductive illusion that as the field progresses and we have more "real data," it will be finally possible to sort out truth from politics in such cases. Arguments on either side of such complex issues as these will always be able to be convincingly bolstered by experimental research, narrative science, or phenomenological or hermeneutic science, and in some cases, all three. Unless and until different ways of knowing and different ways of addressing important existential questions can be accepted for what they are and are not capable of contributing to understandings about human welfare, any attempts to arrive at a "truth" that can be generally applied to all human affairs are bound to lead to acrimonious and interminable debates.

0000FAUST'S THERAPISTS
0000 As if all these internal doctrinal pressures were not enough to tear apart the fabric of the psychotherapy community; another far greater external threat is barreling down that will alter the practice of psychotherapy beyond recognition--the managed care industry.

0000 In many ways, the threat is the latest extension into the field of human affairs of the Faustian bargain modern societies have made between stability and progress. Positivist science and the instrumentalist worldview brought improvements in the material lives of ordinary people. The average worker in the United States today lives a longer, more comfortable, and freer life, afflicted with less illness, pain, and tragedy than any medieval king. Social progress, too, has been brought about by such important, if still imperfectly implemented, cultural innovations as democracy, abolition of slavery, equal rights, and access to education--all inventions of the modern era. These mean that ordinary people have the opportunity to become emancipated and to make life, liberty, and the pursuit of happiness a feasible project for most everyone.

0000 But these gains came with a price, as Alexis de Tocqueville could already perceive by the mid-1800s. The psychic losses have been enormous. Alienated from traditional ways of life, displaced from Old World communities, and brutalized by life in disease-ridden cities and "dark satanic mills," industrialized men and women lost faith in their religions, in each other, in their relationships, and in themselves. Then, as now, large numbers lost hope and many were driven mad. The mid-1800s saw an epidemic of drug use, violence, sexual abuse, and, insanity as people lost touch with the psychic core of their existence.

0000 Psychiatry, or "alienism" as it was then called, was invented as a response to this alienation and for its first several decades, whole-heartedly embraced the fix-it paradigm of the industrial age. There was heavy emphasis on mechanical devices such as restraints of one sort or another, psychic surgery, and electric shocks and the administration of a range of miracle drugs like opium, chioral hydrate, and lots of cocaine, putting modernist science to the service of deranged minds. The aim of early psychiatry was to engineer satisfactory adjustment to the demands of an ordered and mechanistic modern world (Showalter, 1985). This continued to be a major purpose until the early 1940s, when philosophical movements from war-weary Europe such as existentialism met up with thinkers like Adler, Rank, Horney; and Sullivan and the earlier American psychospiritual tradition of William James, and a new humanism began to permeate American psychological thought. Out of this potent alchemy, the humanistic revolution in American psychology was born.

0000 Humanistic psychology; uninterested in and antipathetic to behavioral engineering, focused its attention on the expansion of consciousness. Although many early pioneers might have been embarrassed by the word, their interests were in soul-craft (O'Hara, 1995). Humanistic psychologists were not satisfied with a clinical practice whose ends were adjustment to what they felt were the dehumanizing effects of modernism but strove instead to heal that which was damaged and to restore what had been lost from human experience. Practitioners set out to rehumanize psychology. Existential, humanistic, and transpersonal psychologists in particular rejected the reductionist positions of both Freudian and behaviorist psychology--which they saw as part of the problem, not the solution. Instead, they reached back to classical humanism--both Greek and Christian Renaissance--and to the romantic transcendentalism of Rousseau, Emerson, and Thoreau and sought to create a psychology aimed at releasing the very highest aspirations from within each human soul and facilitating the achievement or evolution of higher levels of consciousness--what Maslow called a "psychology of being."

0000 The therapeutic relationship was to be a place where people not patients--were free to reconnect with their exuberant, if unruly, passions and with what was best, highest, and most sacred within and between them and to explore human life as it is experienced. Clients who were drawn to these new psychotherapies screamed their primal screams, participated in emotional psychodramas and powerful gestalt exercises; they reached into their depths, confronted their demons and their angels; they encountered each other in deep and authentic ways; they touched; they meditated, experienced rituals, rediscovered the healing power of prayer, felt joy, sometimes even ecstasy. Anything but morally neutral, as Christian fundamentalists charged, humanistic psychology was from the outset a values-based psychology, designed to be an antidote to the alienation, ethical corruption, and emptiness of modern secular, commercial, and industrialized life. Anything but nonempiricist, as positivist scientists charged; radically empiricist in the Jamesian or Deweyian sense, humanistic science attempted to return psychological research to the study of actual experience and to place at its center the meaning-making, autonomous subject.

0000THE INDUSTRIAL REVOLUTION ARRIVES IN THE PSYCHOTHERAPY NEIGHBORHOOD
0000 By all measures, the arrival of managed care to the field of psychotherapy threatens to produce a paradigmatic shift as great as that brought by the humanistic movement, only in quite another direction (Kuhl, 1994). For the first time, researchers on therapy effectiveness suggest that the corporate health care budgets should be included as a significant variable in outcome assessment (Newman & Tejeda, 1996). Rapid changes in health care economics such as the rising marketplace power of HMOs, PPOs, and other forms of managed care and the clamor for reduced government spending on entitlement programs such as Medicare and veterans benefits are forcing changes in all mental health practice that unwittingly or wittingly depending on how paranoid you want to be, is pushing all schools of therapy--modernist, romantic, and constructivist--into a mechanistic, medical model and is attempting to push psychotherapists into work environments that have more in common with the industrial production line than with a learned profession.

0000 The humanistic revolution in psychotherapy was led by philosophers, psychological thinkers, social critics, and psychotherapists whose cause was human emancipation. They heard in the voices of their patients and clients individual iterations of the age-old struggle to become fully human. They shared a belief that psychotherapy should be a context in which individuals could heal soul-wounds inflicted by an excessively materialist culture and could realize their potential as conscious beings.

0000 Managed care revolutionaries have different visions of their brave new world. Most do not come into contact with patients and have no commitment to any emancipatory goals, but are business executives, financiers, bureaucrats, and shareholders, looking to make money--lots of it. A recent table appeared as part of an political advertisement in the New York Times (Sept. 6, 1996), which quoted statistics on the stock wealth of some of the CEOs of the top three managed care organizations in 1995, U.S. Healthcare, Columbia/HCA, and Humana Inc. They were $795.3 million, $248.6 million, and $232.6 million, respectively.

0000 The money motive is not the only difference. Like all revolutions, this one too has an ideological base; it encompasses its own world-view or belief system. Managed care spokespeople openly describe their revolution as the industrialization of health care and, with unconcealed enthusiasm and frequently contempt, declare that the days of "therapy as a cottage industry" are over. What is happening to therapists m the 1990s is equated with what happened to butchers, bakers, and candlestick makers in the 1890s. Therapists are told to get on board or get out of business (Kuhl, 1994; Wiley, (1992).

0000 To the managed care industry, psychotherapy is a commodity, indistinguishable from wheelchairs, nurses' uniforms, and open-heart surgery; delivered by interchangeable "service delivery systems." In old-style production line industrial processes, it is not feasible to have the line workers or consumers make design decisions, and in industrialized mental health care, therapeutic decision making becomes centralized and removed, far from the actual therapeutic context. Company policy rather than independent professional judgement determines to whom, for what, how much, what kind, and by whom treatment will be offered. An irony worth mentioning here is that as the health care industry tries to imitate the production line, other large scale industries are giving up on centralized control. With the help of business gurus, many greatly influenced by humanistic psychology, corporate America is discovering that creativity and performance is enhanced when the people closest to the point of any transaction and those most likely to be influenced by its outcome are the ones who make the best decisions about them (see, for example, Covey, 1989; Senge, 1990).

0000 Autonomous professionals-people with the necessary advanced education to practice independently, who have demonstrated their competence before their peers, and who agree to be bound by ethics and practices of fellow professionals do not fit well into the managed care framework. Increasingly, the entire practice of psychotherapy is becoming dumbed-down as higher-order knowledge is replaced with short-term standardized treatments that can be applied by minimally trained workers.

0000 Even more serious, many of the gains in the direction of autonomy and empowerment of clients, made largely as a consequence of the humanistic revolution, are being lost as clients are told which therapist they must see, what the focus of treatment will be, and that they must accept whatever treatment protocol the assessment worker recommends. They might even find themselves coerced into seeing their problem in the company's terms. A July 1995 memo to providers in a San Diego-based HMO Vista Hill (now merged with a large nationwide HMO) made this explicit when it recommended that therapists "Set the expectation from the very beginning that therapy is temporary support. . . . Be compassionate and gently steer them toward the short term model." Last year a utilization reviewer for a national managed care company informed me that my suggestion that a woman I was working with needed to set the pace of her own therapy was "hand holding" and had "no place in the new era of health care accountability." My client had been repeatedly sexually abused by both her father and her brother, sometimes while her mother watched. When I explained to the utilization reviewer that in my professional judgment, such cases needed time to establish a strong therapeutic alliance, he recommended that I attend a seminar on brief-symptom focused treatment.

0000RETURN TO THE FUNDAMENTAL QUESTIONS
0000 Whatever else it does, the managed care revolution is forcing psychotherapists, regardless of their theoretical orientation, to revisit struggles over their core values. Some clinical orientations--particularly those in the biomedical camp--will fit well with the managed care industrialized worldview. Humanistic approaches do not fit nearly so well (see Bugental & Brakke, 1992, for a discussion of this).

0000 Many mainstream psychotherapists are betting their future on some version of the industrialized model. As noted above, recent actions from APA's Division 12 appear to coincide with the needs of the managed care industry; as does the APA College of Professional Psychology's move toward certification of specialists in the treatment of specific symptom-defined disorders such as substance abuse. But there is evidence that opinion may not be all that homogenous even within APA. Dorothy Cantor, APA president for 1996, advocated fighting for psychotherapist's freedom to treat their patients in the ways their best professional judgment and the client's own sense of what is effective for them (Cantor, 1990). APAs 1997 president, Martin Seligman, although a firm advocate for empirical outcome studies, is open to consumer feedback that values longer term, more client-centered therapeutic processes (Seligman, 1995), and the APA Monitor prominently featured a research study that showed that the active ingredient in the treatment of 225 depressed people was the clients' active participation and the strength and duration of the therapeutic bond between therapist and client("Newsline," 1996).

0000 Nevertheless, graduate schools are rearranging their curricula to produce the line workers for the managed care industry. Professional schools of psychology; believing that part of their mission in the future will be to produce clinicians attractive to HMOs, are dedicating more courses to mastering the medical diagnostic systems and emphasizing brief therapy approaches and de-emphasising depth approaches (O'Hara, 1996). In 1995, APA presented its award for educational innovation to a graduate program that had included business courses in its doctoral program. Humanistic psychotherapy--and for that matter psychodynamic, Jungian, family systems, transpersonal, or relational psychotherapies--have a very limited place in the managed care world.

0000 A large segment of the American public is not entirely happy with the state of affairs in the medical world. We know this because of the staggering amounts of money and effort they are willing to put into alternative medical treatments not covered by their health insurance. Also, students keep on pouring into graduate psychology programs that permit studies of philosophy, humanities, political theory, religion, and the arts. New findings in the neurosciences reaffirm the holistic, nonreductionist paradigms long favored by humanistic psychologists as they undermine the more mechanistic cause and effect paradigms of behavioral psychology. And clients continue to seek out therapists who will meet them in authentic relation, even if it means making financial sacrifices. Consumers of mental health care who may not know the difference between a Rolfing and a Rorschach do know the difference between being related to as a human being or as treated as a cost to be contained. They know the difference between being confirmed as an empowered agent of their own change, and as a passive patient to be acted on (Bohart & Tallman, 1996). The American public has come to expect freedom of choice in such intimate arenas of self-care. People have already discovered the important connection between their mind, body, and spirit.

0000 Objections to some of the more egregious problems with managed care--lack of privacy, patient and therapist disempowerment, and lack of freedom of choice--are just now getting rolling, fueled by both professional organizations and public sentiments. Two California ballot initiatives in the 1996 election--Propositions 214 and 216 were aimed at restoring "balance and accountability to an out-of-control health system that's risking patient lives and sacrifices quality of care." Both were defeated (58%-43% and 61%-39%), but when the massive amounts of money spent by insurance companies and business interests to defeat these measures are considered, it is clear that anti-managed-care voices did fairly well. The organizers of the initiative vow to be back in 2 years with another try. There are also several national coalitions and local consumer groups across the nation organizing to ensure the survival of traditional psychotherapy; and many individual practitioners are refusing to practice under HMO conditions (O'Hara, 1996).

0000MENTAL HEALTH COMMUNITY AS A MICROCOSM
0000 The field of psychology represents, in microcosmic form, the crisis of values affecting the society at large. If we read the signs of the times screaming at us everywhere from Oprah, the Republican National Committee, the White House, magazines and newspapers of every political persuasion, self-help groups, and metaphysical bookshelves, we can be left in no doubt that a new generation cries out for a return to the perennial questions with which I opened this essay.

0000 Contemporary culture desperately needs a coherent shared vision. Part of that need is for a new psychology of wellness, of the sacred, and of empowerment; a psychology that gives meaning and significance to individual human lives, that understands the central importance of stable families and communities, and that can make room for diversity; commonality; and the possibilities for significant connections among us.

0000 From the private lives of individuals to the workings of institutions, governance, and business, the whole culture grapples with the question of what will be its fundamental values in the coming global era. If a new story is to emerge that can provide a coherent paradigm or mythos for a 21st-century mental health culture, it is most likely to come from some reconfiguration of the humanistic tradition, together with a holistic neuroscience of mind, consciousness disciplines from non-Western cultures, and various mind-body practices, all framed in the constructivist terms of postpositivist contextualist epistemology.

0000 From their beginnings, humanistic, feminist, and ethnic psychologists, as well as radicals like R. D. Laing and Thomas Szaz, were unapologetic even militant about their rejection of medicalized psychology of adjustment in favor of a growth-focused psychology of individual and group liberation and self-realization. As the world turns itself inside out, the need for practitioners committed to this emancipatory vision is more important than ever.

0000 0000ECONOMIC CONSIDERATIONS--MAKING A LIVING
0000 Noble as such goals are, can psychotherapists make a living by taking such a position and rejecting the rewards of the industrialized health-care system? The answer seems to be yes. Times may actually be very promising for mental health professionals with the courage to declare their independence and offer their psychotherapy practice not as a branch of industrialized medicine but as something closer to soul-doctoring or personal development service. Unlike the 1960s, when psychotherapy was something only for the very sick or the very rich, now well over one third of Americans of all classes, ethnicities, and creeds have experienced some form of counseling or therapy--and most would do so again. More than 30 million people every year engage in some form of psychotherapy or counseling and buy almost a billion dollars worth of self-help books, tapes, and seminars--this latter without the benefit of third party payments. Some of this massive expenditure is for severe and debilitating forms of mental distress and people afflicted by these conditions will require financial assistance from either government of insurance. But when strict criteria of medical necessity are applied, a great many equally important, but less catastrophic quality of life concerns will have to be provided for outside the health care system.

0000 Demand for demedicalized psychological services is likely to be high (O'Hara, 1996). Most Americans are now aware that there is a deep and important inner life, which can seriously hamper or profoundly enrich their dally experience. People today set higher standards for the quality of their intimate relationships, psychological, and spiritual satisfactions than any previous population. They have learned that there is help for their pain and wish to grow, that there are ways to address past traumas, anxieties despairs, and hopes. They understand more about the relationship between the psyche, the soul, and the body than any Westerners have before them, much of this knowledge learned from consciousness disciplines with origins beyond Western culture and imported into American popular cultures since the 1960s. In human relations training at work, in their churches, in their women's and men's groups, with therapists, in abuse recovery programs, in relationship enhancement programs, on spiritual retreats, in selfhelp groups, and on TV talk-shows, Americans of all kinds have enthusiastically embraced the self, relationship, and social evolution agenda of the human potential movement.

0000 There is also an important role to be played by mental health practitioners in prevention, a role that was set aside in the 1970s, once lucrative insurance reimbursements became available for individual treatment (Sarason, 1981). The new workplace, with its emphasis on emotional intelligence, team work, multi-tasking, diversity; and worker empowerment and responsibility, make new and higher order mental demands on workers from the executive suite to the shop floor After a brief period of experimentation in the early 1970s, When humanistic, affective, or confluent education could be found at all levels, American education does not see its role as one of deliberately facilitating the achievement of higher orders of relational and self-mastery. This leaves a serious and frequently stress-inducing gap between workplace demands and worker mental capacities (Kegan, 1994). A growth-oriented psychotherapy geared to workplace competence has much to offer on the level of prevention and remediation of workplace pressure.

0000 The potential demand for higher order ways of growth is expanding rapidly as Western society prepares itself for life in the 21st century. In a recent survey of Americans, social scientist Paul Ray believes he has identified the emergence of a new demographic group within American society: the "Culture Creatives" who are "seriously involved with psychology; spiritual life, and self-actualization" (Ray, 1996). Although the study appears to have some methodological flaws, Ray's conclusions echo findings of the study of Bellah et al. (1985) a decade before, that an increasing proportion of the American people were actively engaged in a self-development agenda. For many, the values embodied by the human potential movement forms the framing conceptual scaffolding of their pursuit of happiness and fulfilment (Bellah et al., 1985). The quintessential American insistence on individual freedom as a core psychological good render them characteristically resistant to systems they find dehumanizing. We can safely predict that these "self-formers" are the people most likely to reject industrialized mental health care and to want emancipatory, transformational, or integral forms of psychotherapy.

0000 A theoretically reinvigorated humanistic psychology that draws on the best of its past, on constructivist developments in theory, and on the newer neurosciences and advances in mind-body studies is well placed to provide the basis of a postmodern emancipatory psychology. Once it embraces its own polycentrism and unavoidable incoherence, its core values of privileging the unique experience of individual human subjects; placing human suffering, well-being, and the universal need to search for meaningful answers to existential questions at its center; embracing the need to contain and comfort the high anxiety now endemic on both individual and cultural levels; and committing itself to both abatement and prevention of suffering and to the further evolution of human consciousness suggests that the humanistic tradition has much of abiding value to offer individuals and groups in a postmodern world that is in the process of being born. Outside the highly bureaucratized and increasingly centralized health care industry, where the marketplace can act like a real marketplace, people are free to buy what they are looking for from those who wish to provide it, there will be plenty of room for dedicated and enterprising professionals to make a decent living without selling their souls to the psychoindustrial complex.

0000REFERENCES

0000 MAUREEN O'HARA, Ph.D., joined Saybrook Institute as vice president for academic affairs in February 1997 and is currently the executive vice president and dean of faculty She is a former president of the Association for Humanistic Psychology and has served on the executive committee of Division 32 of the American Psychological Association and as associate editor of JHP. Although her first career was as a biological scientist, she began to escape the gravitational pull of modernism after a close encounter with death, falling in love with Gestalt therapy, and finally traveling the world with Carl Rogers and colleagues convening large cross-cultural encounter groups. Recent writings have included articles that have appeared in the Journal of Constructivist Psychology, the Journal of Humanistic Psychology, and Family Therapy Networker, and book chapters on relational empathy, a feminist critique of a therapy session of Carl Rogers, and a memoir.

Reprint requests: Maureen O'Hara, Ph.D., Saybrook Institute, 450 Pacific Street, San Francisco, CA 94133; email: ahpohara@well.com