Short Term Treatment of a Depressed Dissociating Client: A Response
The Jewish Social Work Forum,
Reproduced by permission
This article examines Philip Feldmans proposed short term treatment strategy for dissociative clients (1995). The critique reveals a lack of clear goals; total cost for a brief therapy far greater than years of long term treatment; apparent misdiagnosis; and an unjustifiably positive reframing of an unfortunate termination. Rather than mistakes or accidental occurrences, these are all seen as serving a defensive function; a function necessitated by the conflicting demands of managed care versus professional ethics and responsibilities.
In the Summer, 1995, volume of The Jewish Social Work Forum Philip Feldman describes what he calls a short term treatment strategy for dissociative clients. He begins with an overview of the current political and business climate and its effect upon the nature and delivery of mental health services, especially the adoption of a ten session counseling model of therapy. He then gives a short background on dissociative disorders and concludes with a lengthy case description in which the client received short term therapy for her depression and dissociation.
In this response to Mr. Feldmans article we critically examine all three sections. While the critique focuses on the writing and thinking in this particular article, it is in no way directed at the person of Mr. Feldman or even his article. It is our contention that the problems which are apparent in this article reflect wider, systemic problems within every level of the mental health system. The goal of the critique is, through examination of the particulars of Mr. Feldmans article, to shed light on the general, systemic issues, and thereby to stimulate thinking, discussion, and ultimately action.
Specifically, we contend that the errors of logic, the lapses in clinical skill, the omissions, and the reframing of certain events are not due to accident, oversight, or lack of skill, knowledge, or ability. Instead, we hold that each of these has a function for the worker and society as a whole. Each serves as an unconscious defensive maneuver born of conflict. They are inevitable.
In his abstract Mr. Feldman states: As a cost/benefit measure short term therapy with clearly defined goals is often promoted as a treatment strategy. This approach was adopted for use with dissociating clients (Feldman, 1995, p. 41, italics added). In the article though Mr. Feldman never mentions a single treatment goal, much less a set of clearly defined goals. He hints that such goals may have existed when he sates that Educative work about the purpose of treatment was also initiated (p. 44) though he fails to tell us what this purpose (goal) was.
The term treatment strategy is not defined in the article though in conventional usage strategy means a method devised for making or doing something or attaining an end (Merriam-Webster, 1990). Thus strategy is the means to an end. The educative work referred to above would be seen as the means or strategy employed in furtherance of some goal. Short term treatment is itself a strategy, a method devised for attaining an end or goal. Mr. Feldman outlines many interesting and useful treatment strategies but, without clearly defined treatment goals, they seem a jumble of random bits which he mistakes for goals.
Mr. Feldmans confusion of strategy for goal is not simply a personal failing but also a reflection of wider systemic problems. Mr. Feldman correctly points out that while short term therapy is effective in some situations for more severe psychiatric disorders there are limitations and that A questions remains: will these [more severely disturbed] clients be undertreated? (p. 4). In our view you cannot answer the question will these clients be undertreated until you have defined the aim of treatmentthe goal. To do so means that you have once again implemented a strategy (short term or long term treatment, for instance) without first clarifying the goal. The pertinent questions which must first be answered by the entire mental health/managed care field include: is the goal of treatment the reduction of symptoms or is it the cure of the disease itself? If cure is the goal does successful treatment mean full or partial remission? Should there be one goal for all psychiatric disorders or different goals in different situations? If there are different goals who is to make the assessment of the proper goal and then of the strategy to be used to achieve that goal?
In some environments these questions about the purpose of mental health services have been definitively answered. One example is in occupational social work as it is practiced within the military where the goal is clearly stated: to return the soldier to active duty as rapidly as possible. Within this system the goals of individual treatment flow naturally out of the larger systems clearly defined charge to the worker. This, in turn, gives clarity, context, and direction to the workers interventions. Though the worker may disagree with the goals, it is impossible to be confused about them. At present there is no such clarity within American culture about the goal of mental health services. Inevitably we see the kind of confusion evident in Mr. Feldmans article.[Footnote #1]
But a larger question remains: what function does such confusion fulfill, how does it help? We assume it does help as our dissociative clients have taught us that even the most self-harming, destructive, malicious behavior has, at is core, a positive intention (Goodman & Peters, 1995). The intention may well have other, negative consequences, but change will only occur when the positive function is addressed. In the same way we assume that the confusion about goals has a positive function, that it somehow helps.
Returning to our current example, we can see that Mr. Feldman assiduously avoids articulating the goals of treatment. This avoidance might make sense if we look for a moment at Mr. Feldmans client, Rita. This 32 year old woman reports being kidnapped and abused physically and sexually for three days at age 3; being repeatedly raped at age 7 by her adolescent brother; witnessing the shooting death of another brother; and, throughout all of these, living with emotionally abusive parents who not only repeatedly failed to believe or protect her but also deliberately put her at further risk.
Putting aside all practical considerations for a moment, this case description moves us deeply; we badly want to help this woman who, though she has been so mistreated, appears so appealing in Mr. Feldmans writing. If we are then told that we may see her for only 10 sessions, do we feel we can we help Rita in the way she deserves and we would like? Do we then feel good about ourselves, our profession, and our client? We assume all these answers to be negative and yet this is precisely the position of Mr. Feldman and countless other social workers operating under managed care.
For the worker to allow into consciousness what the goals of therapy could be in contrast to what they can be under managed care puts that worker in an intolerable position. The more the case touches our heart, our soul, and our conscience, the more intolerable the position becomes. There is, however, a wonderfully effective solution: do not think clearly about goals. This solution is enhanced further if the worker confuses strategies for goals because the worker is then able to feel that the therapy is effective when the strategy (as in enhancing the therapeutic alliance) is implemented. Looked at this way, Mr. Feldmans failure to set clearly defined goals is not a failure at all but rather a coping strategy which allows him to provide whatever services he can without confronting the underlying questions: what am I doing; is what I am doing accomplishing what I say I am trying to do; and is what I am doing consonant with my ethics, beliefs, and values? In the same way the wider systemic confusion about the goals of mental health services helps us, as a profession and a country, avoid confronting the disparity between what we think we should be doing and what we are doing.
As a cost/benefit measure short term therapy is often promoted as a treatment strategy (Feldman, 1995, p. 41). In this section we examine the cost effective portion of this premise as it applies to the case Mr. Feldman presents and, in our experience, to many similar cases.
In the treatment of chronic trauma survivors, timing is essential as the therapeutic process must not be allowed to overtake the patients ego-coping mechanisms (Davies & Frawley, 1994, p. 204). Short term therapy, however, covertly says to the clinician and client alike that they should be able to do the work rapidly regardless of the clients ego-coping mechanisms. Under this pressure Mr. Feldman gave Rita encouragement to express her thoughts and feelings even though she was obviously distrustful and fragile, had difficulty forming trusting relationships, especially with men, and felt distraught and extremely vulnerable (Feldman, 1995, p. 44). For clients as fragile as Rita such encouragement may be experienced not as a supportive suggestion but as a demand by the expert, the authority. Mr. Feldmans encouragement then, in the face of Ritas evident distrust and her history of distance[ing] herself protectively, (p. 44) threatened the clients ego coping mechanisms by attacking her habitual defenses. Not surprisingly her symptoms worsened resulting in her being hospitalized for two weeks.
Mr. Feldman does not tell us if this was a private or public hospital. If she were admitted to the hospital with which he is affiliated the charge would be about $24,000 for the two week stay.[Footnote #2] While it is impossible to know if this hospitalization could have been avoided it certainly would have been less likely if the treatment had initially respected the clients limitations and had focused, as Mr. Feldman later did so admirably, on building ego strengths before attacking the defenses. What would such a treatment have cost? If, as is common, Rita had been seen initially in once a week individual therapy and then, if she wanted and her ego strengths were sufficient, the frequency had been increased to twice a week Rita could have been seen for four years at the same cost as this two week hospitalization. If seen only once a week she could have been seen for almost seven years. At twice a week for the entire therapy, she could have been seen for a little under three and a half years.[Footnote #3] While extensive outcome studies are not yet available, treatment to cure of Dissociative Identity Disorder, the most severe of the dissociative disorders, generally occurs in two to three years (Ross, 1989, p. 199). In Mr. Feldmans case a couple of months of managed care with valuable but very limited results costs as much as three to seven years of unmanaged care and complete cure in most cases of DID.
From this vantage point Mr. Feldmans implicit claim that this model of brief therapy is cost effective is difficult to maintain yet he appears not to have examined the issue. Here again we argue that not thinking the issue through helps the worker. For Mr. Feldman and others working under managed care to realize that they are providing less than ideal treatment which actually costs more than the ideal would be personally and professional discomforting. Not examining these financial and emotional realities allows the worker and the society as a whole to continue functioning within a system they are unable or unwilling to change.
Throughout his case report Mr. Feldman does an admirable job of conveying clinical material. This is most apparent in the information he gives us about Ritas dissociative symptomatology. Despite the title of his article and his care in presenting all the dissociative symptoms, Mr. Feldman avoids giving his client any DSM-IV (American Psychiatric Association, 1995) dissociative diagnosis, preferring to say She had Post-Traumatic Stress Disorder and Dissociative Traits (p. 45). Dissociative Traits, though capitalized is not a recognized diagnosis. In this section we will examine the diagnostic issues brought out in this case.
Ritas dissociative symptoms are described as follows: periodic episodes where she felt outside her body (p. 44);[Footnote #4] various personality changes [when] Rita would dress differently at times or use makeup in a strange manner (p. 44); that she does not always recognize herself in the mirror (p. 45); amnesia where she would loose track of time for periods of up to one hour (p. 45); finding new clothing in her closet, unlike anything she owned, which she could not recall buying or receiving as gifts which indicates both amnesia and switches of executive control of the body (p. 45); and hearing muted voices which sounded as if they were in her head (p. 46).
These symptoms appear to meet the DSM-IV criteria for Dissociative Identity Disorder (DID). The client shows evidence of two different personalities (Criteria A); changes in executive control of the body (Criteria B); significant amnesia which cannot be accounted for by ordinary forgetfulness (Criteria C); and the symptoms are not due to substance abuse or a general medical condition (Criteria D).
If, as we believe is good clinical practice, Mr. Feldman does not make the diagnosis of Dissociative Identity Disorder because he is being cautious, we see no reason that Rita should not receive the diagnosis of Dissociative Disorder Not Otherwise Specified (DDNOS), a catch all diagnosis for people who do not meet the full criteria for DID. That Mr. Feldman, who is unusually astute to the manifestations of dissociation, does not make this diagnosis, is curious. Though the real reasons for this omission cannot be known we think there is a more general diagnostic issue related to short term therapy which deserves comment.
As Mr. Feldman so delicately puts it, Managed health care and Medicare/Medicaid have begun to influence mental health clinics, social services agencies, and private practitioners to adopt [sic] short term treatment for clients (p. 41); an influence often felt regardless of the particulars of the case. If the social worker recognizes that this short term strategy is inappropriate for clients with particular diagnoses/problems yet must still implement that strategy, the worker is then caught in a difficult moral and ethical conflict. One solution, which appears to have been used in this case, is to simply avoid the diagnosis which does not fit within the mandated treatment paradigm. In this view, Mr. Feldman fails to make the appropriate diagnosis not because he lacks skill or caring but as a way to avoid full recognition that the treatment he is compelled to provide is inadequate for the particular case. Once again, a defensive maneuver saving the worker from intolerable conflict.
This is not the only example of avoidance in the case at hand. Mr. Feldman is admirably candid in listing his underlying biases and assumptions, including that clients have the ability to control what they think about. This is an assumption underlying most models of short term treatment which are geared toward changing cognitions and behaviors with the assumption that deeper or more extensive change will follow. It is, however, an assumption which cannot be maintained in the face of a client having a flashback, writhing on the floor, screaming in terror and pain while reliving a traumatic episode. In this situation the statement [you] have the ability to control what [you] think about is unconscionable. In the same way, the assumption about control of thoughts cannot be maintained in the face of a dissociative client switching between personality states when it is suddenly not clear to which state the worker would address the statement [you] have the ability to control what [you] think about. The diagnosis of Dissociative Identity Disorder with its flashbacks and cognitive distortions clearly threatens the assumptions which underlie much of short term therapy. By avoiding the diagnosis Mr. Feldman therefore avoids not only conflict about the services he is and is not providing but also conflict with the beliefs and assumptions which enable him to continue providing short term treatment where long term seems clearly indicated. Here again Mr. Feldman is not alone. Such conflict is inevitable when the worker is caught between a rigid, inflexible mental health delivery system and the varied, idiosyncratic needs of his or her clients.
In his conclusion Mr. Feldman states: In this particular case, short term therapy was clinically effective. The client began the difficult process of treatment (Feldman, 1995, p. 47). He continues, quoting an article about modular therapy, doing a discrete piece of work now and another later, when the patient is ready(p. 47).
These statements deserve careful analysis. When he writes: therapy was clinically effective. The client began the difficult process of treatment, Mr. Feldman seems to be saying that effective treatment means and is equal to the client beginning the difficult process of treatment. The circularity of this logic is dizzying: successful treatment is beginning treatment. Was this, in fact, the goal of treatment? We can imagine no other field of science in which such a statement would be tolerated. Beginning the difficult process of chemotherapy is not equivalent to successful therapy of cancer.
The use of the subsequent quote about modular treatment further confuses the matter for the quote directly implies that the client is in control of the treatment process, doing a piece of work now, stopping when he or she is done for the moment, and returning when ready. Under managed care this is far from the case. Clients stop therapy when the managers say stop and resume when they say it is OK to resume.
By defining clinically effective as he does and reassuring us that Rita can return for therapy if her symptoms redevelop (p. 47) Mr. Feldman appears to us to be papering over the dreadful bleak reality of having to abandon a fragile chronically abused client who had begun to trust him. Through his accounting Mr. Feldman disguises the reality that he terminated for economic and political, not clinical reason. In so doing he has unconsciously replicated the original trauma in which the needs of the abuser superseded those of the victim though this crucial fact was denied as the abuser, in all likelihood, tried to convince the victim that you really like it, this is what you wanted all along.
Alternatively the therapist could explain to the client the social, political, and economic realities of the mental health field at this time and the ways they impact on the services which he or she can and can not get. To the extent that the worker conveys the message this is the power reality and there is nothing you and I can do about it he or she is unwittingly enacting yet another common abuse role: the ineffectual bystander who conveyed the message: dont say anything, just go along with it, the abuser is too powerful and will hurt us even more if you speak up; there is nothing we can do so just shut up and put up with it.
This is precisely the message which we hear being (covertly) delivered daily by social workers as they accommodate themselves and their treatments to the dictates of managed care. There is lots of private grumbling and dissatisfaction but little or no confrontation of those who wield real power. For victims, the inability to confront those wielding absolute power over them leads to disorientation (Rini, 1995) as they are told that pain is pleasure and hurt is love. Ultimately victims are often unable to know what they know and hence may put a dissociated Happy-Face on the whole confusing experience as no other resolution is possible. In the same way, until we, as a profession, confront the managed care system we are in danger of coming to just such resolutions as seen in this article; resolutions in which we fail to know what we know and put a happy smile on what is sad and sorrowful.
Conversely, by putting the social back into our social work, the explanation we give to clients of the social, political, and economic reality of the mental health field at this time changes from a message saying dont rock the boat to an empowering call for social action in which client and therapist are each engaged (Brake & Bailey, 1980).
Mr. Feldman presents what at first appears to be an admirable attempt to adapt to unfortunate circumstances: the limiting of mental health services for other than clinical reasons. But, while necessity is certainly the mother of much valuable invention, this fact does not mean that either the invention or the necessity are necessarily good and valuable on their own. A clients remarkable adaptation to the loss of a limb does not make the loss or the adaptation good.
In the same way, Mr. Feldmans paper represents an effort to make a virtue out of necessity. Yet there is no virtue in denying appropriate care to clients. Making a virtue of this denial creates a lie by which clinician, agency, and society hide from the painful truth that needed care is being denied certain clients. There is no virtue in lying to clients.
By praising the inventions of necessity we have abdicated our moral and professional duty to speak out about the evils of the necessity. In our silence about what is really happening we become collaborators in the oppression of our clients who are, in cases such as this, doomed to endless cycles of inadequate care. As collaborators we have betrayed not only our clients but also our profession and ourselves. Obviously we cannot live with this awareness and so we hide from it through theoretical justifications and denial of facts which threaten our justification. The defensive maneuvers we have seen employed in Mr. Feldmans article are therefore to be expected. In fact we can predict these and other psychological accommodations by individuals, clinics, social work schools, and, in fact, every level of the mental health system until the underlying conflicts between managed care and appropriate care are resolved.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
Brake, M. & Bailey, R. (1980) Radical social work and practice. Beverly Hills, California: Sage Publications.
Davies, J. M. & Frawley, M. G. (1994). Treating the adult survivor of childhood sexual abuse: A psychoanalytic perspective. New York, NY: Basic Books.
Feldman, P. (1995). Short term clinical social work: Treatment of a depressed dissociating client. The Jewish Social Work Forum , 31, 41-48.
Goodman, L. & Peters, J. (1995). Persecutory alters and ego states: Protectors, friends and allies. Dissociation, 8(2), p. 91-99.
Merriam-Webster Inc. (1990). Merriam-Webster American English Linguibase. Somerville, MA: Akimbo Systems, FullWrite 2. 0.3.
Rini, T. (1995). Gender and dis-orientation experiences, how abuse interacts with developing sexual identity. Paper presented at Sexually abused men: Working with the other victimized population, November 3, 1995, New York City.
Ross, C. (1989). Multiple personality disorder: Diagnosis, clinical features, and treatment. New York, NY: John Wiley & Sons.
1. It should be noted here that the case which Mr. Feldman courageously chose to present is one of exceptional difficulty in which the underlying pathology emerged only slowly, precluding setting realistic treatment goals after the first or second session. Such cases are, however, the norm in many mental health settings.
2. This conservative estimate courtesy the financial office at Barnert Hospital, Paterson, NJ
3. Assuming the therapist charges $75.00 per session and the client is seen for 47 weeks of the year, allowing for vacations and such.
4. This is the symptom of depersonalization, a recognized DSM-IV diagnosis though one rarely used because it almost inevitably occurs in the context of a more pervasive dissociative disorder (Ross, 1989)