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Article Excerpt
ABSTRACT
This article describes the origin and the work of a volunteer run nonprofit agency designed to provide low cost psychotherapy. The agency was developed by psychotherapists connected with the Seattle University graduate program guided by the vision of psychotherapy as a healing relationship and in response to a growing crisis in the mental health system. We address the benefits and the challenges of this collaborative effort, and especially the difficulty involved in successfully running an agency while staying true to a particular vision of therapy, collaboration, and community.
Introduction
In the current climate of cost cutting and emphasis on efficiency, the practice of psychotherapy faces many challenges: agencies are burdened by bureaucracy and proscriptions, psychotherapists in the public sector are challenged to make time and place to practice therapy and not just do case management, and psychologically distressed people are left navigating an increasingly complex, dehumanizing, and often expensive web of treatment options. This article documents the formation and work of the Psychotherapy Cooperative, run by a group of therapists who wanted to address this situation and form a community in which to practice. As members of the Cooperative, we wish to reflect back on its ten-year history and the challenges and benefits of our collaborative endeavor--some that are shared with other nonprofits and some that seem unique to the practice of psychotherapy. We reviewed minutes and documents from over the years, interviewed current and former members, and spent many months in dialogue. In addition to providing a history and a discussion of the practical experience of running our nonprofit clinic, we outline our vision of Existential-Phenomenological psychotherapy, the orientation that undergirds both our clinical practice and the organization of the clinic itself. Finally, we consider what we have learned about the nature of collaboration in a community committed to phenomenological practice.
Background
The Psychotherapy Cooperative, a small nonprofit agency, run entirely by volunteers, was started in 1996 by a group of Seattle University graduate psychology program alumni and professors in response to a growing crisis in the field of mental health services in Seattle and the surrounding area. This crisis was a reflection of changes in both the public and private sectors of the mental health system across the United States. Psychotherapy was becoming less affordable while the advent of managed care, emphasis on "prescribed treatments," and the growth of bureaucracy threatened the very existence of psychotherapy understood as a healing relationship rather than one where the psychotherapist is primarily diagnostician or technician.
Already in 1989 the Seattle Times had run an in-depth report on how the local mental health system was "Facing a breakdown" because of inadequate resources, poor coordination among agencies, legal restrictions, and lack of support for the staff providing treatment (Simon, 1989). The advent of "managed care," an attempt to control the escalating cost of health care by reducing the services provided to clients, typically made things worse. Although outpatient psychotherapy was not a contributor to this rising cost (Pipal, 1995), insurance companies moved to limit the number of sessions that they would cover and to increase the amount of documentation they required for treatment to continue. Ivan Miller (1996) has argued that the efforts of managed care companies to substitute brief therapy for longer term treatment, even when this is counter-indicated, really amounts to rationing treatment. Further, the demand from third parties, such as insurance companies, for more information about the client threatens the confidentiality of psychotherapy, and a form of triangulation occurs as this third party becomes increasingly present in the psychotherapy office (Pipal, 1995, 1996). In the public sector, where the less-well-off seek care, various restrictions were likewise imposed on length of treatment and the types of problems that were covered. Although some authors (e.g., Minkoff, 1994) have argued that managed care does not necessarily pose a threat to community mental health, this is less than self-evident. For example, in their extensive study of over five hundred mental health agencies in New York State, Cypres, Landsberg, and Spellman (1997) found overall a decrease in long term therapy and an increase in brief therapy over a four year period. Most of those who seek treatment from mental health agencies have significant psychiatric problems and it is implausible that they could be adequate addressed through brief therapy.
During this period of crisis in the mental health system, the faculty of Seattle University's graduate program received ongoing descriptions from the students they supervised of how changes in requirements were affecting clients as well as staff. Seattle University's graduate program is closely connected to the local mental health community: second-year students do internships in community agencies, typically for twenty hours a week, over a nine to twelve month period. Increasingly, students reported that mental health agencies were run by people with graduate degrees in business administration, who had little understanding or appreciation of clinical issues. The subsequent preoccupation with the "bottom line" resulted in decisions that often adversely affected the well-being of clients and the morale of clinicians. In addition, these decisions were often presented as being based on clinical consideration when in fact they were at odds with traditional standards of care.
Awareness of these changes at the local and national level led to preliminary discussions among several faculty and a handful of alumni as to how we might help to address these mounting problems in the community. Gradually, we made outreach to two local Catholic Churches with the goal of starting to provide services for the less affluent among their parishioners. We also hoped that they might be able to provide a space for psychotherapy services. In our initial deliberations during 1996 and 1997 we considered naming the fledging agency something like Parish Counseling Services, but we realized that this would lead prospective clients to think that we were a religious agency. Eventually we settled upon the name the "Psychotherapy Cooperative" to reflect both the nature of the service that we would be providing and the collaborative nature of our effort. We also ended up finding our own office, initially subleasing from a graduate of our program who was also a founder of the Cooperative, then leasing our own office in 1998, and eventually taking on the lease for a second office in 2000.
While we were aware of the tremendous need in the community for psychological services, we were also aware of our own limitations in providing services. At the time, the population that we seemed most able to serve were those unable to afford private practice and who were not disturbed enough to be eligible for state services. As clinical services were being developed, we realized that we needed a more structured and strategic approach toward the responsibilities of running the Cooperative. We formed a board of directors in 1998 when we registered with the State of Washington as a nonprofit organization. We developed formal bylaws as a matter of necessity when we applied for nonprofit status (501(c)(3)) with the federal government two years later. Once the federal government granted us nonprofit status, donations to the Cooperative became tax deductible.
According to the mission statement developed in the first two years, the goal of the Psychotherapy Cooperative is "to provide affordable counseling services to those who are not able to afford these services from therapists in private practice or from counseling and community mental health agencies. We also want to provide services where the length of counseling is determined by the needs of the client rather than by limits imposed by insurance companies or other funding sources."
Overview of the Cooperative
Currently, we have sixteen members, eleven of whom see clients, and six of whom provide supervision. Eight of our members also constitute the board of directors. This is a working model board which runs the day-to-day operations of the agency (Gill, 2005). On average twenty to twenty-two clients are seen on a weekly basis.
We do not have a receptionist so prospective clients call our number and leave a message, and then we return their call. The stories clients tell about their experiences of seeking services and ultimately coming to the Cooperative reveal something about the current situation in mental health. When we ask people, as part of the intake, how they heard of us, the typical answer is "I couldn't tell you exactly, I have called so many places that are full and been referred to so many possibilities, that I have lost track." The Cooperative does no formal advertising, but we do contact mental health agencies and the local crisis phone line to let them know the range of services that we provide. A fair number are referrals from current or...
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