WHEN I GOT MY PH.D. AND STARTED A MENTAL HEALTH CLINIC in Oakland, California nearly two decades ago, most psychotherapists I knew felt lucky. We had found work that was meaningful and we faced almost no ethical conflicts between doing well and doing good. Aided by generous insurance reimbursements for services that were rarely scrutinized, we not only expressed our talents and compassion but enjoyed unprecedented esteem as members of our culture's new secular priesthood. We took it for granted that our profession allowed us to make money and be genuinely helpful at the same time.
Now, psychotherapists are in trouble. Our status is declining, our future is in doubt, and many of us are torn between the demands of making a living and doing good therapy. The surface symptoms of our malaise are well known: managed care companies give us more paperwork and less money while pressuring us to resolve complex problems in three to eight sessions or to refer Clients for medication. Fewer and fewer people can afford to pay us out-of-pocket, and we are being increasingly scape-goated in society and in the media, especially if we treat sexually abused children or women with histories of abuse.
These are only symptoms of a therapeutic malaise embedded in larger economic, social, political and ethical systems. If we want to survive as a profession, we have to look hard at larger systems bigger than the family or the extended family and figure out how to intervene in them. We need to understand the sources, the history and the scope of the current assault on psychotherapy. We must build popular support for the caring values that led us into this profession in the first place, values that now stand in direct conflict with the frenzied, cost-cutting ethos of a field that used to call itself "health care" but might now be better called "the health business."
IN THE 1950S, WHEN I WAS BEING raised in what was then the prosperous town of Newark, New Jersey, a rising tide was lifting many ships. Our town was part of a powerful post-war America that was able to set the terms of trade with the rest of the world. My family got our first television when I was 10. Shiny new cars appeared on the streets; there were mink coats at our synagogue and lots of talk about who was making it and who wasn't.
The middle-class suburbs around us were also enjoying unprecedented affluence. The 1950s and 1960s were a time of optimism and post-war exhaustion: new freeways, new families, new schools, new suburbs and lots of mandatory overtime. Men and a few women flooded into factories, turning out steel, cars, shoes, clothes, jets, rockets, televisions, beer, books and other products for an expanding post-war market. Unions won better contracts and built high-rises and housing developments; health plans eventually included benefits for dental work and psychotherapy. Things looked good and most people thought they would get even better.
But they didn't. Few of us understood then that middle- and working-class postwar affluence was not a fact of nature but a socially constructed reality. It was produced, in part, by pent-up post-war consumer demand and by the powerful labor movement of the 1930s and 1940s, which had forced America's economic elite to divide up our post-war wealth, although not equally, with ordinary Americans. In the 1960s and 1970s, the strong unions and collective consciousness that had produced this affluence for
the middle class began to erode victims of consumerism, television-induced isolation and the constant ideological assault that told us to distrust anyone who had ideals beyond material self-interest (presumably, we could trust people out to get money, since we could understand their motivation, whereas anyone who had ideals was probably out to manipulate or dominate us). People spent more energy on personal solutions and less on understanding their collective situation. Individualism and the pursuit of …