Beyond the One-Way Mirror A New Approach to Reviving Public Sector Psychotherapy By Scott Sells with Cynthia Franklin
It was my first meeting as a visiting supervisor at a local community mental health center in the Southeast. To get some background, I asked the clinical staff what had been the biggest change they'd seen since they'd started at the center. Without uttering a word, John, the senior member of the group, got up and led me down a hallway with dirty floors and off-white paint peeling from the walls. He opened the door of a large room filled with boxes of old files that had a mop and a bucket standing in one corner.
"Why are you showing me a storage closet?" I asked.
"This wasn't always a storage closet," he said dejectedly. "This used to be our one-way mirror observation room."
John then explained that from the 1970s through the mid-1990s, one-way-mirror supervision had been the hub of clinical discussion at the center. The treatment team had met once a week to observe and learn from one another. The phone on the wall--next to the mop and bucket--had been used regularly to call in interventions when therapists were stuck with a case. Clinicians were encouraged to bring in not just parents and siblings, but grandparents, aunts, uncles, neighbors, and friends. Medication was used, but only as a last resort, and the psychiatrist had been a working member of the treatment team.
Then, about 15 years ago, everything began to change. Live supervision was the first thing to go. "Our administrators told us to stop because we couldn't bill for it under managed care. So our one-way mirror observation rooms were converted to storage closets," John continued. "The next thing to go was intense group supervision. Our clinical discussions about stuck cases, usually an hour or more, were whittled down to 30-minute case-note reviews. These days, all our work is done unsupervised, behind closed doors."
Family therapy itself was finally abandoned because new Medicaid regulations made it more practical to see individuals and conduct 15-minute medication checks. It had become easier to just take an individual child or teenager out of class and bill the same fee as for an after-hours family session.
"Money and billable hours are now driving our treatment methods," John added. "Individual psychotherapy with meds as the quick fix is now the standard. Psychotherapy is dead at this agency. We feel we're just cogs in a wheel. Our burnout rates are skyrocketing, and the average therapist only stays around until finding something better."
The other therapists nodded agreement. Even though John was the only one who remembered the old days, everyone agreed that better training and more supervision were needed, but no one felt there was much likelihood of that happening.
Things Sure Have Changed
The one-way mirror observation room that's now become a storage closet is a metaphor not only for the transformation of the profession of therapists like John in the public sector, but for many of us in private practice as well. Psychotherapy as we all knew it in the 1970s, 1980s, and 1990s--with its emphasis on quality care, innovative approaches, and patient advocacy--has gone the way of the one-way mirror. Managed care, the relentless push for briefer treatment, and exponential growth in the use of medication have placed the field in crisis.
The private practitioner who says, "Who cares what happens in the public sector? It doesn't affect me" is like the noninvestor who asks why she should care whether the stock market crashes. The psychotherapy field isn't neatly compartmentalized into public and private sectors. When one part is in decline, it's only a matter of time before the ripple effects are felt in the other.
We should all be concerned that almost all the leading training centers of family therapy's golden age from 1975 to 1990--the Family Therapy Institute of Washington, D. …