We suck.

[corwin137]

Random angst here.  This will be stream of consciousness, a rant, unedited.  Not to be taken internally.  Consult your physician before using.  Subject to change without notice.

We suck.  Yeah, I said it. 

This is a thread about the things that blow (in a bad way) in therapy/psychiatry.  I've been doing this 23 years.  I have a right to complain/critique.  Am happy to critique my own stuff too if anybody is terribly concerned about it.

When I say "we", I mean the term loosely, and present company excepted.  This means you.

Lemme (not to be confused with Lemmy, from Motorhead ...) give this some context.  The Hippocratic Oath was apparently created around the 4th century BC (http://en.wikipedia.org/wiki/Hippocratic_oath).  Dude was considered the father of modern medicine.  Since then, physicians have: cured the plague, figured out how to set and cast broken bones, can treat seizure disorders, have MRIs, fMRIs, made all kinds of improvements in preventative medicine (vaccines, handwashing and such), can put people under and perform surgery, have even come up with antibiotics- tooth decay being the primary thing that killed cro mangons ('sides Tyrannical Rexes or Tyrannical Bushes or whatever...).

Medicine has been curing and/or improving all kinds of "ills" in their discipline.  Us, by comparison, have done little... even adjusted for the amount of time we've been around, if you exclude the likes of shamanism and spirituality and philosophy and such.  We've not "cured" depression.  Abuse, neglect, abandonment.  We've not improved the way we communicate (don't even get me started on what we communicate about.  Schizophrenics rarely get better taken care of than when we were using Black 'n Decker "therapy" (AKA "trepanation").  Edison Medicine (ECT/electro convulsive therapy)?  Are you kiddin' me?  The Beck Depression Inventory?  The MMPI?  IQ tests?  Major phail.

Look.  Not saying there's not been improvements.  Not saying there aren't beautiful examples of wisdom and progress.  Maslow, Jung, Kopp, Buddha, all the Carls now that I think of 'em... medicines in some contexts/uses.  All beautiful stuff.

That said though, here is my scream from the abyss.  My laundry list of complaints that will only serve to subdivide me from my "peers".

1.  In recent news, being present during "interrogations" (read: torture).  At least finally 60% of us figured out how retarded that is.  There's more reasons than can be recounted here.

2.  Out of context use of medicines.

3.  Use of medicines without insuring use of other types of therapies.

4.  Diagnosing people that use drugs with various "mental illnesses" before they're even clean.

5.  Us being e-motionally and/or spiritually sick when we come to the profession to begin with.  We have a responsibility to be sane to begin with.

6.  Speaking of: don't we have a responsibility to be more socially and polytrickally astute and forward-thinking than our counterparts in other disciplines?

7.  Overuse of medications.

8.  Overuse of diagnoses- particularly ADHD and BPDO.

9.  Brief therapy, CBT, and other related therapies.  Yeah, I said it.  It's not that there's not useful tools there- on the contrary.  What I struggle with is the context, it supplanting longer-term and arguably more relevant treatments, and what appears to be more a response to the behavior of insurance companies than it is a response to the behavior of patients.

10.  Therapists and psychiatrists that can't handle feelings.  Their own, or the patients'.

11.  Misdiagnosing folk.  Look- mood lability does not a bipolar person make in and of itself.  Same thing with "psychotic" symptoms.  There's a whole laundry list of concomitant symptomatology, time factors and etc that allow us to diagnose someone.

12.  Ignorance of biopsychosocial factors.  We're so often looking at people as bundles of symptoms, and not really looking at folk (I know, groan of a word coming...) holistically.

13.  Lack of boundaries.  If there's anything that makes us look cheap or lam3, this is it.  Employing or sleeping with patients, bartering with fees, recovering addicts sponsoring patients in 12-step programs and the like.  Phai1.

14.  Oh 'god'.  I almost forgot.  Our interviewing skills?  Horrid.  Unbelievably bad.  Embarrassing.  They even transcend social skills- something I think we have a responsibility to possess in spades, no?  Don't ask someone if they were "physically abused".  By definition, it's the job of the patient to say "No." in most cases.  Don't ask someone if they're a drug addict or alcoholic.  I could write a whole book about how bad we are at this.

15.  On the coattails of the above though, don't go for months, I've even seen clients who have been in therapy with someone else in excess of two years that though they described/behaved with many of the symptoms- have never been interviewed about abuse of any kind.  No kidding.  Massive phai1.  Geez.  If we're not here to dig in with people and their demons/psyches, WTF are we doing then?

K.  That's enough.  Use sparingly.  Don't drink your own Kool Aid, and definitely, don't drink all of mine.

[SWM]

Medicine has been curing and/or improving all kinds of "ills" in their discipline.  Us, by comparison, have done little... even adjusted for the amount of time we've been around, if you exclude the likes of shamanism and spirituality and philosophy and such.  We've not "cured" depression.  Abuse, neglect, abandonment.  We've not improved the way we communicate (don't even get me started on what we communicate about.  Schizophrenics rarely get better taken care of than when we were using Black 'n Decker "therapy" (AKA "trepanation").  Edison Medicine (ECT/electro convulsive therapy)?  Are you kiddin' me?  The Beck Depression Inventory?  The MMPI?  IQ tests?  Major phail.

trepanation never gave anyone diabetes, never made anybody obese or massive increase in the risk of cardiac and respiratory failure, unlike some of our current treatments, mentioning no names *ahem* clozaril bring back trepanation.

1.  In recent news, being present during "interrogations" (read: torture).  At least finally 60% of us figured out how retarded that is.  There's more reasons than can be recounted here.

wasnt sure what you where refering to when i first read this, but i just read an news article about interogations in guantanamo bay, where the "inerogatros" where advised about their "interogation techniques" by psychologists, the article never used the words torture though evidently they where talking about torture. instead they opted for the more descriptive phrase of "strong interogations".

2.  Out of context use of medicines.


3.  Use of medicines without insuring use of other types of therapies.

i am coming to a firmer belief that medicine is out of context when it used to treat the mind. psychology and medicine should have never been allowed to fornicate and we would not have to worship the bastard child of a science now known as psychiatry. as we cannot undo the done, anybody who comes into contact the beast known as psychiatry should have vast quantities of therapy( or six-eight sessions in real terms) to exorcise the demons that may have enterd the body of that person. any body unforutnate enough to have been touched by the evil beast of a science and who does not show signs of life after six sessions of solution focused therapy should be treated with trepanation also.

i wonder if in 50 years time, psychiatry will be horrified by the idea that we gave people medication that caused so many problems that the patient could do nothing but crave empty calories and sleep and which increased there chance of premature death by about 600%. what happened to improving quality of life. not to mention the impact these medication have on a persons ability to engage in self recovery.

it saddens me that in some of my professional roles i have to encourage persons to continue to take medication. i have to do this because of the lack of alternatives available to patients.

4.  Diagnosing people that use drugs with various "mental illnesses" before they're even clean.

we dont have this problem. anybody who presents to mental health service and who is using alcohol or drugs will be disgraced and shamed and told to stop their filthy habit. seriously you would not beleive the difficulties i have had trying to get a suicidal client seen by the mental health services because i was calling from an substance misuse service.

5.  Us being e-motionally and/or spiritually sick when we come to the profession to begin with.  We have a responsibility to be sane to begin with.

i kind of disagree with you here, i believe it is of the utmost importance to be in touch with our own insanity. at least enough to be conversant in the languages of fear, guilt, worthlessness and hoplessness

9.  Brief therapy, CBT, and other related therapies.  Yeah, I said it.  It's not that there's not useful tools there- on the contrary.  What I struggle with is the context, it supplanting longer-term and arguably more relevant treatments, and what appears to be more a response to the behavior of insurance companies than it is a response to the behavior of patients.

that is interesting, i am not sure exactly what you mean here as we have a health service and we our health care is public funded. insurance companies dont have much involvement with our health care here so i am wondering what you see happening from your side of the pond. i do know that these therapies are encouraged and promoted by our stategic health authorities, the reason being cost effectiveness and an "evidence base" (using the term loosely) to support the efficacy of these treatments.

10.  Therapists and psychiatrists that can't handle feelings.  Their own, or the patients'.

nurses too. i dont expect nurses to do therapy on the patients but at least to know when somebody needs to have good cry or to express their anger and frustration. too many times if have seen nursing staff being drawn in to a patients emotional explosions and the nurse feeling like the victim of some form of emotional abuse. get real, patients are likely to be highly strung and emotionally charged when in hospital against their will. nursing staff leave your own baggage at reception please.

[corwin137]

...unlike some of our current treatments, mentioning no names *ahem* clozaril bring back trepanation.

So funny.  Agranulocytosis ain't no joke.  It is funny when sometimes medieval treatments seem less problematic than some recent ones.

wasnt sure what you where refering to when i first read this, but i just read an news article about interogations in guantanamo bay, where the "inerogatros" where advised about their "interogation techniques" by psychologists, the article never used the words torture though evidently they where talking about torture. instead they opted for the more descriptive phrase of "strong interogations".

To overstate, have always asserted that the soul of our profession is in providing direct talk-centered services to assist with clarity and elimination of suffering.  I even see peer-reviewed research as secondary.  Mediating or intervening in the process of someone being harmed in a government "investigation" isn't even tertiary- it's a violation of some fundamental principles we endeavor to transmit in our effort to provide treatment.

i am coming to a firmer belief that medicine is out of context when it used to treat the mind...

Of course calls into context what "mind" is.  Here though, will say something I always say to my patients: people ONLY come to us for ONE reason- they "feel" bad.  Prozac deficiency has almost never been a cause that I've been able to identify.  Am overstating here too (as I am want to do...), as I do think it can assist in the process... temporarily.  Very.  Am just saying that we need to get back to working on the soul of what gets people to treatment- it's not just biology, it's basic suffering that comes from having eyes and ears.

i wonder if in 50 years time, psychiatry will be horrified by the idea that we gave people medication that caused so many problems that the patient could do nothing but crave empty calories and sleep and which increased there chance of premature death by about 600%. what happened to improving quality of life. not to mention the impact these medication have on a persons ability to engage in self recovery.

So beautiful that you said this, because we really have gotten away from a lot of the other concerns that might be of great benefit to folk.  Community, "spirituality", recreation, "finding oneself", return to interests, service, even diet and sleep.  Nicely said as usual dude.

we dont have this problem. anybody who presents to mental health service and who is using alcohol or drugs will be disgraced and shamed and told to stop their filthy habit. seriously you would not beleive the difficulties i have had trying to get a suicidal client seen by the mental health services because i was calling from an substance misuse service.

No shit?  That is unfathomable.  Guess we're still in the dark ages when it comes to substance abuse treatment.  We sure are here in the US... "War on Drugs"... phail.

i kind of disagree with you here, i believe it is of the utmost importance to be in touch with our own insanity. at least enough to be conversant in the languages of fear, guilt, worthlessness and hoplessness

Nah.  We're on the same page.  What I was getting at is that I find clinicians' own symptoms actively getting in the way of people getting treatment.  That's gonna happen too, but if it's happening repeatedly, this is bad.  For instance: I've replaced 4 chemical dependency counselors in 23 years.  Every one, all of 'em, got replaced because of relapse.  Am not talking about people having a healthy sense of their own symptoms- am talking about an unhealthy lack of sense of their own symptoms. 

 

that is interesting, i am not sure exactly what you mean here as we have a health service and we our health care is public funded...

Do you guys use "brief therapy" or "short-term problem-oriented" therapies?

nurses too. i dont expect nurses to do therapy on the patients but at least to know when somebody needs to have good cry or to express their anger and frustration. too many times if have seen nursing staff being drawn in to a patients emotional explosions and the nurse feeling like the victim of some form of emotional abuse. get real, patients are likely to be highly strung and emotionally charged when in hospital against their will. nursing staff leave your own baggage at reception please.

Being a Licensed psych nurse (and recovering codependent) too, I can say: it seems codependency is a nursing program pre-requisite. 

[SWM]

Of course calls into context what "mind" is.  Here though, will say something I always say to my patients: people ONLY come to us for ONE reason- they "feel" bad.  Prozac deficiency has almost never been a cause that I've been able to identify.  Am overstating here too (as I am want to do...), as I do think it can assist in the process... temporarily.  Very.  Am just saying that we need to get back to working on the soul of what gets people to treatment- it's not just biology, it's basic suffering that comes from having eyes and ears.

i like the esoteric association of air to that of mental activity. the mind is like the air that we breath, we drew it in and we exhale it, but it exists independent of the brain.

No shit?  That is unfathomable.  Guess we're still in the dark ages when it comes to substance abuse treatment.  We sure are here in the US... "War on Drugs"... phail.

i think over here the problems in the past has been due to how the services are funded. we have had a kind privatisation of public services. any organisation could make tender to provide a service. the service level agreement would state some thing what serivces they would provide, how many clients they would see and over what period of time. inevitably the services becomes less about engaging well with clients and more and more about numbers of clients seen and the time they where kept in services.

Nah.  We're on the same page.  What I was getting at is that I find clinicians' own symptoms actively getting in the way of people getting treatment.  That's gonna happen too, but if it's happening repeatedly, this is bad.  For instance: I've replaced 4 chemical dependency counselors in 23 years.  Every one, all of 'em, got replaced because of relapse.  Am not talking about people having a healthy sense of their own symptoms- am talking about an unhealthy lack of sense of their own symptoms. 

with you now.

Do you guys use "brief therapy" or "short-term problem-oriented" therapies?

yes, we are seing it more and more. but it is being used in what i see as a positive way. i'll try to explain;
in the olden days (read still in some places but uptill this year for other areas) the model of treatment for mental health went something like; individual presents at doctors with depression (or anxiety) doctor presecribes medication. individual goes away and comes back a month later not feeling any better, doctor changes medication and patient goes away. patient comes back, doctor makes referral to mental health team. mental health team review medication and may offer psychological therapy.

not only was this model an inneffective form of treatment, it was a long process, and costly. i know cost should not be a factor in getting people good help but if the help is costly and innefective then it is all a bit backwards.

the new model says that people should have psychological therapy first and medication as a last resort.

these programs are just being set up as an alternative to medications on first presentation of mild to moderate mental illness. i feel this is good. they are using a stepped model of care to put people with the right kind of treatment for their individual needs. people who are just presenting to their doctor for the first time with mild depression or anxiety are referred to a therapist for upto six sessions. if that is not succesful or if the doctor feels that the patient is will need more than six sessions, the patient is referred to a therapist for up to 20 sessions. at this point medication may be considered if appropriate. there is also a long term open ended option. with a psychologist or counsellor.

[corwin137]

yes, we are seing it more and more. but it is being used in what i see as a positive way. i'll try to explain;
...

This is saner than the way it's done here.  Here?

Patient in the Age of Access:  "Hello insurance guy/girl.  I've been having intermittent suicidality, and was ritualistically abused in a Satanic cult.  Can you help me?"

Insurance Company Shill:  "Of course!  Are you actively suicidal?"

PAA:  "Uh, not right now...

ICS:  "OK good.  If you were, I could get you 3-6 days inpatient.  Since you're not, how about 6 outpatient sessions?"

PAA:  "Six?  Is that going to be enough?"

ICS:  "Well, if more are needed your therapist can fill out some forms that will be lost by USPS, or denied because of HIPAA, only to be reviewed and rejected by our board.  Or, you could just pay out of pocket."

PAA:  "How much is that?"

ICS:  "$125 US is the going rate."

PAA:  "But, my car payment is only $300 a month... $125 a week for the going rate?"

Etc. ad nauseum.

Therapist:  "Don't worry PAA.  We have a new technique called __________ (insert current euphemism for treatment here... EBPs, brief therapy, problem-oriented therapy etc).  We can get you stable, and if you need more, you can come back."

Oy.  Am giving this short shrift and not being very entertaining at that, but you get the gist.  Phail.

[Shell]

This is saner than the way it's done here.  Here?

...

Oy.  Am giving this short shrift and not being very entertaining at that, but you get the gist.  Phail.

Wow, that's really... ahh, what's the word?  Ah yes, SHITTY. 

Luckily, we do it Stan's way in the military.  Not exactly like it, but they usually don't resort to medication unless we've exhausted multiple therapies for a significant amount of time.  I was going through therapy for two years before medication was suggested.  Don't know if that was too long of a wait, lol, but I did get the tools I needed before resorting to the meds. 

[corwin137]

Wow, that's really... ahh, what's the word?  Ah yes, SHITTY. 

Luckily, we do it Stan's way in the military.  Not exactly like it, but they usually don't resort to medication unless we've exhausted multiple therapies for a significant amount of time.  I was going through therapy for two years before medication was suggested.  Don't know if that was too long of a wait, lol, but I did get the tools I needed before resorting to the meds. 

Glad to hear that.  I have all kinds of horror stories about such things.  I combat it as I can- sliding scale, see people for free when they're outta work and such.  In the last two days have had two friends of friends call for a diagnostic and a med consult (about side-effects, efficacy and such).

Unfortunately, I still have people coming to me that have been abused, abandoned, had losses.  Am not doing enough.  *shrugs*  Trying to put me out of a job...

[Shell]

Awesome that you try to do things for free - I can imagine that can be hard on you at the same time, though.

How does it work (since you mention the abused) with referrals from a domestic violence shelter?  A couple of years ago I was a volunteer at a local shelter and the residents were assigned to advocates.  These advocates would, depending on the needs/preferences of the resident, get them in touch with therapists for healing.  I never asked what type of program this would be.  Most of the residents were women, most of them either uninsured or, depending on the severity of their abuse, financial unable to pay for such services.  Is there normally some type of program that is offered to these victims for free?  Or is it usually paid for by the shelter?  I would think it would be the latter but have never thought to ask and have found myself occasionally wondering about it.

[corwin137]

Awesome that you try to do things for free - I can imagine that can be hard on you at the same time, though.

How does it work (since you mention the abused) with referrals from a domestic violence shelter?  A couple of years ago I was a volunteer at a local shelter and the residents were assigned to advocates.  These advocates would, depending on the needs/preferences of the resident, get them in touch with therapists for healing.  I never asked what type of program this would be.  Most of the residents were women, most of them either uninsured or, depending on the severity of their abuse, financial unable to pay for such services.  Is there normally some type of program that is offered to these victims for free?  Or is it usually paid for by the shelter?  I would think it would be the latter but have never thought to ask and have found myself occasionally wondering about it.

If I understand your question... as a rule, shelters like that are nonprofits, so they get their funds from individuals, foundations, and pinche corporations.  Some people volunteer their services for free.  Many people who work in such places are actually paraprofessionals.  It may be different in other localities- that's the way it works here in the Valley of Darkness though.

[Shell]

Well that answers my question.  I was just curious.  I am usually bouncing back and forth with my career choices -- forensic psychology or family counseling... would like to help victims of violence and have found myself wondering about therapists' connections with dv shelters.

[corwin137]

Well that answers my question.  I was just curious.  I am usually bouncing back and forth with my career choices -- forensic psychology or family counseling... would like to help victims of violence and have found myself wondering about therapists' connections with dv shelters.

Though I've not been directly associated, I do tons of work with folk that've been physically abused.  Shelter work in this regard often ends up being more social work than counseling, you know?  Referrals, services, resource connections and such.  For me, though I love the basic service stuff, I like to dig in and try to help relieve suffering, get into preventing the next bad relationship and such...

[SWM]

This is saner than the way it's done here.  Here?

Patient in the Age of Access:  "Hello insurance guy/girl.  I've been having intermittent suicidality, and was ritualistically abused in a Satanic cult.  Can you help me?"

Insurance Company Shill:  "Of course!  Are you actively suicidal?"

PAA:  "Uh, not right now...

ICS:  "OK good.  If you were, I could get you 3-6 days inpatient.  Since you're not, how about 6 outpatient sessions?"

PAA:  "Six?  Is that going to be enough?"

ICS:  "Well, if more are needed your therapist can fill out some forms that will be lost by USPS, or denied because of HIPAA, only to be reviewed and rejected by our board.  Or, you could just pay out of pocket."

PAA:  "How much is that?"

ICS:  "$125 US is the going rate."

PAA:  "But, my car payment is only $300 a month... $125 a week for the going rate?"

Etc. ad nauseum.

Therapist:  "Don't worry PAA.  We have a new technique called __________ (insert current euphemism for treatment here... EBPs, brief therapy, problem-oriented therapy etc).  We can get you stable, and if you need more, you can come back."

Oy.  Am giving this short shrift and not being very entertaining at that, but you get the gist.  Phail.

this makes me feel lucky that we have free health care for everyone. no need for insurance.

so does a persons health insurance pay for their medication?

Well that answers my question.  I was just curious.  I am usually bouncing back and forth with my career choices -- forensic psychology or family counseling... would like to help victims of violence and have found myself wondering about therapists' connections with dv shelters.

how is family counselling different to counselling?

[corwin137]

this makes me feel lucky that we have free health care for everyone. no need for insurance.

so does a persons health insurance pay for their medication?

Yeah.  We usually have "copays" for everything- you see a doctor, you pay $10 or $20 or $30, for meds you usually pay $10, sometimes $50 if it's non-generic.

[Shell]

how is family counselling different to counselling?

Prolly not different, lol.  I'm not quite familiar with the field yet.  I just know I want to help victims of violence whether it be domestic abuse, child abuse, whatever.  So... prolly the same as counseling. 

[SWM]

hehe,
that makes sense then, i was thinking you must learn a different set of skills if you wanted to become a family counselor.

anyway i am pleased to see that you are struggling to decide what you want to specialize in too.   

[SWM]

Yeah.  We usually have "copays" for everything- you see a doctor, you pay $10 or $20 or $30, for meds you usually pay $10, sometimes $50 if it's non-generic.

that must be a problem for people with a diagosed mental illness and prescribed non-generic meds like clozaril or risperidone. does this cause problems for them with their insurance?

also would the insurance prefer them to have therapy first rather than go straight onto extremely expensive?

[corwin137]

that must be a problem for people with a diagosed mental illness and prescribed non-generic meds like clozaril or risperidone. does this cause problems for them with their insurance?

also would the insurance prefer them to have therapy first rather than go straight onto extremely expensive?

Most people in the US that have thought disorders get treatment thru Medicare and/or Medi-Cal (here in Cali), which pays for basic services.  Sometimes day treatment, but at least for their medicines.  The idea of e-motional/mental treatment before or as a primary intervention coupled with medicines here is not thought about as often as such is preached.

[SWM]

also would the insurance prefer them to have therapy first rather than go straight onto extremely expensive?

sorry, i was meaning to say "extremely expensive medication" here. i geuss you realised that though.
 

Most people in the US that have thought disorders get treatment thru Medicare and/or Medi-Cal (here in Cali), which pays for basic services.  Sometimes day treatment, but at least for their medicines.  The idea of e-motional/mental treatment before or as a primary intervention coupled with medicines here is not thought about as often as such is preached.

so, is psychological treatment recognised as good practice but not implemented?

[corwin137]

so, is psychological treatment recognised as good practice but not implemented?

Was being "soft" with my sense of it.  Truly?  It's not really considered, let alone implemented.  I never run into people where we're doing treatment and we talk about digging in with someone who is "thought disordered" and identifying issues/losses, processing those, doing assignments, suggesting other support groups and such.  It's all reality-testing, orientation, medication management, symptom management, med compliance.  Overstating, but just a bit.  There is some attending to dual diagnosis- but mostly in light of its affect on Rx efficacy, and immediate consequences.  They don't really get any serious 12-step stuff even.  It's all, "If you drink alcohol or smoke pot with your meds, that's bad."  Again, overstating for simplicity, but that's the gist.

[SWM]

i thought people got poor deal in our country.  your  health care system sounds much worse for people with mental illness.

in this country the changes in mental health treatment have been due to certain factors conspiring inour favour. the financial cost to the government, an organisation called NICE (national institue for cliinical excellence) offereing best practice guidlines and research programmes into the efficacy of psychotherapy.

the information that we get from research and from NICE say that psychotherapy is more  cost effective, more beneficial and less disruptive than medication (i am over simplifying as there are many caveats) and so this has prompted the government to invest in psychotherapy on a wholesale scale.

[corwin137]

i thought people got poor deal in our country.  your  health care system sounds much worse for people with mental illness.

in this country the changes in mental health treatment have been due to certain factors conspiring inour favour. the financial cost to the government, an organisation called NICE (national institue for cliinical excellence) offereing best practice guidlines and research programmes into the efficacy of psychotherapy.

the information that we get from research and from NICE say that psychotherapy is more  cost effective, more beneficial and less disruptive than medication (i am over simplifying as there are many caveats) and so this has prompted the government to invest in psychotherapy on a wholesale scale.

We have such things, but almost always organized by people already suffering- the clients themselves, families, etc.

You have a link to NICE?

[corwin137]

On the coattails of all this: our fees/availability.  I know people charging $250/hour and more.  Most therapists I know aren't doing pro bono or sliding scale work.  Not for real anyway.  It's particularly important now, when... the US is getting a lot of what it's asked for because of our global footprint and "foreign policy".  If one can call it that.

OK.  I guess my hat is officially in the polytrickal ring now.

[SWM]

this is a link to the NICE website, i have posted an internal link to the stepped care model for treatment of anxiety and depression. if you browse around the site you will find more of this kind of thing.

http://www.nice.org.uk/usingguidance/commissioningguides/cognitivebehaviouraltherapyservice/specifying/SteppedCareModels.jsp

On the coattails of all this: our fees/availability.  I know people charging $250/hour and more.  Most therapists I know aren't doing pro bono or sliding scale work.  Not for real anyway.  It's particularly important now, when... the US is getting a lot of what it's asked for because of our global footprint and "foreign policy".  If one can call it that.

OK.  I guess my hat is officially in the polytrickal ring now.

i noticed that therapists over in the states charge so much more. in our thread about online counselling the website of the lady offering online counselling was charging $45 to reply to an email. this is more than i charge for 1 face to face session.

i have just worked out my hourly rate in dollars works out at $32.  i suppose if people are charging so much for therapy then it is not an option for many people who need it.

[SWM]

i was looking around the NICE site and i found this page which indexes all nice guidance for mental health an behavioural conditions.

http://www.nice.org.uk/guidance/index.jsp?action=byTopic&o=7281&set=true