Abstract
This publication represents a logical end point of the ideology of economic rationalism with its corrosive consequences upon DSM-IV and systems of health care. It is what Edwin Harari, in his recent review in this journal of Shorter's technocratic and triumphalist A History of Psychiatry, referred to as: ‘less a sign of psychiatry's scientific maturation than another historically contingent form of institutionalised irrationality' [1].
Shorter would probably praise this book. I find it a miserable symptom of the dead end psychotherapy is getting shoved into. Mind you, this is not a book for reading. Indeed, it is unreadable. Rather, to quote the pinched prose on the back cover: it ‘supplies all of the essential building blocks you need to create focused, formal treatment plans that satisfy all of the demands of HMO's, managed-care companies, third-party payers, and state and federal review agencies'. If only.
We are consigned the 31 presenting problems that occur in couples and relationships. These range from ‘Recreational Activities Disputes’ and ‘Work/Home Role Strain’, to ‘Disillusionment with Relationship’ and ‘One Partner Unwilling to Attend Therapy’, onto ‘Sexual Abuse’.
Each problem is broken down into categories, listed in double column point form. These start with ‘Behavioural Definitions’ (e.g. for the problem ‘Anger’ there are four component definitions such as number 4, ‘yelling, cursing and throwing or breaking objects’); then ‘Long Term Goals’ (six goals for ‘Anger’, of the order of number 6: ‘learn to verbally express hurt feelings instead of expressing them through angry outbursts’). Short Term Objectives follow (‘Anger’ is given 28, e.g. number 11, ‘Define the three main reasons for anger’) and then ‘Therapeutic Interventions’ (with a whole 48 for Anger, e.g. number 22, ‘contract to verbalise angry feelings instead of acting them out’). Finally, the applicable DSM-IV diagnoses and codes are listed.
This format is repeated 31 times. Each individual statement is conventional, uninspired and often clichéd. There is no invention, wit or imagination here. The overall effect is stupefying to the point of being surreal. It is psychotherapy disintegrated to its subatomic parts, without any guide how to put it back together. But then, this book is not to be confused with anything resembling a treatment guide. On this point the authors are explicit: ‘the sourcebook can save you hours of painstaking paperwork, while providing optimum latitude in developing customised treatment plans … with thousands of well-crafted statements to choose from’. Nobody ever needs to ask the patient what they want. But it is just the ticket for keeping the customer happy, which in this case are really the insurance bureaucracies and regulatory agencies. At least to the degree that the protocols are mindless, they are potentially subversive. If you can't overwhelm with your quality (an ancient, outdated idea anyway), you can overwhelm with quantity. Endless individualised treatment plans (TPs) can be generated with just a click of a mouse: naturally, all 262 pages are available on Windows as ‘Therascribe®, The computerised assistant to psychotherapy treatment planning, complete with upgrades’. Any exploratory attempts at constructive conversations are irrelevant. Just press print and off you go.
Indeed the very book itself seems to have been produced without talking. The junior authors boast in the preface that they have never met the mastermind, Dr Jongsma. Instead ‘chapter manuscripts were repeatedly emailed back and forth through various iterations’. Iterations is right. The redoubtable Dr Jongsma has, according to my Amazon printout, produced no less than 28 versions of these Treatment Plans. The original lexicographer, Dr Johnson, once said of a colleague ‘a man could write this way forever if only he would abandon himself to it’. How did he know about Dr Jongsma, with his multitude of TPs ranging across both the life cycle (from The brief child therapy homework planner to The older adult psychotherapy TP), and all therapeutic modes (from The group therapy TP to the Employee assistant TP, to the Pastoral care TP. God bless, have even the Churches succumbed to managed care?).
The complete psychotherapy treatment planner produced in 1995 is a USA best seller (‘over 100,000 copies sold’). I can see why. The Jongsma treatment planners offer an impenetrable defensive array, a veritable Maginot Line against the darker forces of managed care and malpractice suits, the ultimate bullshit to baffle the bureaucracy. Perhaps we should welcome such subversion, but just as the Maginot Line was outflanked, I'm not confident it will work.
And if it did, the results might be even worse. Endlessly iterating these banal vocabularies and simplistic formulae may induce a temporary stay, even chaos, while the functionaries retreat to work out their counter moves. But it will all be at the cost of any human conversation with all of its ironies, ambiguities and contradictions. If, as William Burroughs declared, ‘language is a virus’ then the hyper-rational language of these planners is a malignant and impoverishing germ, indeed.
If you must keep a copy or disk of a treatment planner for your battle with Big Brother, be wary of imagining it has any relation to our work of listening and struggling to help patients make sense of their lives. Don't get infected. These things are only to be used as a last desperate resort as we fight on where we can. They need to be handled with extreme antiseptic care, lest psychotherapy gets lost in hyper-real administrative cyberspace forever.