Since the inception of PsiAN, we’ve planned to maintain a blog on this site, and now that we’re up and running, what better time to post our inaugural offering than on the (almost) first birthday of our organization? Since many of our members are psychotherapists, we figured that they would have a sense of the importance of history — personal and social — and thus wouldn’t mind a tour through the backstory leading up to PsiAN’s formation. Actually, I’m feeding two birds with one millet spray here (or whatever a bird-lover’s version of the phrase would be) — one of our speakers was ill and couldn’t attend our conference, leaving us to scramble for a pinch-hitter. And since that person never emerged, I ended up using that slot to provide an overview of the conference whose culmination was the inception of PsiAN. Because I somehow never managed to follow up and send it to the people who requested copies, I herewith absolve myself of my own nagging guilt by publishing the talk as our first blog post, while in the meanwhile I hope that it can give our members a sense of the excitement of our gathering, as well as a reminder of the urgency of PsiAN’s mission. — Nancy Burke
I am so glad you are here today, and I’m ambivalently glad to be here speaking to you. Ambivalent because the only reason that I am talking to you now is that Leonore Tiefer is not. She’s home with the flu, and because she was planning to give her talk extemporaneously, she had no paper we could read to you in her absence. We could, of course, use the time to make some experiential statement about the fact that there is absence at the heart of every psychotherapy – there is loss, there is mourning, there’s re-finding and re-losing — and perhaps that might be an entrée into discussing why it is that we may be in danger of losing psychotherapy itself, but I wish to leave those discussions to our speakers. Instead, I will attempt to channel Leonore for some small portion of this presentation, because I think she has important things to tell us about how to be advocates for psychotherapy in these tumultuous times.
But meanwhile, I want to use this sudden abyss of time to tell you a story, the story of this conference, so that you might have a sense of the sweep of the whole. Or rather, I should say, following E. M. Forster, that I hope to give you an overview of the conference’s plot. As Forster tells us: “saying ‘The king died and then the queen died’ is merely a story; saying ‘The king died and then the queen died of a broken heart’ is a plot” – by which he means, I think, that the plot not only highlights the chronological coincidence between events, but also an emotional investment, and that it is this latter that draws us forward. It is my hope that you will find that this conference has both, both a causal and an emotional sense of building towards a layered understanding that can form a thoughtful foundation for future action.
This conference would never have come into being without the hard and dedicated work of my CCP colleagues on the planning committee – Claude Barbre, Jill Barbre, Bernadette Berardi-Coletta, Ellyn Daniels, John Garver, Lorel Green, Janice Muhr, Sivan Schneider and Toula Kalven – and each of them has their own account of how our conference came into being and why they took what I see as heroically diligent action in support of it, but I can share with you only my own: My engagement started twenty years ago now, in a conversation I had had with a colleague regarding the publication of Christopher Bollas’s 1996 book called The New Informants. This book surprised us, my co-worker and I – we expected poetry from Bollas, or at least incisive and sensitive case discussion, and yet The New Informants was as prosaic as they come, or so we both agreed at the time, in its discussion of procedures and notes and insurance protocols and mandated reporting. Slowly, however, the concerns outlined in the book took hold, especially as they were echoed in my direct experiences of doing psychotherapy in a clinic and in a private practice simultaneously. Our very sense of a right to privacy is being eroded, said Bollas and his co-author, David Sundelson, and without it, we cannot do the work that we do. Further, Bollas and Sundelson emphasized the seeming complacency of therapists in the face of the incursions of the insurance, judicial and clinic systems into the space between therapist and patient. Why was there no organized defense of the parameters of treatment on the part of clinicians? The question simmered, though at a low boil.
Fast forward to more recent days, to the events leading up to the American Psychological Association’s commissioning of the Hoffman report in November of 2014, and to the events that followed afterwards. As a member of Division 39 and of its Social Justice section, I was able to witness the tireless efforts of a number of key players, Frank Summers prominent among them, to press their concerns regarding collusion between the Bush White House and psychologist members of the APA – and indeed, the APA itself – to support so-called enhanced interrogation techniques employed in the also-so-called war on terror. The dogged pursuit of the truth by a small band of dedicated psychologists – most of them psychoanalytically inclined and affiliated with Division 39 – resulted in a series of stunning revelations and responses that, while more limited than they should have been, nevertheless resulted in a major shake-up at the APA, a clarification of the role of psychology in affairs of state and a collective consciousness-raising among psychologists regarding the true origins and allegiances of the profession to which they are committed. I cannot comment here on the fate of these reforms in the current political climate because it would break my heart, but nevertheless, this action highlighted what a small band of dedicated individuals, to paraphrase Margaret Mead, could do to change the world. Actions by psychoanalysts that followed have included organized interventions in support of the Waterkeepers at Standing Rock, attempts to work for justice in the Middle East, and myriad efforts to take organized political action in the face of our current national Armageddon.
While I find all of these efforts to be inspiring, life-giving and gratitude-inducing, however, I have continued to feel that there is something missing on the list, a hole in the fabric of the collective efforts of the psychotherapy community to contribute to our broader social concerns. Our wishes to be of service outside the confines of our individual consulting rooms, it’s seemed to me, have led us to defend collectively every righteous cause except our own, at least systematically and consistently. Of course, this is not to say that mental health issues have fallen off our national radar. Indeed, every time there’s a shooting in a school or a theater or a shopping mall, there’s a corresponding rush to use the event to make the case for expanded mental health services – screenings, research, early education — at least if the shooter and/or the victims are white and middle class. Most recently, the 21st Century Cures Act sailed through the Senate with a 94 – 5 vote of support, after a 392-26 win in the House, offering a huge bipartisan victory, we are told, for individuals and families in distress. After all, is there anybody who wouldn’t vote to support mental health? Is anyone here against mental health? Please speak up! Yet it appears that the biggest winners in such legislation somehow always turn out to be pharmaceutical companies, researchers on brain diseases, and isolated, problem-focused drug-treatment programs, with a corresponding decrease in support for insight-oriented, relationship-based psychotherapy of any depth. So my question to you: Where are the petition-signers, the marchers, the banner-toting rabble-rousers carrying signs in the streets that say “Get your little hands off my couch” and “my mind/my choice” and “What do we want? Psychotherapy! When do we want it? For as long as it takes.”?
My central concern here is that there is an unacknowledged tendency – unacknowledged and we might say Unconscious – to devalue psychotherapy not just as the canary in the mineshaft, a bellweather of our commitment to social provision, but as a tool of change. The fact that most of the aggregate help offered by psychotherapy occurs one person at a time leads us to an unspoken sense of collective futility in the face of sociocultural trends that seem bigger than one person, with one other person, in one room, over many hours. But it goes deeper than that — and here we hear the echoes of Freud’s famous comment that he was bringing us the plague – to the fact that given that people tend to bring to psychotherapy all of the material that they can’t bear to think about in the other aspects of their lives, the aversion that accrues hangs over psychotherapy like a pitch-dark halo, provoking resistance even in those who make their living as psychoanalytic practitioners. And ours is an odd consumer group indeed; unlike other consumer groups, the most likely target members of our support-for-psychotherapy support group are those for whom privacy in such matters, as Bollas reminds us, matters the most.
In the following paragraphs, I will lay out just a few of the pressures placed upon psychotherapy, that is, a few of the disparate but interconnected pieces that collectively add up to a threat to the continued widespread availability of this most vital and most human of resources for growth. I shall try not to make my list too long or too relentless, both because I don’t want to steal the thunder of our participants, who will talk to you in detail about these issues and more, and because I don’t want us to get so depressed that we will have to resort to marching ‘round the neighborhood in order to restore our spirits (though I do suddenly appreciate marching as an evidence-based treatment verified by millions for situational depression). Then, I will give a broad plot outline of our conference, and specifically of the ways we intend to build toward collective action to address at least some of the issues that feed our larger river of concern.
I will begin with a few innocuous data-related innovations that present themselves as psychotherapy-friendly but strike me and others, rather, as insidious challenges to the sort of open-ended, associational, exploratory processes that result in insight, in the harnessing of feeling, and in deep change. Take NPIs, for instance – we might celebrate the fact that practitioners now have specific tags that are recognized by all insurers and government entities. What could be more convenient? Yet I need to remind you, as Allan Scholom will a bit later on, that the one thing more valuable than oil these days is Big Data. The data collected by corporations are directly monitized, both for use in projects by which you will never be affected and for use in tracking your clinical practices. Do you see one or a number of patients intensively, or for extended periods of time? Big Data knows this about you, and thus so, potentially, does everyone else. Meanwhile, there is a push in several states to mandate EHRs, Electronic Health Records. More big data? You guessed it! These records will be easily shared, and we might remember that what is easily done is done often, as opposed to what is hard to do, which tends to be done rarely. Further, inasmuch as most EHRs mandate note-taking in a standard format, a sort of enhanced SOAP format, we might be reminded of the research on PowerPoint which suggests that when people are required to present their ideas in PowerPoint form, they actually think differently, and less deeply and flexibly, than other people who do not labor under such strictures. If protocol demands that we log each session in the way that an MD logs patient encounters, then thinking diagnostically within the framework of a medical model will prove irresistible, and of course we must acknowledge that how we think determines how we listen, act, respond.
Meanwhile, telehealth is in its ascendancy, and we might ask Todd Essig about its impact on psychotherapy practice. I am not talking here about those of us, probably all of us who are practitioners and who speak to their patients by phone or Skype for short, temporary periods, or when those patients have moved out of town after establishing significant and helpful relationships with them face-to-face. We are also not talking about providing services to areas in which such services would not be otherwise available. We are talking here about the trend towards call-in or Skype-in services that match patients and therapists on a widespread basis, either with consistency regarding the specific practitioner or without, or with no living practitioner but only an avatar, and also those services that offer diagnosis by computer, and so-called therapy and diagnosis via app. These services offer therapy or “therapy” for rock-bottom prices, with all the efficiency – automoatic credit card billing and scheduling! –the digital world can muster. Many of you may remember the Bob Newhart skit in which Bob explains his billing practices: $5 for the first five minutes, with $1 for each additional minute though people rarely need the extra time (and I know I learned all I know about being a therapist from Bob, for sure), only to be offered the following wisdom after they state their problem: “STOP IT!” Needless to say, there is no way that face-to-face psychotherapy can compete with those price points, nor really is there the need for highly trained and experienced clinicians to staff the lines. This may seem like 1984 to you now – Oh! Wait! Nevermind! – but it is reasonable to think that such services will have a decisive influence over the policies of insurance companies and other financial interests. And, needless to say, such practices will engaged in digitized record-keeping – back to the previous paragraph.
Then there is the fact that in our violent world, the lackluster restrictions upon purchasing weapons that substitute in this country for real gun control legislation have implicated the mental health field in their own unwelcome ways. Now therapists are potentially positioned as gatekeepers to gun access, and inpatient units are positioned to create registries that reveal, among other things, whether any individual has had a hospitalization history. More big data? You know it. An irreversible and decisive blow to patient privacy, and to what can be said within the walls of a consulting room? It goes without saying….oh, wait.
Now you don’t need me to whine about the role of insurance companies in the provision of mental health care. You probably do this for some significant period of time every day anyway, and if we could harness that frustration and turn it into megahertz, we could all run our washers and dryers at no charge. Yet there are concerns we might put front and center even so. They may be obvious to you now, but then, as therapists, we are all aware of how simply putting words to the obvious can bring forth surprises and transformations in how we think, such that the obvious is no longer obvious. In regard to insurance issues, ask Allan Scholom and Bernard Turnoy and John Garver about that. Now I do not know whether medically-oriented insurance companies should even be in the business of providing the resources for mental health care. All I know is that somebody should, because psychotherapy is cost intensive in ways that make up for themselves over the long term and then some, but those gains do not necessarily circle back directly to the therapists who have facilitated them. I used to say that it might be more appropriate if the National Endowment for the Arts or Humanities funded treatment, but then, well, we see how that would go. At any rate, without some sort of subsidy for treatment, treatment would likely be available mostly only to the very rich, in other words, precisely not to the people who need it most (not to say that the very rich don’t have problems, but only that some portion of us would trade our problems for theirs, as certain pressures that we know are correlated with high degrees of trauma and emotional distress do not play a systematically determined role in their lives to the same extent, and the resources for dealing with traumatic and difficult events are greater than for those without means.) Given that insurance companies fund the majority of psychotherapies in this country, these companies have enormous power to determine the product they are selling. We as therapists and patients are protected from some of their cost-cutting measures by the Wellstone-Domenici Mental Health Parity and Addiction Equality Act of 2008 – and I want here to give a shout out to my old mentor, Paul Wellstone, for this, but as we read in the papers daily, the reach of this act is limited already in some respects, and will be whittled away daily by the incoming administration. But even as is, insurance companies can wield the sword of medical necessity with great skill, and unless we can clone such samuri as Meiram Bendat to create an army, we will likely be subjected going forward to increasing assaults to our professionalism and autonomy. Needless to say, the material to be used in assembling these assaults is, you guessed it, Big Data, through which insurance companies have ongoing and routine access to things you wouldn’t dream of telling your mother – just a minute – I’ll get to that.
In the meanwhile, insurance subsidy for mental health care will also mean increased attention to physician characteristics, leaving therapists with no more right to privacy than patients. Remember those NPI numbers and those EHRs? Already, as most of you know, Medicare has put into place so-called quality control measures, dubbed PQRS measures. Although there is supposedly some choice among the measures upon which treatments are to be rated, many practitioners have experienced those choices as akin to the one between having rocks for dinner or having sand. They involve tracking patient improvement on various behavioral measures, which are often important signposts to treatment effectiveness but are just as often as irrelevant to the usefulness of psychotherapy. We all have patients who function well but are internally tortured, living lives of quiet or obvious desperation despite or because of their outward compliance with societal norms. And we all understand, when our patients look like they are unraveling, become depressed for the first time in their lives, or suddenly express anger in ways that they were too scared to voice before, that patient’s achievements can often look like backsliding to outside observers. That is why they are outside observers and we go through decades of apprenticeship – in order to appreciate the behavior of complex individuals in context. If it turns out that we have no greater expertise than the poor overworked BA student in Bangalore who is employed to pass judgment on our work, then I see no reason not to pony up for some telehealth – I’ll be first in line!
And even more insidious is the idea of implementing a capitation system for insurance reimbursement, such that therapists will be paid by the patient rather than by the encounter. Bob Newhart will finally strike it rich! And we will all become experts in “STOP IT” therapy, out of our sheer desperation to make a living. We are, likewise, familiar with other bait-and-switch tactics used by insurance companies in response to the creation of the ACA – Blue Cross’s stunt of offering its most comprehensive policy on the exchanges one year, in which its losses were partly covered by the federal government, only to pull it the next, substituting a plan for which so few therapists and hospitals were willing to enroll that they had to grandfather in their PPO practitioners in order to establish network adequacy, and now Aetna’s maneuver to pull itself from the exchanges to doll itself up for its date with Humana (though I’m pleased to say that that one was nipped in the bud). Insurance companies, mind you, are companies, even ones like Blue Cross, which, despite their multi-billion-dollar endowments are legally considered not-for-profits. I am not asserting that there should be no quality control over treatments, nor am I saying that if therapists survive long periods of training they should do what they want, or that that means they are necessarily providing optimal care. I am only highlighting ways in which potentially helpful helping professionals may find themselves systematically unable to fulfill the highest missions of their professions. Indeed, these questions are difficult ones, which require extensive wisdom and effort to untangle, which is, incidentially, why I’m so excited that we are all here together today.
Indeed, we all know what insurance companies and legislative entities rely on at present in order to determine who gets services, and when and where – evidence! And who wouldn’t go for that! Is there anyone here who is anti-evidence? I didn’t think so. We are all people of science as well as of art, and we absolutely must respect aggregate experiences and observations that can supplement and guide our work. But of course, as we heard last night in words much more persuasive and comprehensive than my own from Jonathan Shedler and Robert Whitaker, and as we will hear today from Allan Scholom and others, the question of what constitutes evidence is a thorny one indeed, not as clear cut as we would wish and certainly not immune to bias, distortion and economic and ideological influence. I am fond of calling certain therapies look-in-the-light therapies, as inspired by that old joke in which one guy finds another guy crawling around under a lightpost. “What are you doing?,” The one guy asks the other. “I’m looking for my watch,” says the second guy. “Did you drop it here?” “No, but here is where the light is better.” Something like that. I never could tell a joke. But you get the idea, and I won’t go on about the issue, other than to say that it is at the root of everything we are doing. There is myriad evidence for the effectiveness of long-term, psychodynamically-informed psychotherapy, but this evidence will be of no use if we cannot figure out how to persuade the powers that be to recognize it as such.
And of course, there is always more research to be done, the outcomes of which will be determined by the degree of insight, wisdom and sophistication that are used to formulate the questions we are asking and to interpret the results. You know, the sort of evidence that is time, labor and therefore economically intensive to obtain. The kind that NIMH used, ambivalently, to fund, but which is now virtually non-existent in the funding stream of any major granting organization in this country. Insell’s Decade of the Brain has given way slightly to make room for a few other foci, but none of these are psychotherapy-based, and whither NIMH goeth, so goeth most other funding sources.
Now, while we are talking about psychotherapy as a profession, one that necessitates extensive training as well as certain relatively rare sensitivities and allegiances, we might just talk a bit about training, though we will talk in much greater depth about this issue with Oksana Yakushko later on in this conference. I am, like some of you, of a species that has officially been placed on the endangered list by my academic institution, known as a dinosaur, though fondly, I’m sure. Indeed, in most psychology and social work graduate programs around the country, longer-term, insight-oriented, psychodynamically-informed psychotherapy is simply not taught. During my period of employment at my institution, I witnessed the organization move from recognizing psychology interns/post-docs and psychiatry residents as equals in their training programs to watching the demise of this sense of a common endeavor, and in the clinic where I worked, which treated so-called severely mentally ill adult outpatients, I saw the psychiatry residents move from seeing these most vulnerable and compromised patients for sometimes as many as three years to their seeing them for six months at most, during which time the patients had no incentive whatsoever to trust their therapists or expect their deep and complex concerns to be treated as anything but guinea pig feed, and the therapists had no reason whatsoever not to conclude that psychotherapy was ineffective for that population. Later, we can ask Bert Karon and Jessica Wall about that. And if we wonder why there is such a paucity of training, we might well ask Oksana Yakushko about that. My guess is that she will have much to say about the pressures upon psychotherapy training in this country, about the roles of the American Psychological Association itself as well as the Department of Education, Big Pharma and insurance companies in creating such pressures, and the resultant effects of this training across generations of academicians. The trainees in these programs are the people who will be teaching our students, the ones who will choose their research questions on the basis of what can be studied within the time frame of their training programs, and the ones whose psychotherapy practices will represent the modal forms of treatment endorsed by their respective professional organizations.
Of course, the pressures upon psychotherapy run both bottom-up, as a result of the aggregate practices of individual therapists, and top-down, as determined by legislation at the local, state and especially federal levels. We are pleased that Noel Hunter, Daniel Biss and Ed Santana will be here to speak about how legislation affects us as practitioners, and as to how we might affect it in turn. The one thing I and my colleagues can add to the conversation at this point is my own personal experience in talking, with Allan Scholom and John Garver, to my own elected federal representative about the issue of mental health care, and that is that the people who make major policy decisions are not psychotherapists. In fact, many of them do not have any idea as to the difference between what psychotherapists do and what psychiatrists do. Most of them have no experience in psychotherapy (as much as, in our eyes, most cry out as in need of such experience over a very long, long time) and do not appreciate one whit what we mean when we try to speak up for psychotherapy practices in the public arena. And this, folks, is not only their fault, but ours. We see this conference as a way to develop a collective voice such that we can be of use to those with their hands on the levers of power, many of whom are paid off by Big Pharma and other interests, but also many of whom are truly dedicated public servants who want to do well by their constituents and their country. We need to be present in the dialogue, and we are determined to innovate effective ways to do so. That is the most overarching of the reasons why I and my committee are glad you are here.
Now, in case you have fallen into the black holes of depression and helplessness you might have seen open up in the chasm in front of me through my talk, I would like to say just a few words about how we see this conference as a catalyst for change. First, I’ll note that we made the decision early on to form all of our panels as plenaries. We figured that if these people were important enough for us to invite them and to transport them here to speak to you, they were important enough for us all to hear. We are interested in creating a united voice as well as in tolerating our varying points of view, and in that vein, we thought we should be all together, even though the room is crowded and we had to cross many worthy invitees off our lists. And while I’m at it about procedures, please note that you should have your lunch tickets packed away in your name tags. If you ordered lunches but don’t have tickets for them, please see Toula. Also, CEs will be offered separately for every session. In order to receive them, you must fill out the evaluation forms our volunteers will be handing you. Also, you need to fill out the forms directly after each individual program. We did this so that we don’t have to keep track of who is attending which panel, and who has absented themselves to go out to march in self-defense. In addition, as you might have seen, we will have petitions circulating throughout the day, though we will have the official signing and discussion of these during our wrap-up inaugural meeting of the Psychotherapy Action Network. Please feel free to sign them or not, now or later, but make sure you keep us aware of your interest in joining us in any efforts we might make following our conference.
As you have seen, we have used our Friday night kick-off program to give us an overview of mental health care in the America of now, so that we can get a sense both of our baseline and of some, yes, evidence-based policies and directions that can guide us. Although the days don’t completely divide up as neatly as we had intended due to our need to accommodate the schedules of our various presenters, we had thought of Saturday as essentially a study-day, a day in which we could think about the wider cultural context for our questions and about some of the dilemmas we have faced in the particular arena of psychotherapy in which we have encountered these cultural concerns. In view of our Saturday mandate, we had invited Leonore Tiefel to speak to us about her efforts to combat what she views as a culture-wide turn towards the medicalization of the female body and sexuality in general. She would have told us about her observations about how this perspective has had far-reaching effects upon how women especially are treated by the medical profession, and particularly about how a diagnostic perspective on women’s approaches to sexuality has resulted in constricting norms for women in the name of increasing freedom for them, as well as in the dominance of generally ineffective medication-based treatments that carry with them a host of their own side-effects, both physical and cultural. Further, she might have given us insight into the formation and activities of her New View campaign, which you can visit on the web, which combines a substantial print and video presence with think-tank conferences like ours and active testimony to the FDA and other public agencies. Clearly, this one specialized treatment area is but a microcosmic representation of psychotherapy as a whole, and we do well to learn from her example.
The rest of our Saturday program, with two exceptions, is devoted to a big-picture look at the cultural context for the dehumanization and medicalization against which we in the psychotherapy field are trying to protect our work against, as well as a closer look at specific areas in which the pressure upon psychotherapy is currently greater. Frank Summers, Claude Barbre and, at a more specific level, Allan Scholom, will lay out their accounts of this context, while Bert Karon and Jessica Wall will speak to one particular type of situation in which psychotherapy is most vulnerable, that of the treatment of psychosis. In the midst of these presentations, we offer you two hopeful, get-your-chin-off-the-ground presentations that demonstrate the psychotherapy is alive and well. First, Angela Sedeno and Mike Snedeker will speak to you about an exciting new funding model in Illinois that is replicable in other states and that has made psychotherapy more accessible to a population that our mental health policy, with its emphasis upon closing programs rather than opening them, would have otherwise forgotten. Then, at the end of our long day, we will hear from four artists who are living evidence – if we are looking for an evidence-base – that psychotherapy stands as an integral contributer to art making, and to culture in general, with wide-ranging effects in turn. Then, I hope those of you who have registered for it will join us as we blow off some steam at our dinner reception. The reception is, sadly, sold out at the moment, so if you did register in advance but cannot attend, let us know and we will likely find someone to take your place. Likewise, if you would like to join us but have been closed out, please let us know that too and we’ll try to accommodate. Otherwise, we encourage you to meet people at this conference, and to make your own plenary dinners at one of our lovely Chicago dining establishments.
Sunday was conceptualized by us more as a day of action. We have the background by now to begin to formulate a game plan, not a rigid one, of course, but at least a menu of hopeful options. We are fortunate to have Meiram Bendat talking to us by Skype about his ground-breaking legal defense of psychotherapy via his firm, Psych-Appeal, and then Todd Essig, columnist for Forbes, among other outlets, who will teach us how we each can be vocal advocates for psychotherapy in the media. Then, we are grateful to have a panel focused on political avenues to change, as Daniel Biss, one of our Illinois State Senators, joins forces with Ed Santana, a lobbyist, and Noel Hunter, an influential observer of mental health legislation, to discuss how we might best make a difference in that arena. Hopefully, we will be energized to Tackle Goliath along with Bernary Turnoy and John Garver, so that we can understand our predicament vis-à-vis insurance companies as well as have some insight into their workings and where they offer openings for us to be heard. As I’m sure you know, our conference culminates with a call to direct action, or at least, with an organizing meeting in which we can put our heads together to think about the best avenues through which to fulfill our goal of rehumanizing mental health care and defending psychotherapy for the next generation.