Making Therapy Harder: When Corporate Forces Interfere with Therapy
Every therapist is familiar with therapy-interfering behavior (TIB). Historically the literature has focused on TIB in the client or patient, such as when a client misses a session, shows up late, sits silently, or even refuses the treatment altogether. Chapman and Rosenthal (2016) define TIB as follows: “any behavior that interferes with the client benefiting from therapy could be considered a TIB.” They further state that “TIB can be intentional or unintentional, strategic or automatic, calculated or absentminded.” Of course we all know that, in many cases, the source of such behavior may be outside the awareness of the client, at least at the beginning of treatment.
TIB in the therapist has also been explored, and examples include being late, ending early, changing policies, forgetting information (Vaughn, 2021). And of course, just like clients, the source of these can be conscious or unconscious. There may also be TIBs from individuals involved with the client, but outside of the therapeutic relationship. For example, with friends, partners, or families, these might include being under- or over-involved in the client’s therapy, intrusions into privacy, and being unreliable with transportation needs, or nowadays, access to the internet.
Although the TIBs discussed above may be challenging to deal with, especially when unconsciously motivated, many therapists of depth, insight and relationship are familiar with what has been presented here so far, and we have developed fine-tuned responses or preventive measures for such things.
What we may not typically frame in this way are behaviors from other entities that clearly interfere with the therapy, and may even be more damaging and pernicious than the TIBs already discussed. A prime example of such “corporate TIBs” stem from the interference from insurance companies and administrative entities that represent attempts to control, constrain, or direct therapy, at times to the point where such individuals or groups are actually practicing without a license.
For administrative hosts of therapy practices, such as the systems which oversee services in various clinics, state agencies, and higher education settings, therapists often wear many hats, and can encounter TIBs in many forms. For example, in agency settings of many types, clinical staff have obligations in at least four areas: therapy, consultation, crisis management, and outreach (psycho-education in the community). All have their place and are valuable, but very often the amount of time needed is not given much consideration by management. During busy periods one may have six to eight therapy sessions a day, serve on call at the same time, take same-day consultation calls from concerned third parties, and have an outreach program to deliver. It takes an enormous amount of energy and multitasking skills which can negatively affect therapy in particular, because there is little time to reflect before or after sessions, read and write notes, connect with ancillary services, do some research, etc.
Thus, in an agency setting, TIBs might include the agency establishing unreasonable “performance” targets, onerous documentation requirements, or outcome measures not directly related to therapy. In addition, there may be policies that are contrary to ethical practice and wisdom in the field, such as directing therapists to make cold calls to individuals not yet in therapy, conflicting demands for therapeutic and non-therapeutic activities without respect for the time needed (expecting high clinical productivity and around the clock responsiveness), even communicating expectations regarding specific priorities for clients (“Tell him to stop using drugs.”)
In my opinion, these particular TIBs can significantly hamper and even harm the therapy, give the client a distorted view of quality therapy, and also contribute to therapist exhaustion and burnout. Professional organizations tend to focus on offering moral support for therapists, but advocacy with upper administration and others is sorely needed. Staff members in these settings need more advocacy regarding reasonable, sustainable, and safe workplace standards, with an eye towards eliminating behaviors or policies that interfere with helping clients.
For insurance companies or other payors, TIBs can be found throughout their administrative processes and controls. For example, payors interfere with therapy when they set severe limits for coverage (rendering therapy nearly meaningless or neutering it), have a lack of transparency in data sharing arrangements, use overly complicated or convoluted explanations of benefits and reimbursement procedures, and delay processing claims. Beyond these, and perhaps even more problematic, are instances of insurance companies defining therapy itself through the ruse of “evidence-based treatments,” and creating improper and unvalidated “equivalents” for therapists, such as bots and other forms of artificial intelligence.
For law- and policymakers, TIBs may include setting or creating obstacles to full mental health parity, draconian and chilling information-sharing expectations, expectations for seamless transition of care at all levels, but then holding a therapist responsible when transitions understandably falter. Also, we see, in law or policy, preferences for certain therapy practice, orientations and systems, contrary to the full range of available evidence, and policies that are mandated yet unfunded. For example, when policies mandate compliance with national efforts concerning suicide prevention, but fail to provide resources or tools to accomplish this purpose, then efforts to fulfill these policies are doomed from the start, and therapists, clients, and policymakers themselves are all frustrated.
If we are serious that TIB refers to any behavior which interferes with the client’s ability to benefit from therapy, then all of the above should be considered a form of TIB and treated as such. While some TIB is visible to us and occurs between the client and the therapist, much of it is not, especially that which occurs in boardrooms and the halls of government. No doubt the proponents of these forms of TIB can articulate reasoning for such choices which they feel is sound. However, with some exceptions, they are not therapists themselves nor bound to our code of ethics. Also, their goals and priorities are often quite different from ours; they may be focused on cutting costs or increasing revenues, and not the care of the client or the therapeutic outcomes of the treatment.
Given the profoundly negative impacts on the client and the therapy process, our profession must take a firm stand against interference with therapy wherever possible, and call it what it is: TIB, therapy-interfering behavior, which amounts to practicing without a license in many cases. “Corporate TIBs” can often exist for reasons having to do with improper motivations to frame therapy for the benefit of others and not the client, thereby harming the latter. Thus, we must insist on our authority to define and frame what therapy is, and, importantly, what it is not.
Lee Keyes, PhD is a semi-retired licensed psychologist in part time private practice. He has also practiced, consulted, and taught in higher education, hospital, and agency settings. He is the author of Delivering Effective College Mental Health Services, available from John's Hopkins University Press.
References
Chapman, A. L., and Rosenthal, M. Z. (2016). Managing Therapy-Interfering Behavior: Strategies. Dialectical Behavior Therapy. Washington: American Psychological Association.
Vaughn, S. (October 5, 2021). TBIs of the Therapist: Balancing Change and Acceptance. Retrieved from https://psychotherapyacademy.org/dbt/therapy-interfering-behavior-of-the-therapist/.