The Art of Helping

"A little learning is a dang'rous thing;
Drink deep, or taste not the Pierian spring:
There shallow draughts intoxicate the brain,
And drinking largely sobers us again."
~ Alexander Pope

Is it, though? 

We're in a mental health crisis and people need more access to help. How much learning is necessary to help one another, and is it dangerous to listen and offer another perspective or even some suggestions without an advanced psych degree? In old movies, people told their stories to bartenders, hairstylists, or cab drivers for the price of a beer or trim or trip to the airport. They just needed a captive audience willing to listen to their worries Now we want people with credentials as if that will provide more certain results.  

But not all credentials are created equal. 

Last year BetterHelp got in the news for allegedly sharing confidential health data to social media sites, and was fined $7.8 million. TV writer Mike Drucker wrote:

"EVERY BETTERHELP AD: 'We're like therapy but cheaper and easier! We have people for every problem so you get care just for you!'
ACTUAL BETTERHELP: 'We're gong to set you up with a confused therapist that will ghost after two sessions. Also we told Facebook about your assault.'"

More recently, the New York Times had an article on scams in the wellness coaching industry, describing scenarios in which the new recruits were bilked out of massive amounts for "tuition" made up of a few hours of videos, and then were never helped to find clients. 

"Business is booming. . . . The number of coaches increased 54% between 2019 and 2022. Because the industry lacks standardized accreditation, it's most likely larger -- one of the dangers of life coaching is that anyone can claim the title of life coach. . . . [One coach] has spent an extraordinary amount of money on the certification and clung to the dream that had been sold to her . . . found herself short of clients and scrambling to make any income. . . . There is a problem in the industry of coaches who coach coaches to become coaches. . . . Life coaching attracts people who are vulnerable to exploitation."

In a video from a British psychologist commenting on a episode of Friends (which I can't seem to find in the plethora of similar videos out now), he kept questioning why everyone was talking about going to therapy to help make pretty minor decisions when none of them had any kind of disorder affecting their lives. 

We seem to be pretty quick to want professional help for any little bump in the road, potentially getting taken in by scams, and too many still aren't able to find help for more difficult or serious conditions. Despite the lack of standardized credentials, the demand makes mental health coaching a useful industry. 

Coaching isn't licensed. There are licensing organizations, but anyone can legally call themselves a coach, including a therapist who previously lost their license. A therapist, by contrast, is a protected term that comes with regulations. But the regulations aren't universal. 

It's complicated. 

About 48 minutes into this video with Forrest Hanson and Dr. Rick Hanson, they explain the key difference between coaching and therapy is that coaches can't treat psychiatric conditions. However, they argue, so much of what's happening in many therapy sessions is about social dynamics or feeling trapped, non-medical issues that are appropriate to address in other ways. Like the characters in Friends, most people in need of help don't have specific medical issues, so there's a place for coaches in mental health support despite the lack of standardization.  

However, it appears there's not really a standard for therapists in any universal sense either. According to the Hansons' video, therapists in California require 3,000 hours of supervised training in which supervisors actually directly observe or watch recordings of the sessions to be discussed with the trainee. In Ontario, getting an RPQ designation (Registered Psychotherapist Qualifying)  allows someone to call themselves a therapist and take clients after just completing 144 hours with clients in a practicum that must include just 32 hours of one-to-one supervision. Just 32! And that's often just a conversation about any concerns with clients from that week. Unlike a training therapist's supervision in California, in Ontario, supervisors are not required to watch or listen to any of the trainee's sessions or recordings of sessions. An RPQ designation can be granted before finishing school, and courses vary from place to place. An RP designation means the therapist finished school, saw clients for at least 450 hours, and met with a supervisor for 100 hours. 

There isn't nearly the rigour that's discussed by some American therapists, BUT RPs in Ontario ALSO can't diagnose or treat psychiatric conditions. The meaning of therapist is different across the border. Here, there are lines between psychiatrists, psychologists, RPs, MSWs, and coaches, all meaning different things and providing different services, despite the first four all typically referred to as therapists. MSWs in Ontario also can't diagnose or treat psychiatric conditions, so it's on par with an RP, which is very different from in the states. I'm a bit concerned that none of this is well known or understood. 

An RP typically learns a small selection of the over 200 different ways to do therapy, and then can pick and choose which ones to use, so any two therapists from the same school might practice very differently from one another. They all tend to be covered by insurance, but often for only 8-10 sessions each year, which encourages therapists to create brief treatment plans. -- Aside: As a teacher, I asked an insurance rep why we can get almost 100% coverage for meds, but can't see a therapist for more than 8-10 visits, despite the fact that anyone on SSRIs or any other kind of medical treatment for depression or anxiety should be seeing a therapist weekly. He didn't have an answer for that. -- Because typically coaching isn't covered by insurance, and it tends to be cheaper, sessions can go on for a longer period, but, of course, coaches can't provide any advice on medication (but neither can RPs or MSWs). Coaching is often just Motivational Interviewing: reflective listening, open-ended questions, validation, and rolling with resistance. The client leaves feeling heard and better able to notice and understand their internal conflicts without the coach needing the history and theory behind all the many, many types of therapy. 

Clear as mud??  

In an interview from last year between Dr. Mike and clinical psychologist Dr. Ali Mattu, they expressed concern that anyone in mental health can technically do anything, even though they might, ethically, be outside their area of competence, and they pointed a finger at the number of therapists on Psychology Today sites who list having expertise in a ton of stuff, which just isn't possible. According to Mattu, a practitioner should have years of experience in each modality (psychodynamic, CBT...) or issue (sleep, eating disorders, depression...) before claiming expertise, and practically speaking, it's not possible to be an expert on a long list, so those are all a bit suspect. Having a general understanding of many things is like being a family doctor, but their main activity is assessing the problem and then referring to an actual specialist. Family doctors don't also do orthopedic surgery and brain scans. The huge issue in mental health is there just aren't enough specialists out there. 

Coaches don't necessarily have training in discrete modalities, yet they might use the tools of CBT, for instance, but not officially do CBT because they're not trained in it, and I question what the difference looks like. I imagine it might involve acknowledging, "I'm not trained in this, but we can try becoming aware of your thoughts in order to stop negative self-talk and replace it with more accurate statements." I mean, I taught the bare bones tools of more popular modalities in my high school courses to give teenagers different ways to approach their own issues. It can be useful for everyone to recognize when they've been sucked into a negative thinking trap.

Dr. Mattu isn't about CBT though: 

"I haven't seen success in trying to get people to think differently. It's invalidating to discuss rational thoughts as if they're irrational.  . . . They need to gain experiences that lead to outcomes they want. . . . It's about inhibiting fear memories. . . . Engage with them, but you don't have to muck around with thoughts. . . . Have them realize where anxiety is coming from and give them power. If they can't access a therapist, then journaling is the next best thing."

I've seen these arguments back in second year university with the behaviourists prof at odds with the Freudians. Various modalities are always in conflict with practitioners arguing in favour of one or the other. But if journaling is enough when a therapist isn't around, does it even matter if we see a psychologist or an RP or a coach or manicurist if we're not in need of help for a diagnosable disorder??

He talks (at 56 minutes) about the huge role for coaches to provide help for overcoming stress, relationship issues, and other broad things. But because it's unregulated, people can build some bad habits that feel good with a well-meaning coach. I'm not convinced that's not also true of therapists and psychologists as well. 

And I'm not sure it matters at all for people not looking for medical treatment. I mean, you want to get what you pay for, but does having the best-educated psychologist out there necessarily guarantee the best quality of care? Is it possible to resolve more issues while getting your roots touched up? 

Like teaching, it all seems to be more of an art than a science. Only so much training can help. It's useful to know the basics, but connecting to the person in need might get us further than knowing the difference between DBT and EFT. Several studies have found a strong correlation between the "therapeutic alliance" - the strength of the relationship between counsellor and counselled - and the client outcomes, suggesting the relationship is more significant than the choice of therapies anyway. 

It's a good reason for not using AI for therapy. An article in Forbes argues AI outperforms radiologists at detecting cancer, and suggests, therefore, it might outperform in matters of the mind. But that ability to detect a subtle shift in tone and gaze and posture after a specific word is mentioned requires more than AI can muster. More importantly, we need a variety of people available in order to find the best fit, not a well-trained computer program.

If variety is key, then what if we all had a basic education in helping one another? 

I came across an old New York Times article, from 1974, about a few bartenders who were given a 15-hour course to help to actively treat patrons and help them find more professional care as needed. Their guidelines were that the patron must express interest in help; bartenders couldn't be judgmental or moralizing, and the bartender could offer a set of numbers to call but couldn't act as a broker in securing a psychiatrist. It seemed to be successful, but I couldn't find what happened to the program after that initial trial. 

More recently, there was a study conducted on almost 500 depressive patients assigned either to psychologist only or to a psychologist plus a HAP - a lay-person trained in a Healthy Activity Program who took additional appointments with the patients. The participants did much better with the HAPs. So having trained professionals at different levels of expertise can be an excellent model, but it would work better if integrated with non-professionals. This idea can be taken further, training everyone in school on basic mental health help. At the very least motivational interviewing techniques could be made common knowledge. It doesn't have to be in the hands of educators, who are already busy enough. It's already happening on social media. It's variable, and a bit hit or miss, but so is some mental health being taught ad hoc in schools, where some teachers are getting kids meditating en masse, unaware that some forms of empty-mind meditations could provoke traumatic memories in some kids by clearing away their defences before they're ready for it. 

Reflective listening would be a great start. It's explicitly hearing people out thoroughly instead of just waiting for a chance to talk. Mirroring what a friend says back to them lets them hear themselves, which is so simple and remarkably effective. Letting someone take a whole turn to just speak and be heard can be a mind-blowing experience at a time when we're all completely distracted by social media. And listening to people without judgment has tons of ramifications that can ripple outward. 

But there's another aspect that can make cab drivers better at hearing you than your closest friends. It's easier to listen from a detached perspective when you don't know all the ins and outs of the people involved in the story. Listening better can definitely improve relationships, but we still sometimes need those impromptu in-depth conversations within a larger community. We seems to have forgotten how important they can be, but it's not too late to recognize their value. The alternative can cost $200 an hour.

ETA this article from 2009 in which a psychoanalyst describes his own methods and explains that, "it escapes me how such practices as these can possibly be differentiated from good coaching." He thinks some prefer coaching because it has less stigma, but that the claim of substantial difference, "aims to insulate coaching--a profession in its infancy--from claims that it's therapy without a license." I think he's on to something there!  

And also this image (inspired by lungta's comment)

Also, this important bit of wise counsel: always think if someone's advice is actually right for you irrespective of their credentials! The most educated professional from the most prestigious school can still steer you wrong, and so can your bartender. 

Crossposted, more or less, at 3 Quarks Daily

(Images: Life Coach Jez from Peep Show, bartender and "listener" Guinan from Star Trek, analyst and therapist Tobias from Arrested Development, and Lloyd, the bartender from The Shining.)