Mark  Lipman, LMHC

WHY I PREFER TO WORK OUTSIDE INSURANCE

AND DIAGNOSIS

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All therapists are guided by ideas of how best to facilitate healing or progress, and this can inform anything from their theoretical approach to whether or not they take insurance. In my practice, I make every attempt possible to refrain from more standard ideas of mental illness under the assumptions of the Western Psychiatric Diagnostic Model (see more below). I generally do not refer to my clients' experiences using diagnostic language, nor do I use it in my own formulation of their therapy unless it is language that my client chooses because it is meaningful to them in some way.

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I believe that there are many issues with the diagnostic system by which therapists and other providers get paid through insurance. Mainly, I believe that DSM diagnoses and the way the Western psychiatric system generally uses them is not trauma-informed. Different diagnoses obviously carry different weight in terms of stigma. The more heavily stigmatized diagnoses (Schizophrenia, Borderline Personality Disorder, Bipolar Disorder, to name a few) have the real potential to hinder a person's belief that they can heal, change, or find a sense of belonging in their life. When we are called something that is synonymous with "broken," or "unable to be fixed," it can affect the way we think about ourselves, especially if part of our story comes from trauma or unwanted negative messages in our past. If we can find more meaningful language to define ourselves, we can open up the possibility to believe in ourselves as whole, as not the sole problem in the bigger picture, as able to enact change within ourselves and in our lives, as able to heal.

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The Western Psychiatric Diagnostic Model (also referred to as the Illness Model) works under the assumption that:

• The diagnosis is always located in one person. As far as I know, there are no diagnoses in the DSM that can be billed for the dysfunctional relationship between people, in groups, or in a society or culture. 

• Many diagnoses assume chronic, even degenerative conditions, such as Schizophrenia and Bipolar Disorder, or other Axis II (personality) disorders. These diagnoses frequently infer that a person cannot recover, and also leave a person subject to extreme stigmatization and fear of their own experience that adds undue strain to their mental health. Often times, the experiences that have lead to these diagnostic labels are related to trauma (personal/intergenerational/complex, etc.) or are simply misunderstood by way of Western cultural biases (e.g. "mania" vs "spiritual crisis/emergence"). 

• The best course of treatment via Western Psychiatry standards is to accept a diagnosis, and to believe--or at least behave as if--you have a problem (genetic, chemical imbalance, etc). This model does not encourage a person to explore their own experience in a way that would allow them to integrate it into their identity and explore a multitude of healthier storylines (as a whole person with a human experience). The Western Psychiatric Illness Model asks us all to assume that there is "something wrong with you."

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In my practice, using the framework of the "healthy narrative" model, I work under the assumption that:

• You are a person who is in relationship to many many things around and within you. Holding you wholly responsible for what has happened to you or what has resulted from lack of emotional support is a disservice to your autonomy, and is thereby disempowering. With my help, you can begin to release blame of self (unjustified shame and guilt) and also release resentment toward others. Healthy boundaries, autonomy, a sense of empowerment, confidence, self-love, self-responsibility, compassion, empathy and joy are a part of what has the potential to heal not just us, but all that we are in relationship with. 

• Therapy begins with me seeing you as able to heal with the goal of you seeing yourself as able to heal as well. This is regardless of any diagnosis you have been given or any experience you have had.

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FURTHER THOUGHTS

ABOUT THE RISK OF DIAGNOSTIC LANGUAGE

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To reiterate, diagnostic language locates a problem in one person. Even in couples and family therapy where the problem indubitably lies in the dynamics between people and where the solution lies in everyone's needs being negotiated together, one person must be identified as the problem-bearer in order for insurance to reimburse. This diagnostic label then stays on a person's medical record indefinitely. This all-too-realistic scenario means that, at any point in time, that diagnostic language may be viewed by anyone who has access to it, which leaves an opportunity for that person to view the client/patient as having a "disorder." There are a number of pieces to this scenario that I find unethical, including the idea already discussed regarding the inference that a disorder is located in an individual. 

 

It is a basic tenet of my approach that a group or a culture bears equal responsibility for the mental health of all within that group or culture. This is different from blaming someone else for our own actions, it is instead a simple agreement that we all take responsibility for our own actions and how they may affect others. It is also counter-therapeutic to infer that a person diagnosed with a disorder will always have that disorder, or that any reoccurrence of symptoms at any point is considered a part of the person's underlying disease process rather than considering it as withdrawal symptoms from psychiatric medication. Another basic tenet of my approach is to hold the hope that everyone and everything can and does change. I do not consider this unjustified hope. It comes from both my personal experience, as well as professional experiences of having witnessed a range of people come through their trials and into living fulfilling lives and reaching and exceeding their potential. Personal transformation and recovery are possible for both people with more commonly spoken experiences (e.g. anxiety/depression) and people with what would widely be considered "chronic debilitating diagnoses," such as Bipolar or Schizophrenia. Find more resources on these and other healthy narrative approaches on the RESOURCES page.

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OFFERING SERVICES TO CLIENTS FROM 

UNDERSERVED COMMUNITIES

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I want to express my awareness that those who choose a private pay therapist such as myself are more likely to do so because they can afford it. I imagine that those who can't afford private pay would also benefit greatly from a non-pathologizing healthy narrative approach. I try to offer flexibility and more affordable options such as sliding scale and group therapy. I am also part of the Hearing Voices Network community, and I encourage people to utilize the free resources and groups available through the Hearing Voices USA site.

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A NOTE ON THE COLONIALISM 

OF PSYCHOLOGY IN REGARDS TO

SOCIAL JUSTICE MOVEMENTS FOR BIPOC

AND ALLIES

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The history of the field of psychology is problematic in its establishment of a power dynamic along race, class, gender, and ableness lines. I am doing my best to actively learn about how to hold space for social change for myself and for my clients. My aim is to be able to provide a therapeutic environment where clients can explore and reflect on their role in the fabric of this change if that is a part of what they want to explore. See RESOURCES page for further education along these lines. It may seem sometimes like change is emotionally overwhelming, but I believe that with education, self-exploration, and conversation, we can work to help each other toward a better future together.