Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?

Monday, November 30, 2009


According to this month's AARP magazine, Sting (the artist formerly known as Gordon Matthew Thomas Sumner) says that winter is "a time when we reflect. As global warming takes over, we're losing some important balance in our psychological makeup... we need that time to regenerate."

As Riley the parrot is fond of asking me, "Whatwhatwhat??"

We, who? Northern white male European honkies like Himself? What about all those people who live in the Torrid Zone? Africans must have been seriously psychologically out of balance for thousands of years, hunh. Central Americans, too. Wonder how they managed to produce some of those magnificent civilizations of yore without all that reflection and regeneration time?

What about all those people for whom it's all winter, all the time? By this theory they should have produced truckloads of "reflection". Inuits and Norwegians must have some kind of lock on psychological balance, hunh.

This is why people who (a) don't know anything at all about psychology, and (b) are so glaringly culturally short-sighted should never, ever pontificate about the subject. Especially not for attribution.

Thursday, November 12, 2009

You're not going to tell my parents about this, are you?"

How much privacy does a teenager have a right to in therapy?

Not much, actually, as it turns out. Here's why.

"Privacy" is how we typically think of the kinds of issues such as whether a parent has the right to go through a teenager's room, read his text messages, examine her browser history, or friend a son or daughter on Facebook. In that regard, how much privacy a child has will vary from culture to culture, and within a culture, from family to family, because it's a value question. As relates to a child's mental health records, "privacy" has to be distinguished from terms such as "privilege" and "confidentiality".

Legally, we have the right to protection from undue intrusions into our private lives, and that includes the right to have our medical records kept private. "Confidentiality" is the client's expectation, and our professional obligation, that we not further disclose the private information shared with us. A client can waive that by signing a release; in the case of a minor, only the parent or guardian can do that, and they can do it against the client's will if they wish.

"Privilege" is a special exception from the obligation to testify in open court to what we know from a client's communications in therapy. As such, privileged communications are protected from discovery, which means that they can't simply be subpoenaed. A client can waive privilege, and in the case of a minor, the parent or guardian can waive it--again, whether the minor wants it waived or not. If the client's legal representative makes his mental health an issue in a legal proceeding, that is an automatic waiver.

On the upside, most states allow minors to seek treatment without parental consent for such issues as sexual abuse or substance abuse, and in these sorts of situations of course the point is moot. By definition the minor will have control over his records.

So how much privacy a kid in therapy has depends on what kind of information-sharing we're talking about, and with whom. A minor client generally cannot act on her own behalf in that regard, any more than she can in any other legal matter. Ultimately it's going to be up to her parent(s) or guardian. And this includes the power to compel the therapist to discuss the child's therapy with the parents, and even to let them read the record. So the real question becomes, "How much right do parents have to information about their children's treatment?"

Legally, in most situations, they have every right to all of it. Practically speaking, however, privacy is a sine qua non for therapy. No teen is going to share any but the most banal of her thoughts and feelings if she thinks I'm going to trot (well, ok, limp) across the hall to the waiting room after our sessions to report to her parents, "Guess what your daughter just told me!"

For that reason, most of us who see minors try to negotiate the gap between what's legal and what's practical before therapy begins. We discuss the dilemma with the client and her parents. We ask the parent(s) to sign a statement agreeing that they will (a) not have access to the record and (b) be given only general information about their child's progress in therapy unless there is some threat to that child's safety.

This is the pertinent language from my Consent to Treatment paperwork:


Patients under 18 years of age (who are not emancipated) and their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the minor client or s/he and I agree otherwise. Because privacy in psychotherapy is ESPECIALLY important to progress with teenagers, it is my policy to require an agreement from parents that they consent to give up their access to their son or daughter’s records. I will provide general information about the progress of a teen’s treatment and his/her attendance at scheduled sessions—and nothing else. I will also provide parents with a summary of their son/daughter’s treatment when it is complete. Any other communication will require the teen’s consent, unless I feel that that s/he is in danger or is a danger to someone else, in which case of course I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the minor client, if possible, and do my best to handle any objections s/he may have.
The older the child, the more likely I am to obtain his permission, too, because it is a decision that affects the minor and I believe minors should progressively take more responsibility for their own lives as they approach adulthood. Developmentally, this is a gradual process, not an ability that manifests full-blown on the day a person turns 18. That, and being out of control of one's life not being a pleasant sensation: Anything I can do to increase a client's sense of power and control must therefore necessarily be A Good Thing.

So far, so good. Sounds simple, right? Well, no. In the first place, the written agreement may not be enforceable. Fortunately, most parents get the need for privacy, and, having the children's best interests at heart, will respect it. But if push came to shove, I probably would have to open the records to a parent or be in contempt of court. That's never happened in several decades in practice: My problem is more usually that I have decided I need to bring the parents in on something, and the teen does not wish to.

The second problem is, how do we define "danger"? Some things are obvious: A teen has suicidal ideation, a plan, the means to do it, and clear intent (like a time and a place) and I can't negotiate any solution in the session. A no-brainer, that. I pick up the phone and call the parents.

But what if the child is using drugs? Having unprotected sex? Does it make a difference whether it's pot or crack? Whether the sex partner is a kid his age or someone 20 years older? What if he's driving drunk? Or just driving too fast? Do I tell parents if a kid is ditching school?

Therapists constantly weigh these questions, and in practice different ones of us resolve them differently--depending on our values, the minor, the parents, and the situation. So in practice, there's a lot of variability. Some practices don't limit parental access at all. Others believe that minors, especially older teens, should be entitled to the same protections as adults, regardless of what the law says. In this view, the child is the client, and it is to them that we owe our duty of confidentiality. Thirty years ago, the American Psychiatric Association had a task force look at the matter, and they recommended that the age be dropped to 12.

The American Psychological Association is not much help. Their recommendations range from respecting a minor's privacy at the same level as an adult's, to establishing local policies in accordance with the law, recommendations which are obviously and completely contradictory.

So while legally a teen has little right to privacy, in practice most teens have complete, or nearly complete, confidentiality observed. But again, there's lots of variation. So if you are a teenager thinking about getting into therapy, or thinking about sharing something big with your therapist, my best advice is to ask her or him what her policy is, and what she might be likely to do in a given situation.

Wednesday, November 11, 2009

Tommy Bryan on World War I

My Mom's Dad had three war stories.

In the first, he is marching toward the front when his squad passes through an olive grove. He claims that he'd always loved olives and so began picking them from trees near the road, carrying them in his helmet and eating them on the march. Which apparently made him quite sick.

In the second, he is in the trenches, watching the little aeroplanes go over, thinking that was the place to ride out the war--safe home at base every night. So he applied to be a pilot, but was not accepted. I am glad, in retrospect, because while I certainly would have wished him out of the trenches, the death rate for fighter pilots in those days was staggering.

He did manage to transfer into a supply/transportation battalion and would spend the rest of the war driving food and ammunition back and forth from the front. He might not be at home base safe every night, but he would be most nights. In this, his third war story, he is driving toward the front and is close enough that he can hear the guns. His truck slides into a ditch, sort of accidentally on purpose, and he spins the wheels "trying" to get out until he is well and truly stuck there. He is happily sitting cantilevered into the ditch, eating a sandwich, when along comes a French tanker who insists on pulling him out.

He would giggle at this point, that funny hee-hee laugh of his, and tell us that no sooner did the tanker pull him out than he promptly slid back into the ditch. Again, the Frenchman, cursing, hooks up the chains and pulls him back out. Again, my grandfather, making a big show of his incompetence, slides into the ditch. The Frenchman throws up his hands in Gallic disgust and rolls on. My grandfather ends the story by telling us that was as close to the front as he ever intended to get.

I do not think my grandfather was a coward: Quite the contrary. He never spoke of his experiences other than this. You just could not get him to. My grandmother, however, once said that he came back from the war with his health ruined, and that it was years before he got it back. You don't ruin your health sitting in a ditch eating a sandwich and giggling. So I always believed that he suffered, as infantry did in that war, horribly, and was lucky to return home alive. And that it was a combination of modesty and discomfort with painful topics that kept him to his three-funny-story repertoire.

As an adult, and later as a mental health professional, I found this pattern pretty common. Vets tend to talk to vets, and to demur with everybody else.

My father in law never said much about his
World War II Navy service, either, but I watched him light up when he met my cousin who'd also served. They spent the whole time during that family gathering comparing notes on their experiences. On another occasion, we took my father-in-law to a movie about the Pacific war. I don't remember which one. But again, I remember how he perched on the edge of his seat, eyes riveted to the screen, excitedly whispering to us, "That's where we were. . . yes, it was just like that!" and so forth during various invasions and sea battles throughout the movie. And then not one word in the car on the way home, nor did he ever mention it again.

Vets are pretty sure we won't get it. They may be right, but we have to be willing to try. We owe them that, and so much more.

Sunday, November 1, 2009

Disturbed patient, disturbing therapy by St. Cloud psychologist |

Somebody on Twitter alerted me to this story. Briefly, a therapist got over-involved with two of her clients and was disciplined for it. The problem, at least as it is framed by the local newspaper, is that she has poor boundaries and poorer reality testing: As they so cutely put it, she believed the client's delusions more than the client did.

The line between a memory and a delusion is a fine one, especially in Dissociative Identity Disorder (DID). DID occurs in people who have suffered especially severe and often bizarre, but quite real, abuses while at the same time there is an unreal quality to the disorder itself. Real memories, in other words, quite commonly exist side-by-side with unrealistic beliefs in DID.

Therapists are not, and cannot be, in the business of validating clients' memories. However, when a client questions her/his own memories, we can encourage reality-testing by the client. In doing so we must not forget that perpetrators of abuse quite naturally go to great lengths to hide what they are doing, so that validating a specific memory may simply not be possible. We also need to caution clients against attempts to validate that may be dangerous, such as directly confronting perpetrators.

Sometimes the only validation available is indirect: We are working on a dysfunctional behavior in therapy, a memory surfaces, and the behavior “spontaneously” clears up. Other examples of indirect validation that come to mind include addicted and sexually-acting-out siblings (possible co-victims) and an arrest of a relative for a related crime. None of these things proves the validity of a specific memory, but it does lend credence to the client’s family portrait.

It is a myth, by the way, that a person has to remember in order to heal. Or that survivors have to remember more: To quote the late Ann D. McAllister, Ph.D., "What [they] already remember is more than enough." Digging for additional memories runs the risk of (a) producing "memories" that aren't, and (b) completely unraveling the client's ability to function in the present.

Since disbelieving real abuse can be as harmful as becoming part of a delusional system, the therapist serves the client best by focusing on current functioning. The focus of treatment becomes teaching the client to manage flashbacks, switching between alters, emotions, appropriate boundaries, insomnia, self-harm, addictions, self-image, etc. And the key phrase here is “teaching the client to manage,” not managing it for the client. Treatment for DID is emotionally intense, and it’s not going to happen without a degree of dependency developing. But throughout the therapy, the therapist maintains the boundaries of the working relationship and encourages the client’s independence.