Hell

In you are here: Discovering the Magic of the Present Moment, Thich Nhat Hanh writes,

To me, the definition of hell is simple. It is a place where there is no understanding and no compassion. We have all been to hell. . . If there is compassion, then hell ceases to be hell. You can generate this compassion yourself. If you can bring a little compassion to this place, a little bit of understanding, it ceases to be hell.

Then he writes what, to me, is the perfect definition of the psychotherapist's job:

"Your practice consists in generating compassion and understanding and bringing them to hell."

The 24-Hour Experiment: Love Your Body

Yes, that's right. Love your body.

Identify something your body can still do right (and it's doing something or you wouldn't be reading this. Then appreciate it. Tell your body you appreciate it.

Then for 24 hours, treat your body like you would an adored child. Rest it, wash it, dress it, and feed it like you would a precious infant. Play with it. Talk to it.

Bigotry is not a mental illness. . .

Image via Wikipedia

. . . and neither, ladies and gentlemen, is domestic violence.

I had planned on another A.A. blog post today, either about individual members who try to cram their personal God down your throat, or what to do about the ones that want you to stop taking your meds "or you're not really sober."

But then, alas, up pops yet another female apologist for Mel Gibson, and I just couldn't let this one pass. Alicia Sparks is a layperson who writes for PsychCentral, which I usually recommend but am lately having doubts about.

"...think about why Mel Gibson (and anyone else, for that matter) has done these things," she writes.

OK. Here's my theory:

1. He drinks because he is an alcoholic.
2. He abuses women because he hates us. And because he can.
3. He uses intimidation, threats, and physical force to get his way.
4. He's bigoted because, well, because he's a bigot.

Ok, Ms. Sparks. Next?


"The verbal abuse and threats were bad, yes."

"Bad?" Oh, oh. Anybody else here see a minimization coming? Sure enough:

"The physical violence was bad, too (if there was any – there’s now speculation as to whether Gibson actually hit Oksana Grigorieva in the mouth, as she claimed, or if that all plays into the extortion theory)."

The link takes you to a brief Entertainment Section story which refers to photos Ms. Grigorieva has given to the police of herself with damage to the veneers on two teeth. Apparently, "sources familiar with the medical charts, photos and examination notes of Grigorieva's dentist indicate there is no evidence Oksana was struck in the mouth."

Well, no sh*t, Sherlock. How could there be? Unless the dentist got DNA off Mel's fist from between her front teeth, all he can say is whether her injuries are "consistent with" or "not consistent with" being punched in the mouth. What he actually said in a sworn statement was that she showed signs of blunt force trauma, and that he was concerned enough for her safety to offer to shelter her himself.

So first, you have a non-professional blogging on a psychology website. Second, she's citing entertainment pieces as if they were investigative journalism. Third, she's accusing Ms. Grigorieva of extortion, and doing it without the courage to come out and say it directly herself, using the mealy-mouthed "there's been speculation".

OK, just for the sake of argument: I think I'd like to strike out on my own with a child, leave my husband. I think that I will cause myself some extremely painful, potentially permanently disfiguring injuries, and tell him if he doesn't give me money, I'll claim he did it to me. Does that make sense to anybody? And does anybody really think that Grigorieva bruised their daughter herself, to make money??

For what it's worth, the police have opened an investigation into the DV allegations. They have not opened one into the extortion claim.

Sparks is also conveniently ignoring two other little minor details, that being Ms. Grigorieva's description of the alleged incident on tape, followed by a little snappy repartee from Mel, to wit, "You know what? You f**cking deserved it." And then there's the photo of the baby, with bruises.

Details, details. 

Next, Sparks asks,

But even amidst all that, it is possible to eventually set aside the inevitable shock and confusion and anger and evaluate the situation. If indeed Mel Gibson is suffering from untreated mental illness, which would be better: Hoping he seeks (and benefits from) professional help, or writing him off as a lunatic lost cause?

Here, the logic breaks down entirely. But let's try to follow it.
#1. Who's confused? You? Not me. I see a clear case of domestic violence here. Yeah, yeah, I know, innocent until proven guilty and all that, but we are not in a court of law. This is a blog.
#2. If indeed, Mel is mentally ill, what does that have to do with anything? Domestic violence is not a mental illness. It is not even about mental illness. (It is not about anger management either, but that's another rant for another day). No, ladies and gentlemen, domestic violence is about power and control. Period.
#3. Bigotry is not a mental illness, either. Not as it is expressed in racism, anti-semitism, or hatred of women.

I defy Ms. Sparks to find me even one sloppy study that shows that bigots or wife-beaters can be helped with diagnosis and treatment of a mental illness.

Alcoholism, of course, is a disease. However, I would also like to see the study that shows that sobering a guy up will make him quit spewing hate-talk, making anti-semitic movies, and hitting people.

Just one. Even a sloppy one.

#4. Mel, according to friends quoted on MTV's website (yet another shining example of investigative journalism, I know, but there you are), is already in therapy. And he already knows he needs to quit drinking.

So what, exactly, is Sparks' point here? Is she saying he shouldn't be held accountable for what he's done? Does she want us to give him a pass?

#5. Who's writing him off? There's a straw man argument if ever I heard one.

No, going back to the title of her piece, I think what she wants is for us to have compassion for him. So I looked it up. Compassion means "deep awareness of the suffering of another coupled with the wish to relieve it."

Funny thing, that describes exactly how I feel about Ms. Grigorieva. 

Suicide, again

Jolene over at Graceful Agony had a suicidal person Google her blog on the way to trying to find out "the best drugs" to kill herself with.

Jolene's response is thoughtful and on the money, so I'm going to limit myself to putting up a link.

Blue Cross Blue Shield Of Georgia Is Skimping On Mental Health Care, Says Georgia Psychological Association

This story is from last year. I found it when I Googled Blue Cross/Blue Shield tonight looking to download an Outpatient Treatment Report form for a patient. Given the problems I've had recently had getting treatment re-authorized, I also downloaded a 50-page explanation of what Blue Cross/Blue Shield considers "medically necessary". You can read that for yourself here. I found it enlightening.

Because I am on their panel and neither wish to be tossed off it nor to have clients convicted by association, I'm not going to say anything more.

You can read the article for yourself as well:

Blue Cross Blue Shield Of Georgia Is Skimping On Mental Health Care, Says Georgia Psychological Association

Enjoy.

Why I Hate Managed Care in General, and the Medical Model in Particular

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So this arrogant psychiatrist in another state, who has never met nor spoken to my patient, decides in less than 10 minutes on the phone* to deny coverage for depression and ADD because she's made only minor progress in 12 weeks of outpatient psychotherapy ("three months!" quoth he, obviously horrified).

Oh, yeah, and because she's not getting "standard" (read: "cheaper") treatment, to wit, psychotropics.

He actually asked me why I was asking for more sessions! Um, because she's still depressed? still has family issues? Still doesn't know what she wants to do with her life? After all, he says, it's not working, is it?

Yes, it is. It may be slow, but it is working. Her problems have been years in the making and we're not going to turn them around in three months. He seemed astounded by this concept.

He implied more than once that my treatment of her was substandard. She wants a non-drug solution and I'm not forcing the issue, partly because her depression is moderate, therefore not an emergency, and partly because most of it is environmental in origin, not endogenous. As for the ADD, well, it is definitely holding her back, but it's not going to kill her, and I see the decision whether to medicate or try adaptations and accommodations as a personal one. I respect patients' ability to make decisions like that for themselves, and support their right to do so.

And by the way, the standards of care are written by--wait for it--the American Psychiatric Association.

Not to mention, success with medication is hardly guaranteed. I have had dozens of patients who have not responded to medication after medication after medication. Do insurance companies then want to stop paying for any more drugs? No. This is about money, pure and simple, and it pisses me off. This, people, is why we need national health care.

So if your insurance company doesn't want to pay for ongoing psychotherapy, fine. If it doesn't fit within their definition of "medically necessary," fine. I get that, and I have no problem with it. But don't imply that my work is substandard, dude. Do not go there.

*actually, he'd clearly already made up his mind before he even picked up the phone, based on a one-page request form I'd faxed in. I suppose I should have claimed "moderate" progress on the form. Her role functioning has improved because she's learning to structure herself better ("yes, but is her concentration better?" the insurance company care manager wanted to know) and she's made one of the major life decisions she came here to make. But I really feel we're just getting started. "Moderate" to me implies that we're about halfway through. "Major" progress would be close to the end, right?

While I was writing this the care manager called to see if I wanted to appeal. You betcha! And she pointed out that this all happened because I didn't return their calls quickly enough to suit them. I got passed on for this "peer review" thingy (Do you really think he's my peer? Do you think he's got a doctoral degree in psychology and 30 years experience providing psychotherapy?) partly to punish me.

Anyways, if I had, she went on to say, she "might" have given me two more sessions!! to get the client to agree to a med consult.

Makes me want to set my head on fire. 

Mental Housecleaning Time

"What's on Your Mind?" is the prompt for Facebook status updates.

Recently, I've noticed that there's a lot of junk on my mind, much of it unpleasant and worrisome. We unconsciously shovel in junk all day with the news, tv shows, and even the books we read! So after serious consideration (and one of those "last straw" experiences) I'm giving up reading fiction with any form of violence in it.

Which means most of my beloved murder mysteries and thrillers. I used to love, for example, the Dick Francis mysteries because they were all about horse racing. And you know how I feel about horses. But the novel I've just finished involves bad guys abusing horses, and one disturbing mental image in particular stuck with me long after the book was done. And I thought, why would I traumatize myself like that on purpose? Don't we have enough in our real lives to worry about as it is?

Jon Kabat-Zinn suggests that we think of what information we take in the same way we think about our diets: Pay attention to what floats up unbidden in your mind from things you've read, heard on the radio, or seen on tv. Be mindful of what you shovel in during the course of a day. See what you might want to change.

I can't believe I p***ed away the whole morning on this, or

OMG! Someone's wrong on the Internet!

I had other things to do this morning. Lots of other things to do. But this is a subject that absolutely gets my blood boiling, because I believe it is harmful to steer people away from AA and its sister programs. This is my entire response to yet another gross misinterpretation of 12-Step philosophy. Basically, the poster conceptualizes mental health treatment and addiction recovery as opposing forces, compares AA to Scientology, and calls 12-Step programs blaming, punitive, and  "dangerous". I am not giving a link or naming the poster, a professional who is at least in part touting her book with her post, as I have no wish to give her argument any more exposure than it already has. Since, unfortunately, she is a guest-poster to a site I used to have in my blog roll and some of you may have read her already*, I am posting my response, verbatim, here:

[Poster] claims that AA is anti-treatment. This is totally not my experience, not as a recovering alcoholic 24 years sober, not as a psychotherapy patient, and certainly not as a psychotherapist with 29 years in clinical practice.

Alcoholics Anonymous (the Big Book) states quite clearly that medical professionals and medications have their place. Other officially-sanctioned AA literature includes brochures and pamphlets on mental illness, medications, and recovery. What is discouraged is medication that merely replaces (by mimicking the effects of) the alcohol/drug of choice (e.g., Valium, Xanax). In meetings it's called 'taking your alcohol from a prescription bottle' or 'taking your alcohol in pill form'. It is the abuse of prescription drugs and the naïveté of physicians who keep handing them out that AA sponsors worry about, not appropriate treatment.

Alcoholics and addicts are experts at obtaining prescriptions that they don't need and which may interfere with recovery to the point of precipitating a relapse to the drug of choice. Old-timers recognize this drug-seeking behavior when they see it because they spent many years doing it themselves, and warning against it is not "bad advice". It may save a life.

My professional and personal experience is that very few groups will tolerate the handing out of advice. It's one form of "cross-talk" when it happens within the meeting itself, and is actively discouraged if not forbidden outright. Sharing in meetings is supposed to include our "experience, strength, and hope". When we tell our stories we share "what it was like, what happened, and what it is like now". This basic instruction is read aloud at the beginning of every meeting. It means that when a topic is introduced, we share how we use the Program to deal with a given issue--not how you should do it. "Take what you want and leave the rest" is an oft-repeated slogan in 12-Step groups.

In the context of fellowship outside the meeting, telling another member what she should or should not do is considered to be working the other party's Program instead of your own, a sign that you at a stuck point in your own recovery process, and is similarly discouraged. While we will point it out if we think a person we are sponsoring is engaging in (pre-)relapse behavior, rarely, if ever, would a member with good quality sobriety tell another member not to take their medication or not to see a given professional.

Even so, of course some members will dispense bad advice. We're only human! The Program offers a built-in protection against that, as members periodically remind themselves and each other that for successful recovery one must place "Principles before personalities". In other words, keep the big picture in mind. Don't let one person's bad attitude or general wrong-headedness get you off track.

[Poster] is right about one thing, though: Of course nobody wants to hear about your diagnosis at meetings--because that's not what meetings are for. AA members recognize that they are not professionals and are not equipped to treat mental illness. AA can be independent, primary, or supplementary, to mental health treatment, but is not in competition with it. Meetings are for getting clean and sober. They are for talking about the solution rather than living in the problem.

The whole point of working the Steps is to learn to live life on life's terms, which is to say, clean and sober regardless of what happens to you inside or outside of your body. Got a funeral to go to? A divorce to get through? The Steps teach you to handle it sober. Talking about how you can't handle it will not. (That, by the way, is a basic principle of Cognitive-Behavioral Therapy--not anti-scientific at all!) Depressed? Working a good Program will get you through this episode sober. Sitting around talking about your depression will not, and anyway, you can (and should) do that in therapy.

This may sound cold, but it is not. It is practical. Raise your issue in the meeting then take the cotton out of your ears, put it in your mouth, and listen to how people who are happily sober many years longer than you handle similar situations in their lives. You may learn something. Again, far from being anti-scientific (or even lacking in common sense), modeling is a basic principle of learning theory, intuited and put into practice by recovering alcoholics decades ago. AA is like dust-bowl empiricism: We use what works.

Old-timers hold newcomers accountable because they ARE accountable for their behaviors, as is everyone else trying to live life as a mature adult responsible member of family/society. Relapse is a behavior, a decision, a choice. Alcoholism is not. It is a disease. But now that you know you have this disease, you are responsible for your recovery. AA does not hold people responsible for their mental illnesses any more than they hold them responsible for being alcoholics.

"Think before your drink" and "the time to call your sponsor is before not after" are no different than our expectation as therapists that a cutter or suicidal patient be responsible for her recovery by picking up the phone to call us before she picks up a razor blade or a gun.

Nor does AA apply consequences for relapse. When your patient returns to his home group to pick up another white chip (think behavior therapy tokens) after a period of 'going back out to improve on his story', he will be greeted with a chorus of "Welcome back!" and hugs, not punishment. Relapse has its own natural consequences--another basic learning theory principle intuited by Bill W. and the other originators of the Program.

Most, if not all, AA members have struggled with symptoms of anxiety and depression at some time, if not chronically, and many may qualify for formal diagnoses. Child sexual abuse survivors, for example, are heavily represented in women's meetings. I believe you would be hard put to find a home group that has not lost at least one member to suicide. So the old-timers know exactly what it's like to suffer from emotional pain. The Big Book from the First Edition addressed the dual-diagnosis issue directly in the Promises, where it reads that even the severely mentally ill can achieve sobriety if they are capable of being honest. But old-timers also know that drinking when you are feeling blue or antsy not only will not help, it will inevitably make symptoms worse: Statistics show that alcohol is directly involved in a significant proportion of suicides, and AA members are more aware than most of this connection. The quip heard in meetings is that "I never had a problem that was made better by pouring liquor on it".

Because of AA's acute awareness of the consequences of untreated mental illness/addiction, "hitting bottom" does not mean abandoning a person to his own self-destruction. AA members fully appreciate the dangers therein. However, just as in therapy, the person needs a certain amount of motivation to succeed in recovery. All "hitting bottom" means is becoming sufficiently "sick and tired of being sick and tired". Members compare it to being on an elevator going down: You can get off on any floor. But sobriety is not something you can impose from the outside in: It's an inside job. AA members reach out to the suffering alcoholic as part of their 12th Step work, but at the same time recognize that the newcomer has to "want what we have and [be] willing to go to any lengths to get it" in order to resist the siren call of alcohol.

In short, AA as a whole--completely unlike Scientology--is hardly anti-treatment, never mind anti-science or lacking in common sense. C.J. Jung had a lot of input into the early development of the Program. As noted above, a lot of common-sense psychological principles are incorporated into it.

Many members come to the Program through treatment, because it's the rare addiction program that does not incorporate required attendance at AA meetings as part of the treatment plan. AA, NA, CA, and other groups meet on treatment-facility campuses. Off-campus groups send representatives to host meetings in hospital facilities, serve as temporary sponsors, or meet one-on-one with patients. Many, if not most, of the staffers in these facilities are recovering alcoholics/addicts.

I have personally seen a pair of old-timers bundle a newcomer into their own car and drive her directly from her first meeting to a treatment facility, recognizing as they did that she was in withdrawal and needed professional attention, STAT. Members routinely refer each other to their own psychotherapists and psychiatrists, many of whom are in recovery themselves.

Real world, then, the overlap between mental health and addiction "cultures" is nearly 100%. Setting up a false dichotomy like treatment-vs-recovery tears a great hole in the safety-net fabric for alcoholics/addicts to slip through, potentially falling to their deaths. It does this by providing them with an excuse not to participate in real recovery, to wit, "My therapist says it's a cult". Just going to psychotherapy alone is a softer, easier way, and if we enable people to do that, the choice is a no-brainer for the active alcoholic/addict. And it won't work. We can practice our empathic listening skills, pretending we are doing something to get them clean and sober and feeling good about ourselves, until we coddle our poor victims of mental illness right into the grave.

"Poor me, poor me, pour me a drink" is not just a slogan, it's a real and deadly phenomenon.

My professional experience over three decades is that I cannot get patients clean and sober without their active 12-Step involvement. In all that time I have never once found either the Program or its members to interfere with someone's mental health recovery. I have, of course, often had clients engage in splitting between the therapy and the Program, and I am reasonably certain they employ the same defense in reverse when they are at their meetings. Seasoned therapists in possession of a deep familiarity with personality structure, the dynamics of addiction, the process of good psychotherapy, and with how 12-Step programs work, however, will recognize that for what it is and work through it with the patient to the latter's ultimate benefit.

AA has succeeded in helping many people who were formerly considered hopeless causes, and they've done it in a completely transparent manner, from the publication of the Big Book (probably the original manualized treatment!) forward. Furthermore, they do it entirely through the efforts of volunteers who wish only to give of their time and energy to share what they have found with the still-suffering alcoholic. It is a gross insult (not to mention, a false analogy) to compare AA to a secretive cult that charges its members each hundreds of thousands of dollars over a lifetime for a completely bogus process. All AA asks of you is that you put a buck in the basket if you have it, and that you stick around to "pass it on". You do your patients a grave disservice when you compare individual A.A. members to a manic, over-paid actor who publicly insults people who seek treatment for emotional problems. You do them a disservice when you dismiss all the people over the past six decades who have found sobriety and a new life through the Program as lacking common sense.

*Also, because it is so ridiculously long (longer than the original post!) that it may not make it through moderation.

I guess I'm just a sentimental old fool

Image by George Eastman House via Flickr

"I'm a dog person," I told my client. "I'm going to cry right along with you." And I did.

I have cried with clients before. I have cried with women whose fathers were dying, couples whose children died, and once even at a wake for a client who died. But mainly, I cry when people's dogs die.

I can only hope that it's therapeutic. Because I really have little choice except to proceed. I mean, what am I gonna do, say, "Sorry, I don't 'do' dogs"? Because really, I do dogs. I am, after all, a dog person.

I feel your pain. 

I have always had dogs. There was a dog in the house before I was born. I got a puppy of my own for my seventh birthday. Starting with her, I count six who have blessed my life with their love, companionship--and in some cases, sense of humor--over the years. They have, variously, served as playmates, bed-warmers, bodyguards, co-therapists, physical fitness trainers, and travel companions. I loved every one, each in her or his own way. I have grieved the loss of five, and I can tell you that it never gets any easier.

We're supposed to be objective professionals. But lose your dog? I will lose all objectivity.

Huzzah, anyway

Apparently, some time last weekend, while I was distracted by all the kooks likening Mr. Obama to Hitler, the former snuck through a law to make pharmaceutical companies reveal in detail their payments to physicians, including which drugs they are flogging, where, and when. Doug Carlat writes:

It is this kind of granularity of information that will truly make doctors think twice before pursuing careers as hired guns.

Probably not, actually. Some docs, by virtue of the nature of their caseloads (geriatrics, families on welfare, psychotics, etc.) can pretty safely bet that their patients will not even know about the law, never mind have the computer access, cognitive capacity, or general literacy to do the research. Others will do the math and figure out that they are still better off as hired guns.

For example, if one makes $23,000 a year selling, say, one of the newer antipsychotics, one would have to risk losing 230 appointments per year just to drop to the break-even point. How many psychiatrists have 57 patients (each seen quarterly =  228 appointments) who are (a) going to look up this information, and (b) quit over it and go looking for a new doc? Out of those, how many will have the option of finding a doc who's geographically accessible and takes their insurance and is taking new patients and treats their particular problem? And who cares? Psychiatrists are generally booked months out: There are always more patients where that 57 came from.

Still. Some patients will, and even one life saved will be well worth it.

And colleagues like me can (and hopefully will) look up each and every doc to whom we refer, and alter our referring habits accordingly.

Huh?

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I mean, what is it with Jason Aronson lately? Once the premier publisher of psychodynamic literature, they've gotten embarrassingly sloppy lately. Seems like everything of theirs that I pick up these last few years desperately needs editing: Their books are riddled with errors ranging from the merely distracting ("eliotogical" for "etiological") to the completely obfuscating.

As an example of the latter, I hereby challenge you to tell me just what the heck the the following sentence is supposed to mean:

Vaillant demonstrated that there is a very high correlation between the severity of a person's alcoholism and social deviancy/consequences, and the assessment and identification of these related factors has a much higher reliability than the measurement 'of ephemeral concepts of loss of control or alcoholism p. 17' and subjective reports on consumption levels.

Other than the obvious "p. 17" thingy floating there where it does not belong, I'm not even sure where the error is. Is Vaillant saying alcoholism is an ephemeral concept that can't be reliably measured in the very same sentence in which he is telling us it can be reliably measured? Surely that is not it, because the author is too critical a thinker to let that one pass. Perhaps the very occurrence of the word "alcoholism" in the second clause is itself in error. Or could part of the sentence be missing? I just don't know.

I give up. I've been studying on it for some time now, but I just can't sort it out.

This was at least the fourth error in 19 pages. There is "integratetively" on p. xi, a misattributed--or unattributed, it's difficult to say--quote (p. xii), and "lightening rod" (p. xiii). So far, we're running right at one error per page--and we're not even out of the Foreword yet, which was written by a Harvard professor, for heaven's sake. I think it's a safe bet these are not his errors any more than the Vaillant mish-mash is the author's.

The whole thing reads like it hasn't even been edited: One wonders if the new owner (Rowman & Littlefield Publishers, Inc.) laid off all the Aronson editors in one fell swoop during the takeover. Regardless of the cause, an error on every page is inexcusable.

(Although I will say, I kind of like "integratetively". That probably ought to be a word, except that it reads a bit like a visual hiccup, and is somewhat difficult to pronounce. So, well, maybe not.)

But to get back to Aronson, the shame of it is that this is a meticulously researched book by one of the greatest thinkers in the field. Aronson ought to hang their heads over how poorly they've served this author.

The last book published by Aronson that I tried to read, a collected work on technique, was so badly edited that I could not understand the first article at all. I am not exaggerating: It really was that badly mangled. It might as well have been written in Cuneiform. I didn't even try to finish that book.

Those of you who know me might, understandably, at this moment be thinking to yourselves, "Aw, that's just her being her usual hypercritical self." Alternatively, some of you may be thinking I'm just not smart enough to understand, say, a book on technique. So let me just mention here that I am also currently reading van der Kolk's latest on trauma therapy, and having no such difficulties with it. That book is no walk in the park, intellectually speaking, but if it is not 100% error free, I haven't found the goof-up yet. And that it is well-edited allows it to be not only understandable, but enjoyable.

By contrast, this current tome will be the last Aronson publication that I will ever spend money on. I had really looked forward to reading it, but it's being very frustrating. I'm not naming it, although technically I suppose I should in order to appropriately credit the source, but I deeply admire the author and am reluctant to slam anything that he's had anything to do with, especially in a manner that would pop up in a Google search on his name. And as I say, it's not just this book, this author; it's everything Aronson has touched lately.

It is my fervent hope that the author will find a new publisher for his next work.

Therapeutic Texting

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My young client arrived in tears. Seems she'd not only had problems with a date this week, but also with the friend to whom she'd turned for support. A good deal of these problematic interactions had taken the form of text messages back and forth between the three of them. My client scrolled back to some earlier texts to quote both the date and the friend.

And then, and this is where it gets interesting, while we were talking about all this, she received a text and dashed off a response. I considered asking her not to do that during the session, but what the heck? Here was the very interpersonal issue we were discussing unfolding in the here and now! So I sat back and waited.

Pretty soon, the little phone buzzed with a response, I asked her about it, and so it began: We would talk a bit, she'd send a text or receive a response, and we'd process them. The whole thing was most interesting, and different from work I've done in the past. People have printed out e-mails before and brought them to therapy, and have even brought their laptops in to show me MySpace pages, but this is the first "live" internet interaction I've processed in session as it unfolded. I think it was productive.

Having the actual texts as they unfolded gave us accurate data from her interpersonal world as a basis for discussion of gender roles and expectations--this gave the work a here-and-now immediacy, vs. the there-and-then that is all too often the stuff of psychotherapy. In the course of the hour we were able to establish that she doesn't like confrontation. Smart, perceptive, and funny as hell, she responds with sarcasm when wounded. She is a feminist. She is highly empathic and tries to be supportive to the important people in her world, yet finds herself again and again in non-reciprocal, sexist relationships.

If I have a problem with how the session unfolded, it is that if one has needs that aren't getting met in one's relationships, then the phone is a tremendous distraction from the face-to-face opportunity to get those needs met, available right here, live and in real time, in the therapeutic relationship. So I guess I wouldn't want to do this every week. But today? Cool.

#7: Patience is a virtue

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Patients occasionally (okay, frequently) express impatience with their progress in therapy. Impatient with themselves, they become impatient with me for not fixing them faster. And they worry that perhaps I am impatient with them for not doing more, better, faster than they actually are. 

Wood's Rule #7: Patience is a virtue

Because cultivating this virtue helps you "cease contributing to your own suffering and confusion and perhaps to that of others", Jon Kabat-Zinn¹ describes patience as a "fundamental ethical attitude" (1994, p. 48).

"From the perspective of patience," Kabat-Zinn writes, "things happen because[emphasis added] other things happen" (p. 48). You get sober, whether sooner or later, because you got drunk. The teenager you've brought to me for therapy will develop maturity and judgment (eventually) precisely because he has been immature and impetuous. For that matter, we can only learn patience who began our journey with impatience.

And if that is true, then it is also true that

what will come next will be determined in large measure by how we are now. This is helpful to keep in mind when we get. . . frustrated, impatient, and angry in our lives (p. 50). 

What will being impatient and irritable right now this two seconds create in our next few minutes, days, weeks, or months? Years down the road, what quality of life will all this rushing around and crankiness have produced for us?

So I would remind my patients to, in Kabat-Zinn's words,

. . . [remember] that things unfold in their own time. The seasons cannot be hurried. Spring comes, the grass grows by itself. Being in a hurry usually doesn't help, and it can create a great deal of suffering--sometimes in us, sometimes in those who have to be around us (p. 48).

It's how I think of you when you are struggling, when you have hit a wall. I know that I cannot make a flower bloom, or control its form and color when it does. All I can do is make sure to plant it where it receives enough sunshine (but not too much); then I must water and fertilize it (but not too much). It grows on its own, in its own time and in its own way. And so will you, dear, so will you.

Kabat-Zinn closes this chapter, poetically titled "The Bloom of the Present Moment", with a quote from Lao-Tzu:

Do you have the patience to wait
till your mud settles and the water is clear?
Can you remain unmoving
till the right action arises by itself
                            -from the Tao-te-Ching 

If I allow myself to become impatient in session, then I act before my mud has settled. It is not likely that anything that I do will come out of right mindfulness or right understanding. To the contrary, it is highly likely that I will do something to make your journey harder, or longer. And that would be unethical.

 

1. Kabat-Zinn, Jon (1994). Wherever you go there you are: Mindfulness meditation in everyday life, pp. 47-51. Hyperion: New York.

The Carlat Psychiatry Blog: WebMD's Big Lie

The Carlat Psychiatry Blog: WebMD's Big Lie

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Just Who the Hell Do You Think You Are?

In which Dr. Phil scolds a family, and I scold him

I came home early from work Friday, and caught a snippet of an ad for Monday's episode of Dr. Phil. I must say, the experience was a bit like coming home early and finding one's partner in bed with someone else. What I saw, however, was not Mr. Wood in flagrante delicto, but Dr. Phil verbally abusing a patient.

I caught Philip Calvin McGraw shtupping my beloved profession. And I have a few things to say about that. (You knew I would, didn't you?)

But first, the disclaimer: I do not watch the show. I do not believe that work around such personal, private issues should be done on national television. We are ethically bound to work exclusively in the patient's best interest, and this is in no one's interest that I can make out other than Philip Calvin's. I could not bear to watch another psychologist exploiting people's pain for money, or to get his narcissistic needs met. It would make me physically ill. And because I don't watch, I have no idea what is clinically indicated in this case.

Here's what I do know. You don't yell at patients. Never. Not for any reason. It's abusive, it's incompetent, and it's unethical.

Among the basic Principles that form the foundation for our Code of Ethics are the following:

Principle A: Beneficence and Nonmaleficence Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally . . . .
Principle B: Fidelity and Responsibility
Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct. . . .
Principle E: Respect for People's Rights and Dignity
Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. . . .

Back when I was a young grasshopper just starting out in the profession, some of the elders in the therapeutic community here liked to distinguish between two groups of therapists--huggers and hitters. Generally speaking, women were said to be huggers (literally and figuratively speaking) and the male therapists mostly tended to be hitters (not literally, ok?). I'm a hugger. McGraw obviously considers himself a hitter.

Even allowing for differences in therapeutic style, the man is going too far now. This is beyond Reality Therapy (anybody here besides me old enough to remember William Glasser?), beyond tough love. This is verbal abuse. "Who the hell do you think you are?" and calling a female client "Sister" in that tone of voice is inexcusably disrespectful. Telling her "It's time to grow up!" is not therapeutic, it's insulting: He might as well have told her that he thinks she's being childish. She's sitting there frozen, wide eyes fixed on him, tears rolling down her face. And speaking of hitters, if she'd ever been hit in her life I'd be willing to bet that at that moment she was physically afraid of him.

It's incompetent. Everything a patient does or does not do, and I do mean everything, is grist for the mill. All behavior has meaning, and the single best tool we therapists have in our armamentarium is the analysis of behavior. Part of what he was yelling at the patient for was not showing up for appointments and walking out of a session. After, and only after, he analyzed his own behavior for technical errors, McGraw could have gained a lot of mileage in the therapy by helping her analyze her own feelings, thoughts, and actions.

Any time we offer an observation, an interpretation, or some other intervention, we pause, observe the patient's response, and adjust our next move accordingly. The patient's response is the measure of whether we've got it right or wrong, so that if I were to say or do something that resulted in a patient getting up and leaving the room, I would have to automatically consider first that I screwed up somehow. This is so obvious I can't believe I have to say it.

So I look at myself first. Have I made the patient believe it's no longer safe in my office? Maybe I triggered overwhelming anger in her which she does not feel ready to handle yet. Regardless of the exact nature of what just happened, most likely the power differential between therapist and client prevents her from thrashing it out with me one on one. Whatever, she's not being bad. I have made an egregious therapeutic blunder of some sort, and she's taking care of herself the best way she can.

If I can get her back in the room, it will be my job to make this a safe space again to start the process of analyzing what happened, to apologize if necessary, and to help the patient learn from it something that is useful to her. Telling people to be different than they actually are is not therapy. Also, it doesn't work. You might as well yell at the weather for all the good that it will do you.

It's disrespectful, too. To be a good therapist, you have to believe that everyone has in themselves the potential to grow into their own best selves. Imposing what you think is a person's best behavior upon them not only ignores what they want for themselves, it discounts their own abilities to get it. McGraw is telling this woman by his behavior that he knows what's better for her than she does (she's stupid) and not only that, he's going to do it for her because he doesn't believe she can (she's weak). McGraw even talks on his website about "giving" people tools, as if they were his to give.

On the other hand, helping a client see that she can use words to deal with feelings instead of acting them out, that she has the power thereby to make changes in a relationship, helps her find within herself a capacity she has always had but has lost touch with. She will never again believe that when she runs into problems in a relationship that she has only Hobson's Choice between staying and taking abuse/neglect, or walking out. A good therapist can in this way turn potential therapeutic disaster into personal growth for the client.

If she's truly responding to something internal--especially likely in a trauma survivor--then my job is still to get her back in the room any way I can and help her analyze it. This probably happens elsewhere in her life and by understanding herself better she can get some control over her reactions and learn some better tools for handling them. She will only do that if she feels safe with me to explore her internal reality. That won't happen if I'm busy yelling at her.

Yelling, getting angry at a patient, is not about the patient's therapy any more. It is about using the power inherent in your professional role (and perhaps also in gender, racial, class, and other differences) to gain control of another person's behavior. It's now about the therapist and the therapist's needs, not the patient's ultimate welfare. What we have in McGraw's clip is an older male authority figure yelling at a younger, female client. This is a flagrant abuse of power, and as in any abusive relationship, it is about controlling the victim's behavior.

McGraw also yells at her that when he asks her a question, she'd better 'tell the damn truth'. This reveals a total lack of understanding of the patient's experience of psychotherapy and of the process of therapy. It's the kind of incompetence you might expect from a first-year graduate student in the first weeks of his therapy practicum. Clients don't tell the truth. Any lawyer can tell you that, without the first bit of training in clinical psychology. In the first place, clients don't always know the truth. That's what they're here for, dumbass Doc, to learn the truth about themselves.

In the second place, they are afraid to tell the truth. They are afraid that we will think they are crazy, or evil, or stupid. They are afraid we might yell at them for it. They are afraid that they might scare us, disgust us, anger us, and then we might refuse to work with them any more. Which of course is exactly what happened here: McGraw acts out the patient's worst fears instead of working through them.

You see, Philip Calvin, whatever we think or act or feel (or don't) is also grist for the mill, except we don't just blurt it out in the session. We analyze it privately or in supervision--which I think Philip Calvin could really use--and then and only then decide if we want to use it in the hour and how we might best do so. If a client makes us angry, for example, or renders us impotent (as seems to be the issue in this case) by not showing up or not getting better or whatever, first we need to check and see if this is our issue. Did my mother make me feel like that? My Dad? My boss?

If so, I need to let that one pass on through me and get myself back to the reality that is the client in front of me. If it's not primarily an issue from my past, then my next best bet is that the client makes a lot of people feel this way. Will I help her understand her impact on other people if I scream at her? No. Will I help her change her behavior by telling her to cut it out, or else? No. If it were that simple, she'd have done it already. But if, on the other hand, I can help her look at what just happened in the session and the feelings and intentions behind her behavior, then she has a chance of learning something that will help her in the future to behave in a way that works better for her.

Instead, McGraw takes the no-shows and the lying and the walking out of sessions personally, as if it were about him and not the client. Which of course by now it is, due to his ham-fisted attempts to exert control. If the only way she can retain some of her power and dignity is to not show up or to leave when he's being an asshole overbearing, that's what she's going to do. He's so contaminated the therapeutic field that by now it's going to be nearly impossible to sort out what's hers to work on and what's his. If I were his employer, I would assign the family to another therapist at this juncture, because it's not the family's job to help him sort out his stuff. They're here to get help for themselves, and they aren't getting it. 

Don't get me wrong: There are times you have to fire a patient. If you are working in the patient's best interest, though, you don't yell, "You do that again, Sister, and we're through!" and "Don't try me!" The sacking is a therapeutic process, handled properly. McGraw, again, is trying to control another person's behavior with threats--in this case, as if he were a parent threatening to withdraw the father's love if the child doesn't do what he wants. He's attempting to get his needs met in the therapy, and if he does fire them in the coming weeks, it's going to do damage.

While we are on the Daddy thing, by the way, you may have noticed that I have been speaking about this case from the standpoint of individual psychotherapy. The reason for that is that I don't practice couples or family therapy--I don't have enough training or experience in it. I'm guessing McGraw might not either, because one thing I do know is that the therapist's job in family therapy is most emphatically not to step in and be the Daddy. If I'm right, he's practicing outside the boundaries of his competence (Standard 2.01, Boundaries of Competence) and that's not only unethical, it's dangerous. Do the wrong thing in family therapy and you have the power to not only permanently disrupt vital relationships in people's lives, but even to get someone killed.

Specifically, that Standard states in part:

(a) Psychologists provide services. . . only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

Philip Calvin wrote his dissertation on rheumatoid arthritis. Make of that what you will.

But I digress. The way to handle this is to point out the reality of the situation to the client, to wit, therapy cannot happen if you [fill in the blank]. We need to find a way to help you stop [whatever it is that's undermining your treatment]. How can we best do that? Or is it possible that your behavior is your way of saying that you are not ready to be in therapy yet? Or perhaps just not in therapy with me? In this way, you are helping the client see that she is making a choice--to engage herself at the next higher level in her therapy or to stop treatment for now. It's her choice, to make with integrity. McGraw's approach is punishing her for being herself, for doing the best she can with what she's got. The method suggested here challenges her to to make a conscious decision, and that's growth for her no matter which way she goes with it.

According to Wikipedia, McGraw is no longer licensed, and presumably he's not a member of the American Psychological Association (APA) either. If correct, he does not subscribe to and is not bound by the Code. Also according to Wikipedia, he claims his show is entertainment, not the practice of psychology. Assuming a judge would accept that distinction, he's therefore not practicing psychology without a license, which otherwise would subject him to possible legal sanctions. His website is a bit fuzzier on this latter point, listing as it does his academic credentials and talking about helping people, so somehow I seriously doubt that either his victims--dang! I did it again!--patients, I meant to say, or his audience fully understand these fine distinctions.

It makes me sick to see something like this on television. It is exactly the reason that people do not come to therapy, or if they come they can't fully engage--they are afraid that the therapist is going to judge them. Our job is not to judge. It is to act as guide to the client's inner life. One three-minute tirade like McGraw's, and 6.7 million people will be frightened off forever.

I'm telling you, it just makes me sick.

Welcome to Rape Culture, Joe

Image via Wikipedia

Valdosta State University's remarkably inept recent posting of Rape Prevention Tips for Women triggered a number of blog posts on Rape Culture in which the bottom line was as follows: There is only one cause of rape, and that is the presence of a rapist. Tips for preventing rape, therefore, should be targeted at rapists. (Anna posted a great one in the Comments section, here.)

Personal Failure at Forever In Hell was one of the bloggers responding to the VSU gaffe. In response she got, perhaps inevitably, the usual mansplaining troll who took her to task for her "tone", among other things. He criticized her for being angry and anti-male. Fannie, of Fannie's Room took him on, and her post is so right on that I feel compelled to reproduce a goodly chunk of it, verbatim, here. (The last time I asked someone to attempt such a flip-flop, I got totally flamed. I hope she does not, because seriously, this is really good.) I would ask every man who does not believe that we live in a Rape Culture to try this one on for size:

"A good flip-flop comparison would be to imagine a world in which women routinely kicked men in the balls really hard for no reason at all, so much so that men wore protective cups on their genitals at all times and, if they didn't, they knew full well what they were asking for. One wonders, how would men react if the ball-kicking led to the formation of Ball-Kicking Prevention Tips that advised men to never walk alone at night, to avoid dangerous neighborhoods (especially where groups of women congregated), and blamed men for Getting Their Balls Kicked if they chose to move in the world like how people got to move?

It's not so much that the tips are not useful. Some of them are. But wouldn't the men rightly be angry about living in a culture that seemed to focus more on all the ways men could limit their lives to avoid getting kicked in the nuts, as opposed to how we could make women feel less entitled to attack men in the first place?

. . . .

Welcome to Rape Culture, Joe."

Right on, Fannie! There's really not much I can add to that.

Always Be Aware of Your Surroundings

Do you monitor the internetz for potential rapists? Perhaps you should.

I myself have one of those automatic Google thingies set up to scan for variations on my name and report links to me in a weekly e-mail ('course that's not why I do it, but never mind). Perhaps that's how this rape victim discovered a Craigslist ad in her name asking for a partner to act out a rape fantasy. Or not.

In any event, by the time she found out about it and got Craigslist to take it down, a real-life rapist had already seen it and was happily on his way to her house to fulfill some of his deepest fantasies.

Turns out she was set up by her ex-boyfriend.

So if we are responsible, as so many rape-prevention experts advise, for maintaining a constant awareness of our environment, now I guess we are to not only acquire eyes in the backs of our heads (this would be especially tricky if, whether for religious reasons or simply because it is raining cats and dogs, you cover your head when you are out in public), figure out how to see around corners and through parked cars and tree trunks, but also be aware of every transaction on the internet around the entire world in every language all the time! Because you will have nobody to blame but yourself if you get raped because you were unaware of your surroundings.*

My goodness. When will I ever find the time to wash my hair?

*Nobody in the original article--not the reporter, Ben Neary (AP), or anyone interviewed, implied any such thing--but wait for it. It's only a matter of time. I'll bet you a guest post that someone, somewhere, will at least say that once the victim found the ad she should have taken extra precautions. Any takers?

You CAN Prevent Your Own Rape, You Know

Image via Wikipedia

I heard it from an expert.

I've been at an otherwise pretty good two-day workshop that was supposed to be on the neurobiology of trauma, but turned out to be a whole lot about treatment. The seminar leader is a genuine nice guy, a brilliant researcher and clinician who has devoted his career to helping people recover from trauma.

In some ways, I think, that makes what happened today even worse.

He was telling us about a case of a martial artist who was raped, and suggested that women like her get raped because they are unaware of their surroundings and/or are frightened into immobility due to past trauma. He clearly could not think of any possibility other than something about the victim. And I gotta give it to him, maybe she was spaced out--trauma survivors often are. Maybe she did freeze--trauma survivors often do. But still. Why be trying to puzzle out what it is about the victim that gets her raped? That makes me want to set my own head on fire.

Maybe it was a "blitz attack", which of course by definition would mean she wouldn't have known she was even being attacked until she was already down. Or maybe her rapist had a weapon: I have to ask--do men really believe that a martial artist can kick a gun out of an attacker's hand like good ol' Chuck Norris on the teevee? And then there's the rapist who comes in through the bathroom window in the middle of the night and has you under his control before you even wake up. Now how you gonna karate-kick his ass outta bed with your legs all tangled up in the kivvers? And then there was the woman I knew whose attacker told her if she cooperated, he wouldn't harm the children sleeping in the next room: All the martial arts training in the world won't trump that one.

And seriously, even assuming a normal (i.e., non-traumatized) level of awareness, how far can tracking your surroundings possibly take you? You can only watch your back-trail so closely before you get a crick in your neck--or worse, stumble into traffic. A guy who's determined to sneak up on you will. Or jump out from behind something: Can you see through tree trunks, around corners of buildings? I can't. And how aware can we be when we are sleeping in our own beds? 

The expert thinks it is empowering to teach a woman to kick the shit out of a model in pads and a helmet. He noted her proud stance after the class and said something to the effect of, 'Now she's in control of her own destiny.' The sheer illogic of this is stunning when a lifetime of training in martial arts didn't protect her. (I've seen this from a women's self-defense expert, too, who repeatedly tweets that it is up to you to be appropriately assertive--in control--so you don't get raped.)

Let us note that one in every six women in the U.S. will be assaulted in her lifetime. Maybe it's just me, but I think that's frequent enough to suggest that we are not, in fact, in control of our own destinies--at least not when it comes to rape. Indeed, that kind of thinking sounds to me like a form of privilege: The not-raped can believe they did/do something to earn/deserve that status ("I kicked the shit out of him!" or "I'm always aware of my surroundings." Always? Really?). That kind of thinking allows the not-raped to feel safe and secure in the fantasy that "it will never happen to me" and to look down on victim/survivors as people who screwed up somehow.

But I digress. I'm sure beating up on that guy in class was fun for her. And maybe all women should know some self-defense. But shouldn't anybody think that's going to necessarily prevent a rape (see above). Heck, it might get her hurt worse or even get her killed, because some rapists escalate when you fight back, either because it angers them or because they are excited by it.

These are all reasons why it is both cruel and ignorant to blame women for not paying sufficient attention to what every potential rapist within arm's reach might or might not be doing, or for not fighting off a dude who outweighs her, has a longer reach, has got the drop on her, or who is carrying a weapon--or all of the above. I'm sure the presenter didn't mean to blame anybody, but that is, precisely, victim-blaming.

My stance has always been (and I learned this at Grady's Rape Crisis Clinic back in the '70s, by the way--I don't get original credit for it) that whatever the woman does and survives is the correct thing. I wasn't there. You weren't there. The expert wasn't there. She was. She read the situation and handled it instinctively--and survived. That right there gets her a grade of A+.

The scary part, again, is this guy is a recognized expert who amply demonstrated a high level of sensitivity at other times during a career spanning decades. If he can have a mental lacunae like this. . . well, I just despair sometimes.

And of course he's not the only professional to do this, nor is it always a man. A recent report of a "female" getting raped in a park caused a female psychologist to nearly throw herself onto Twitter to warn "girls" not to go to parks alone or after hours. I clicked on the link and found that the original news article had never specified the victim's age, the time of day, or whether she was alone. Never mind that none of these things is in the least bit relevant anyway, because rape, dear readers, is caused by rapists.

Trust Means Letting Go of Control Over the Outcome

Vigil for Dr. Tiller       Image via Wikipedia

What is Blog for Choice Day?

Each year, NARAL Pro-Choice America poses a question to pro-choice bloggers before the anniversary of Roe v. Wade, and then asks them to blog their answer on January 22.

In honor of Dr. George Tiller, who often wore a button that simply read, "Trust Women," this year's Blog for Choice question is:

What does "Trust Women" mean to you?

Ironically, I was inspired to this post by another disabled feminist blogger's expressed opinion that abortion is just another way for upper-class Caucasians to get rid of  "bad babies", which is to say, fetuses who might already be defective in some way or who have the genetics for a future disability. 

The blogger is right when she points out that we have such a prejudice against the disabled in this country that we often disapprove of either disabled women having children, or women in general having disabled children. For example, she points out that we even frown on older women conceiving because of the mere risk of problems. The gist of her post is that no, she does not trust women: She thinks we are all out to kill her and her kind.

She notes that people who think that raising a disabled child is a terrible burden are making a basic logical mistake: It's not the child's disability that is the biggest problem. It's the lack of affordable health care, accessible child care, and so forth. In other words, that baby is facing all the societal prejudices against disability from day one. And by extension, the miserable lives that the able-bodied envision for those of us with disabilities is premised on the same logical error: It is often not our disabilities that are our biggest problem, but the attitudes of others (including the unwillingness to hire us at comparable pay), the lack of accessibility everywhere we wish we could go but can't get in, the lack of decent health care in this country, and the ignorance of our health care providers about our specific needs.

About all this my sister blogger and I are completely in agreement. But also, and unfortunately, there is little social support in the United States for any woman to raise any child. If she is a single, young, unemployed woman of color? Fuggedaboudit. No support. Indeed, she is likely to be punished in any number of ways, large and small but equally cruel, every day for the entire dependency of that child. And this, my dear readers, is why most women seek an abortion. Not because the child is going to be disabled but because the woman in question simply cannot have and raise a child. Any child. Maybe especially not a disabled child, and maybe especially not if the woman herself is disabled, but the bottom line is that any woman may find herself unable or unwilling to carry a fetus to term.

Find me one case of one of these mythical Caucasian upper-class women with, say, a hereditary crippling disease, selectively aborting pregnancies until she gets a "good" one, and I'll buy you dinner. I can safely make that bet because the fact is that "abnormalities in the fetus" is the least-frequent reason cited, world-wide, for seeking an abortion. 

The able-bodied aren't the only ones making logical errors here. Sometimes disability advocates and pro-lifers do, too:  pro-choice is not synonymous with pro-abortion, but some people have an annoying habit of conflating the two. I am not personally acquainted with any pro-choice folk who think that there is any circumstance in which a woman should have an abortion. What we want is for women to never again be forced to carry every pregnancy to term, irregardless of her personal circumstances.

Which brings us to what "Trust Women" means to me. The dictionary definition of trust is, "reliance on the integrity, strength, ability, surety, etc., of a person or thing; confidence." You will note that there's nothing in this definition about outcomes, only about process. We, as women, if we trust each other, must rely upon each other to make our own best, ethical decisions about our own bodies. Pro-lifers do not trust us: They have one specific outcome in mind and that's what they want come hail or high water, whereas people who are pro-choice by definition express confidence in each woman's strength and integrity, in her ability to make the right decision. Pro-life is a paternalistic approach that treats women as children; pro-choice respects us as the adults that we are.

To me, "Trust Women" means just that. Trust us. Trust each other.

Stupid EOBs, Edition 1

Mount Aetna         Image via Wikipedia

An EOB, for the unitiated, is an Explanation of Benefits. More often, they are better described as Obfuscations of Benefits.

This one is from Aetna. It purports to explain why they did not pay me for a session:

 "The member's plan provides benefits for covered expenses at the plan's recognized percentile level of charges received by Aetna for the same service."

I feel like I need a shower now

A recent thread on a professional listserv I belong to has taken up the topic of using client/patient testimonials on psychotherapy websites, in brochures, and for other marketing materials. A couple of people responded to the original poster that he should not do it. And then this:

My [partner] is an attorney and we looked into this before I obtained my testimonials. It is true that in [State] testimonials are not allowed regarding current clients. However, clients that you have terminated with are fair game.

"Fair game"? Egad. What a way to look at one's patients. Would you want to see a therapist who looks at you as the marketing equivalent of a deer in his crosshairs?

The commenter goes on to say,

Some of my clients fill out a form. . . and some I speak with over the phone. The phone interviews are much more productive because you can discuss what may be relevant to your marketing needs, e.g., getting them to talk about specific results that have come from our work together rather than just praise about me.

Finally, the commenter refers the original poster to the website of a practice coach who says, and I quote:

. . . through the course of your work together perhaps a client spontaneously expresses how he or she is benefiting from seeing you.

When this happens, you should write down what the client said about how he or she benefited from your service and then ask permission to use these statements in your promotional materials.

Seriously. I need a shower.

As the commenter notes, certain states' licensure laws do not expressly prohibit soliciting testimonials from former clients. Our ethics code does not specifically forbid it either. However, it is my position that ethical behavior ought to consist of more than simply not doing what is expressly forbidden. Striving to be as ethical as we can should include having our clients' best interests at the forefront of our minds at all times, acting like a professional (as opposed to, say, a used-car salesman), and maintaining our professional objectivity in any given case. It is a vital part of our professionalism and essential to our objectivity that therapy is about the client's needs, not ours.

Taking notes during a session with an eye to posting clients' statements on your website is hardly keeping your eye on the therapeutic ball. Even if you wait until a client is "former" to ask permission to use a quote, how can you help but think in terms of that client's potential effect on your bottom line rather than doing your best work at the moment? Sometimes our best work is going to make the client uncomfortable--anxious, sad, even angry. We may hesitate to say what they need to hear, as opposed to what they want to hear. What if a client wants us to violate a boundary in some way? We may give in, gratify that wish for them instead of helping them work it through, so we can get a good ad out of it. We're only human: If we walk into that consulting room with any agenda other than the therapy, we are at risk for skewing things to get our needs met at the client's expense.

Waiting until the client is no longer a client to ask for a testimonial does not keep it from being an issue with active clients. Clients who found you through promotional materials using testimonials know perfectly well, even if you haven't mentioned it yet, that this is on the table. How will this affect their work with you? Will they use criticisms for leverage? Will they worry that if they don't give you a testimonial that you will not write as good a letter for their probation officer, or give them whatever else they are needing from you? Conversely, will they spontaneously offer testimonials in order to win your good will? Clients know we're only human.

Clients who form strong, long-term relationships with their therapists are particularly desirous of pleasing us. Might such a client be even more reluctant to hide relapses if they have the extra, added pressure of knowing we need a success to bolster our practices? Could they feel pressured to look like they are getting better than they are, faster than they are, to help us out? Nobody knows the answers to these questions, because nobody's researched it. It would be unethical. But we can make educated guesses, and our best guess is that any or all of these things could happen; our best guess is that this testimonial business is bound to affect the work. It can't not.

Our ethics code and state law do prohibit soliciting testimonials from "persons who because of their particular circumstances are vulnerable to undue influence." Many therapists think that this latter category includes former patients. We are uncomfortable with the legal and ethical distinction between current and former patients that allows certain behaviors toward the latter. Psychodynamic therapists argue that transference, the displacement of feelings from parent to therapist, lasts forever. To them, "once a client, always a client" is the rule. Even if you aren't psychodynamic in orientation, it is difficult to define "former." I've had clients return after a hiatus of as long as 10 years, and probably these folk considered themselves my clients even when they weren't active in therapy.

Contact after a brief period is very common. Perhaps the client you just saw for a 5-session Employee Assistance Service (EAP) assess-and-refer gives you a testimonial--or refuses one--and six months later needs you to testify to your work in court. Will you be squeamish about testifying to things that will hurt your client's case? Will you not want to go if they wouldn't give you a nice sound-bite for your website?

Even if they never come back or need you again for anything else (like court), on what magic date do you stop having most of the power in the relationship such that a client would truly feel free to refuse you? There is no research that I am aware of which would tell us how many days, weeks, months, or years it takes after therapy ends for us to stop being an authority figure to our clients. On what magic date would we no longer be using our position and prestige to get our "marketing needs" met by the client? By the time we get done with a course of therapy, we know things about a person, things we can use to get what we want. On what magic date to we un-know these things? I think the commenter above intuitively recognizes, even as she fails to consciously consider, that power when she recommends telephone interviews: We can exercise a lot more influence, due or otherwise, on the phone than we can through the mail.

The American Psychological Association (APA) ethics code also forbids dishonest or misleading public statements, in which they include your advertising. There is plenty of research to show that, psychologically, humans want things to work. We are hard-wired to believe that a treatment or a product did work for us, and the more time and money we put into it, the stronger is this bias. Asking a client if something was helpful is not going to get the same kind of objective information as, say, before-and-after psychological testing might. Plus, presumably, if a client tells you, "Heck no, you bite," are you going to post that on your website? No. For these reasons, your promotional materials are apt to be misleading, if not downright dishonest, in direct proportion to your dependence upon testimonials.

Bottom line? Just because we can do a thing doesn't mean we should. What we should do is strive to go as far beyond the minimum standards outlined by legal and ethics codes as we possibly can. I simply do not believe that we can do our very best possible work if we are thinking about how what we are doing is going to look in a brochure, and I do not believe for one minute that clients will have the freedom of action or sense of absolute privacy that are the sine qua non of productive therapy if they know they will be used in an ad. There is a risk throughout the therapy and well after it that we will be using our position as the client's therapist, and the power and insider information that goes with it, to get our needs met. Finally, testimonials are not an honest means of advertising.

I tell my ethics students that, "There's illegal, unethical, and just plain tacky." Testimonials may not be illegal, and they may not be unethical, but they are surely tacky. In fact, I would go so far as to say that they are downright sleazy.

Just sayin'.