Docsplainin' -- it's what I do

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

Friday, January 22, 2010

Trust Means Letting Go of Control Over the Outcome

An attendee at a candlelight vigil in Boston, ...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.

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Stupid EOBs, Edition 1

Mount Etna (Aetna)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."

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Wednesday, January 20, 2010

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'.

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