R-E-S-P-E-C-T!

I read an article a while back about physicians' arrogance and how it results in poor patient care. And as I read, I thought that much of it translated well to the field of psychology.

Psychologists, as a rule, are an arrogant bunch.

I was lucky to be therapized, supervised, taught, and mentored into the profession primarily by psychologists who understood respect. But I had some bad experiences, too, with arrogant supervisors that left me so scarred it took years to recover. And I'm not the only one -- I once had a prospective supervisee burst into tears when I told her I never yelled at students. Apparently she'd been yelled at through most of her grad-school career and was expecting more of the same from her practica.

We as a profession have a tendency to believe that we know it all now that we have that 'terminal' degree, and to fail to take seriously those coming up behind us. We stop being teachable. In our arrogance, we can fail to take our duties to our clients seriously, as well, resulting in everything from poor service to egregious ethical lapses. In that vein, I have seen:

• A psychologist disrupting a psychometrist's testing sessions to ask questions, obtain items from the testing room, and even to introduce another patient -- because it would have been an inconvenience to wait
• A psychologist deleting critical safety recommendation from an intern's report
• A psychologist stating he didn't need to read the new manual for a radically revised test, then disagreeing with the intern about conclusions based on new norms
• A psychologist using cheap photocopies of test materials and cutting corners in administration  because s/he wasn't getting paid what s/he thought s/he was worth to do the work right

In these cases confidentiality was violated, tests were invalidated, a staff member was assaulted, a client failed a placement, and countless inaccurate conclusions went out in reports. The seriousness of these consequences would be hard to overestimate.


Arrogance can produce abuse or neglect of student interns and staff as well as of patients. I have either experienced myself or witnessed:

• Staff psychologists and professors sexually harassing students, interns, and nursing staff
• Staff psychologists attempting to influence interns' communications with site visitors from certifying bodies
• Senior psychologist telling junior psychologist, who was asking for help with staff management problems on her unit, "Buck up, Bucko!" 
• Psychologist telling intern, "[Expletive deleted] rolls downhill. And you're downhill."
• The psychologist leading a supervision group being dismissive of supervisees' input, actively discouraging such participation as "taking over my group"
• Clinical faculty blowing off supervision appointments and seminar meetings required to meet state licensing standards and then threatening interns who complain

Needless to say, not a lot of learning can occur in such an atmosphere, and that translates into obvious gaps in the care of those students' patients down through the decades over the course of their careers. Over and above the gaps in the learning of facts and skills, such an atmosphere sets an example for students that says that patient appointments are not important to respect, patient and staff input is not valuable, rules and regulations can be bent as long as nobody knows about it, and nobody should ever report anything untoward.

Inadequate supervision of students and staff (when the arrogant psychologist just can't be bothered) translates into patient abuse going unchecked, and in patient neglect. Patients in turn are inadequately supervised or under- or mis-treated, resulting in self-injuries, untreated medical issues, assaults, suicide attempts, elopements, and deaths. I am not just speaking theoretically here, either: These things have actually taken place.

Then there's the arrogant dismissal of patients' needs and lived experiences. We have

• A psychologist commenting in reference to a severely mentally ill patient s/he deems hopeless, "I can heal the sick but I can't raise the dead!" 
• A center director considering it taken as read that a person with schizophrenia (most of the center's caseload) is incapable of participating in hir own treatment planning
• Psychologists failing to advocate appropriately for minor clients or to support self-advocacy in adults
• Psychologist making fun of a client's parenting style
• Psychologist blaming dead victim of domestic violence (parent of a child client) for getting into/not leaving the relationship

This sort of attitude trickles down to other staff, students, and even clerical employees, with the bizarre end result that one clinic I worked at was actually cited in an audit for -- wait for it! -- not providing mental health care.  I am not making this up.


The experience of stigma is, by the way, a known health risk. By copping an attitude that we are better than our clients (because we are thinner or healthier or more fit, better-educated or more financially well-off -- any measure seems to be fair game these days), not only are we not being helpful, we're actively making our clients' mental and physical health worse. We're putting tremendous pressure on our students and staff, who are, after all, exposed to our prejudices many more hours each week than are our clients, and we're setting terrible examples for them.

Obviously parents from different cultures, with differing parenting styles and victims of domestic violence and their children are not getting good therapy from such therapists. But there's a ripple effect. A respectful therapist working with members of such groups is going to be reluctant to be forthcoming in a team treatment setting or in clinical supervision, where the sharing of information is normally considered necessary to good treatment, lest their patient become a target. 

And then there's

• Psychologists using patients to house-sit
• Psychologist using client to help pack up office at retirement
• Psychologist having intern come in to clean the office on the intern's off days
• Psychologists using students and patients to buttle parties in their homes, and
• Faculty using students to babysit.

A patient is not a servant. Neither is a grad student. And it is the height of arrogance to presume so.

I think part of the problem is that we live in a cultural climate of general disrespect. We are always attuned to matters of class and rank, to where we stand in the pecking order -- and woe betide anyone on the rungs below. And then of course there are some people who just seem, as individuals, to be particularly arrogant/disrespectful. We've all known at least a few: No one, it seems, is safe from their disdain or their verbal abuse.

Plus, with some psychologists, there's a tendency to overvalue the doctorate, to demand respect for themselves while believing it somehow frees them from the obligation to show respect for others who might be just as smart, just as knowledgeable, but who for one reason or another, lack the diploma. They seem blissfully unaware that there is often no difference in intelligence or drive between them and the therapist with a masters--or, for that matter, the parapro with the high school diploma. To a degree (if you'll pardon the pun) the difference is often only a matter of privilege: The "I'm-a-doctor-and-don't-you-ever-forget-it" crowd as often as not are people who were born on third base but think they hit a triple.

And speaking of triples, sometimes you get the triple-whammy -- a psychologist who is (1) not only a product of hir culture but who also is (2) particularly self-important and who (3) takes too much credit for the achievement of a degree which is in itself overvalued*. . . and you have someone who is especially bad for morale, disruptive to the work of the unit/practice/facility/team, and who is potentially downright dangerous to patients.

Get people like that at the top of the office heap, and they tend to run off the folks who aren't like them and hire more who are, until the whole culture of the institution, be it a huge psychiatric hospital or tiny private practice, will be disrespectful. And when that happens, patients beware!

I don't know what we can do about it, other than shout out,

R-E-S-P-E-C-T!

Find out what it means to me!

R-E-S-P-E-C-T!

*Trust me, it's not all that special -- there are thousands of us in the state of Georgia alone.

A monstrous ethical dilemma

I just finished reading Stephen White's first novel, Privileged Information (Viking, 1991; 363 pp.). I'm surprised I'd never heard of him before, because I love murder mysteries and I particularly love those written by or about psychologists. But somehow I'd missed this one: A friend, in town for the holidays, turned me on to it. "Be sure and start with the first one," she said, and I did.

At first, I didn't like it. It wasn't all that well-written, in the beginning at least, and I thought the ethical problem was kind of contrived. But it picks up along the way.

Here's the dilemma. The novel opens with the suicide of a patient. The patient unfortunately wrote up her sexual fantasies about her therapist, the protagonist of the novel, in her diaries without identifying them as fantasy. The executor of her estate reads them, and thinking that the protagonist, Dr. Alan Gregory, not only may have been sleeping with his patient but may have precipitated her suicide by doing so, files a complaint.

Gregory certainly is in a bit of a pinch here, because the complaint hits the papers and of course the therapy community is abuzz about it as well. Gregory can say nothing in his defense, publicly at least, due to patient confidentiality. He of course can defend himself before the licensing board, but that is not the problem here. What felt contrived to me was that he seems to think he can't talk to his colleague and business partner, his lawyer, or even his clinical supervisor about the case, which is completely incorrect. He can. And should.

But this is a relatively minor flaw in the book, because as it turns out the privileged information of the title primarily refers to another patient altogether, one whom Gregory begins to suspect of murder. Now he really is in a bind, because he cannot reveal what the patient is up to without a more clear and convincing threat to a specific person. Which the patient is smart enough not to give him. So the rest of the novel turns around how to stop a killing without giving away privileged information.

Along the way, Gregory, who is completely innocent of the boundary violations with which he is charged, does manage to rationalize some other, serious ethical breaches. And his final solution is not ethically perfect, either. It's creative, though, and it does solve the problem.

White is himself a psychologist who practices in Boulder, CO. In his writing he gives a good picture of the life of a psychologist. But ethical issues not addressed in this novel include (1) Gregory seeing 38 people a week when his caseload is its usual size, and (2) Gregory continuing to work while his personal and professional life crumble around him. He also takes on a patient who represents a clear conflict of interest. He should have referred this guy on during the first session--but then, if he had, there would have been no novel, so I guess we're stuck with that.

Gregory makes boodles of money seeing 38 people a week, but my God. When does he do anything else? Like billing, charting, reading, eating lunch, going to the bathroom... He books people back to back, referring once to "my 3:00 and my 3:45" so he's not doing any of this between sessions. I once interviewed for a job with a psychologist who claimed to see 50 to 55 patients a week: My first instinct was to run like hell. That can't be healthy. You can't possibly, in my humble opinion, maintain a high standard of performance at that level.

He is also working with a couple while his own marriage is breaking up, and one has to wonder if how he sees his own relationship troubles is biasing his view of what the couple he's treating "should" do with theirs.

And finally, he takes on a client who had an affair with a former client. I wouldn't touch that with a ten-foot pole. Or as a former colleague of mine used to say, a 12-foot Russian.

So we hope White doesn't practice like that. And while the book gives a better portrayal of the profession than, say, Prince of Tides, I'd still warn you to take it with a grain of salt (it is, after all, fiction). The Alex Delaware novels by Jonathan Kellerman are much better in that regard. I've read them all and the worst thing I can recall Dr. Delaware doing is having a drink at lunch when he has a patient to see in the afternoon.

Courtroom Antics

I have two cases going to court in the next couple of weeks, one civil and one criminal. And it's got me to thinking about past forays into the justice system and how weird it can get.

Used to be, we were the only private practice up here for miles around, and we had folks drive from as far north as Dalton and Copper Hill for therapy. As a result, we were occasionally in courtrooms just about anywhere in the Blue Ridge circuit. Judges and attorneys varied wildly in quality. On one memorable occasion, I drove all the way up to Calhoun to testify in a divorce case in which I had already warned both parties that I had nothing to say that would be good for either of them. But one of them subpoenaed me anyway, so off I went at the crack of dawn to the wilds of north Georgia. No sooner had I been sworn in than the judge asked me if I wanted to waive privilege. I said "No," he excused me, and that was that.

Now I am no lawyer, but it is my understanding that, in the first place, the privilege is not mine to waive. It is the client's, and the soon-to-be-ex-wife, by subpoenaing me, had already waived hers. (Not to mention that, under Georgia law at the time, communications with me weren't privileged in the first place.) But whatever. I didn't want to be there so this suited me just fine.

Even some counties close in to Atlanta were pretty back-country when I started my practice. I was in Dallas one day for a child sexual abuse case. This Court liked to assemble all the parties, including witnesses, before beginning trial and was calling roll. The child victim was female, and was accompanied by her mother. The mother had brought her divorce attorney, who was female, as there was also a modification of custody action pending. I'm a woman, of course, as was the pediatrician who was going to testify to some physical evidence. A female police officer was there to testify as well. At about this point in his roll call, the judge, clearly exasperated, turned to the (female) ADA and asked, "Is everybody in this case female?" to which the ADA, straight-faced, replied, "No, Your Honor, the Defendant is a man." The courtroom broke up. Even the bailiff was laughing.