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.

Bullying

Physical bullying at school, as depicted in the film Rebecca of Sunnybrook Farm. (Photo credit: Wikipedia)

Bullied as a kid? Does it still bug you? Then you will be not the least surprised at the results of a study published in JAMA last week. This study is being touted in the media  as demonstrating that the effects persist into adulthood ("Scarred for life", says the Standard, a UK paper), which I suppose any adult bullied as a kid could have told you. After following over 1400 kids from 11 North Carolina counties for nearly 20 years, researchers found that victims had a higher prevalence of agoraphobia, generalized anxiety, and panic disorder in young adulthood than kids who were not bullied. 

A search of the American Psychological Association's database turned up only one--one!--other study of long-term effects, a retrospective study asking gay and lesbian adults about their experiences in school and checking for any correlations with mental health concerns in adulthood. Their results suggested that as many as 17% of gays and lesbians bullied in school might have at least some symptoms of posttraumatic stress disorder in adulthood.

An author of the first study has been quoted as being surprised by the results. I am not.  Therapists are exquisitely attuned to the verbal messages our clients received from their parents about who they were, their place in the family and in the world, their value as human beings. And we all know, and have known for nearly 100 years that clients who were told, just as one example, that they were stupid will continue to believe that right into their dotage. Anything smart they do will be seen either as a fluke, as dumb luck, or as not smart at all--something anyone could do. Our peers have less influence on us, but not by much. And they have nearly as much access to us, seeing us five days of every week, nine months out of every year, throughout some of the most formative years of our lives. They have plenty of opportunity to beat us down.

One very damaging aspect is the response of the people in charge. Bullying victims get doubly traumatized when teachers, administrators, and parents do nothing: This is experienced as a betrayal, an abandonment, or as further abuse--and sometimes, as all three. For example, a boy who was physically assaulted in front of a raft of teachers who did nothing reported it both the assault and the faculty's inaction to the principal. That worthy's response was that this would not have happened had the student not chosen to come out. In actual point of fact the boy had been outed by one of the bullies some months previously in a separate incident, and he had reported it at the time. So the victim gets the message that nobody cares, nobody's going to do anything, and it's his fault anyway. I suspect that, as studies of childhood sexual abuse have demonstrated, this kind of response on the part of adults is a risk factor for some of the more negative outcomes for the child.

Nor, as far as I can tell, are long-term effects limited to childhood experiences: I know one fellow, retired about four years now, who still has regular nightmares about workplace bullying he suffered. And I have worked with several veterans who count abuse by their superiors as among the worst experiences of their careers.

So am I surprised by the results of this study? Not hardly.

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.