Author: Psychotherapy.net Team

Duped and Recouped

Posted on by Psychotherapy.net Team

A Business Venture

As a young therapist in a solo practice, I routinely met a colleague for breakfast and peer supervision. I arrived at the neighborhood deli to find my former group therapy instructor waiting for me; his broad, toothy grin and Pacific-blue eyes were electric with anticipation. We had met during my doctoral studies.

I laughed. “What’s up?” “I thought you’d never ask!” blurted a very excited Jeffrey Kottler.

He then proceeded to explain that he had answered an ad for a clinical therapist. When he went to the interview, he convinced the clinic owner to sell him two-thirds of a Blue Cross–approved outpatient psychiatric clinic (OPC). Jeffrey and another therapist/ friend would operate its satellite, located in a busy Detroit suburb. This was a rather significant coup since there was a moratorium on the opening of any new clinics and the only way to own one was to purchase an existing clinic for a great deal of money.

“What?” I screamed. “Why didn’t you ask me to be your partner?” “I thought you were so happy in your little practice that I didn’t think you’d consider…” “Well, I do consider,” I interrupted petulantly. “Your other friend’s out; I’m in!” I declared.

And in that split second, Jeffrey and I committed to each other with complete trust and confidence to be partners in this venture. Were we merely trusting souls by nature, or was there something in our training as therapists that encouraged us to blindly trust people without reservation? Perhaps it was a shared personality trait that drew us into the profession originally and, likewise, into this partnership wherein we simply trusted what others say and how they characterize themselves.

There we were, Jeffrey and I, about 30 years old, masquerading as businesspeople, skipping due diligence, moving the satellite to new digs, signing a lease, buying furniture, hiring support staff, and interviewing dozens of therapists for positions in our new enterprise. We decided to hire only those professionals who seemed to be not only good clinicians but also fun people to hang out with at work.

We each paid a significant amount for our share of the business and began billing Blue Cross and other insurance companies for services rendered. Eventually we hired close to two dozen other therapists to work with us, all of whom met our criteria. In purchasing the clinic, we also inherited a few therapists and Dr. Jolly, our medical director. Dr. Jolly seemed competent enough and awfully amiable. What did we know?

Two months later, Dr. Jolly was caught soliciting sex in an airport men’s room. That was obviously the end of him! But the euphoria of owning our own business carried us through that initial setback. We justified our lack of judgment by claiming that we didn’t actually hire Dr. Jolly. And there were certainly other concerns to distract us.
The most pressing concern was the apparent snag in the money flow from Blue Cross to our third partner and then to us. With each passing week, we became increasingly more anxious about our bottom line.

Our daily calls to the partner, who was handling our billing, were met with sympathy and reassurance that these delays were quite normal in the industry. That seemed logical to us. After three months without payment, we suggested to him that we meet with Blue Cross to try to expedite the cash flow. “No!” he stressed emphatically and cautioned us that contact with Blue Cross would trigger an unwanted audit, which typically resulted in disastrous consequences. He asked us just to remain patient because his bookkeeper was receiving treatments for a brain tumor, immediately eliciting our sympathy.

At the end of the fifth month without payment, Jeffrey and I decided to take decisive action and confront this man who sold us the clinic. Alas, we discovered that all along he had been billing Blue Cross fraudulently. It also turned out that he didn’t actually own the clinic he sold us! It had all been a scam. We poured our hearts out to the executive at Blue Cross who agreed to hear our case, admitting that we had been duped but convincing him that we were honest and trustworthy professionals who were only trying to help people. Much to everyone’s surprise, he rewarded our honesty by assigning the provider number to Jeffrey and me. We were the first recipients of a new authorized clinic in many years.

Trusting souls that we were, we got back on our horses and rode into the sunset believing that enough had happened to us for a lifetime. At last we must be safe from all future peril. And now that we had lost our innocence, we were much better prepared for dealing with unexpected chaos running and operating a clinic. Little did we realize that our innocence and gullibility to deceit had only just begun.

Over the next year, we fired another medical director for inappropriate sexual conduct with his patients. Our part-time book- keeper was caught in a sting operation soliciting sex in a freeway men’s rest stop. One therapist went to jail for fraudulently billing Blue Cross; another therapist went to jail for practicing with a forged license and the malpractice insurance of a dead person; and still another therapist made an out-of-court settlement with a female patient with whom he had been having sex in the clinic after hours.

As therapists, Jeffrey and I erroneously thought that because we were skilled diagnosticians and experienced clinicians, we were inherently good judges of character. Yet time and again, we were duped by people we trusted. In truth, I think we projected onto everyone we encountered our own need to believe that all people are basically good. We refused to imagine that we were actually vulnerable.

It took at least three earth-shattering fiascos before I actually began to consider that I was somewhat responsible for the series of misfortunes that were raining upon us. For a while I became hypersensitive because I no longer trusted myself. I was suspicious of everyone around me, fearing that there were secrets lurking behind the facades of those I thought were loyal friends and colleagues. I was actually paranoid waiting for another shoe to drop. It was like walking through a minefield every day. I hated the feelings and retreated to my office where, ironically, I felt safe in interactions with my patients. After all, I expected them to have secrets under the surface and to be less than authentic with me since they were struggling to be authentic with themselves.

I had a very difficult time accepting that I was unable to fore- see the consequences of my gravitational pull toward people who would eventually fail my litmus test. My rose-colored glasses now had a double edge: While it had been wonderful to always see the good in people, I realized that I had been ignoring signs of trouble to preserve my need for everything to be okay. Challenging my inner belief system shocked me to the core. I had to ask myself, What am I supposed to be learning from these painful and frightening experiences?

To make sense of this episode in my life, I resorted to the only path I thought would yield any answers, self-exploration. And the first question to ask myself was, “What am I getting from this turmoil?” In every fiber of my being, I know that in all of us a self-healing power exists. I just had to figure out why it was so important for me to be telling myself that everything will be okay. After a rather difficult and circuitous route, I realized that the childhood trauma of having a terminally ill mother was the motivation to adopt the mantra everything will be okay. No matter what happened in my life, during childhood or during the years as a clinic owner, I had to believe that everything would eventually be okay. So when each betrayal occurred, I quickly resumed my position as sentinel for my inner belief system and continued to guard the hell out of it.

The personal lesson in all of this is not in the failings of judgment but rather in the repetition of the failings. If I had ruminated on each betrayal and become stuck in the quagmire of details, I would not have heard my inner voice beckoning me to attend to a significant piece of unfinished business. My echoing mantra held the key to the reason for it all. I was duped over and over because I needed to find my own place in the drama.

Once I acknowledged my role, I no longer felt vulnerable or paranoid. My trust in the basic goodness in people returned. I was again unafraid of the goodness of my own heart. In truth, I have made only a very slight change in myself; I am no longer surprised when my expectations for others are dashed. But I consciously refuse to surrender my eagerness to seek the best in people. In the end, I would rather suffer the occasional betrayals than cut out my own heart.

The many episodes of being duped during my ownership of the clinic resulted in an amazing gift to me as a therapist. I learned to help my patients honor their own inner voices. I became better able to observe the ways they guard their inner beliefs and became better skilled at diagnosing why. Ultimately, I learned that, inherent in the repetition of turmoil and struggle, there is always an unfinished piece; when addressed, confronted and honored, calm and balance can be restored.

Jeffrey’s Personal Commentary

Reading Nancy’s story about the trials and tribulations we experienced during our sojourn as clinic directors reminded me of how deeply I buried this chapter in my life. Over the years I’ve talked about the incredible lies, deception, manipulation, intrigue, and immorality that took place under our roof. Like Nancy, I blamed myself for my naïveté and innocence, and for our collective inclination to believe the best in people, even in the face of contradictory evidence. As psychologists, we deluded ourselves into thinking that because of our sensitivity, caring, and clinical acumen, we could tell when people were trying to fool us.

I felt both surprised and moved by Nancy’s confession and acceptance of responsibility for our plight. Nancy describes what she considers “the key to the reason for it all,” as if there was a single mistake or misjudgment on her part that led to the debacle and serial betrayals. Yet in my version of the narrative, or at least my remembrance of what happened, I have also accepted full responsibility for our innocence and misplaced trust in others. Like Nancy, I also found it easy to be forgiving, not only of those who crossed the line, but mostly of ourselves. We were inexperienced in the domain of business. We applied the trusting attitude that serves us well as therapists to another context in which different rules operated—and I see that as our biggest error.

Speaking for myself, I learned some hard lessons about the limits of my ability to read people and uncover so-called truth. Yet these therapists were our friends; they were people we trusted; they were professionals with track records and sterling reputations among their colleagues. Even more disturbing, they were also good therapists and had very successful practices.

Whereas Nancy talks about this repeated deception as a gift, an important lesson learned, it took me many years to come to terms with my lapses in judgment. Eventually, I did rekindle trust, enough so that I still prefer to give people (clients and colleagues) the benefit of the doubt.

As I read over Nancy’s version of the story, and then consider my own narrative, I find it interesting that each of us blames ourselves (instead of the other) for the crazy things that took place under our watch. We mistakenly assumed that because we operate from a position of transparency and honesty, that our colleagues, whom we carefully screened and supervised, would do so as well. That was a huge mistake, one that changed the way I function in some arenas in that I am more cautious and skeptical at times. Yet I think we have both been able to maintain a deep faith in the ability and willingness of most people to do the right thing.

Working with the Unemotional in Emotionally Focused Therapy

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It is pretty clear from research that focuses on how change happens in therapy, that emotional engagement is essential for significant change to occur. This is true in individual therapy (for example, research by Castonguay and by Beutler ) and it is certainly true in couple therapy (research by EFT therapists like myself). So what happens in an intervention like Emotionally Focused Couple therapy when one person emphatically denies or avoids emotion? The Boy Code insists that men are at their best when they are strong and silent. So, it is not surprising that male clients tend to deny their emotions a little more often than their female partners.

Process of change research and over 30 years of the clinical experience of numerous EFT, suggests that in fact, this does not seem to be a problem in EFT. Men who are described as “inexpressive” by their partners at the beginning of therapy seem to do very well in EFT. Now why is that?

First, it’s because as EFT therapists we have a map for emotions. For example, there are only 6-8 emotions that everyone on this planet can read on another’s face and assign a similar meaning to. The main difficult emotions that come up in couple therapy are reactive anger, sadness, shame and fear of rejection and abandonment. If you understand emotions, you can help people make coherent sense of them. Once you and your client find the order and logic in an emotion, it is much easier to deal with and work with. Emotions are the most powerful music in the dance called a love relationship and EFT therapists learn how to shape that music and use that music to guide partners into new dance steps.

Second, EFT therapists are emotion detectives. They know emotions are wired into our brains and they have simple, safe, systematic ways of helping folks access and explore them. So, Jim will say in session 8 of EFT, “I used to think I was just frustrated, angry in these fights with my wife; but now I see that mostly I am afraid. It’s a relief to get this – to understand my own feelings and to be able to ask my wife for reassurance rather than stomping around the house in a huff or zoning out and withdrawing into my loneliness.”

Third, tuning into your emotions, especially your fears and longings and shaping these into new messages to your partner WORKS. It is what securely bonded folks naturally do. It pulls our partner close to us and this connection sparks little floods of the cuddle hormone, oxytocin, in our brain. The calm contentment and a sense of belonging that oxytocin induces is the ultimate reward for our kind – little bonding mammals that we are.

When folks tell us, “I don’t have emotions”, we know that this person is working very hard and stressing out his body to suppress his feelings, so we gently explore how and why he does this. He always does it out of fear to avoid being overwhelmed, feeling helpless or ashamed, getting rejected or abandoned. The trouble is that when you shut down your emotions, you shut others out and then you are ………… all alone. No-one wants that. So if you show folks another path to take and support them, they will take it. Even people who do have to shut down as part of their jobs, firefighters, policemen, marines and surgeons respond to EFT. Even traumatized partners who swim in the turmoil of emotional storms learn to order those storms and use their emotions to tell them what they want and need and so find direction in their lives and with their partner.

The traditional route to change in psychotherapy is the haloed “corrective emotional experience”. Without this, any therapy is just an intellectual mist that evaporates once a strong emotion hits. The EFT experience is that even the most seemingly “unemotional” among us respond to corrective emotional experiences of being reassured and treasured. Who can resist this ? Who wants to?

Why a Therapist Should Care About a Clients Favorite Brand of Shampoo

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When I was a youngster my father owned a company that manufactured shampoos and hair conditioners.  His bestseller was the original Rum & Egg Shampoo, a product he invented himself.  Now here’s where the story gets a little humorous (or perhaps not so humorous depending on your vantage point).  We would routinely receive correspondence from folks who just loved the Rum & Egg . . . heck, they thought it was the best darn shampoo on the face of the planet.  In fact, they’d go a step farther and trash another brand or two of Rum & Egg and say something like, “Why can’t Brand X or Brand Y make Rum & Egg like yours? The product they manufacture is pure junk.”

These folks wanted the original Rum & Egg. Anything else was a poor copy of the real thing. Now you might be thinking that we were patting ourselves on the back for making such a great product. Well if that’s what you thought then hold onto your horses because I haven’t gotten to the punch line yet.  Moments after the first call we receive another telephone message. This time it would be from an irate customer who would be ranting and raving about how inferior our product was, “Why in the heck can’t you guys make a decent Rum & Egg Shampoo like Brand X or Brand Y?  I’ll even send you a bottle of their brand so you can see how good the competition’s product really is.” 

These folks had invariably seen the Brand X or Brand Y advertisements that stressed that their rum and egg products clearly surpassed the original formula. And send us a bottle, they did!  Now what the aforementioned dummies (um excuse me, I mean customers) didn’t know was that most of the time it was the exact same stuff!  Let me put it in a different way.  We’d fill a thousand bottles to the brim with Rum & Egg and some bottles would get our label, others Brand X, and others Brand Y, Z or whatever.  We never had a clue which bottles received which labels. Hello folks: you’re all buying the same stuff . . . it's called a private label product. Often the same shampoo or conditioner would even be made under the same name with ten different colors, ten different brand names and ten different perfumes.  (Sorry to disappoint you, but in cosmetics generally the most expensive part of the product is the package and the perfume, in that order.)

But this principle goes way beyond hair care products. At one time made in Japan meant junk, but that’s hardly been the case for the last twenty years.  Now Japanese always stands for superior quality . . . or does it? A few years back researchers took models of automobiles and VCRs that were sold either with US nameplates (Dodge or RCA) or Japanese badges (Mitsubishi or JVC).  Like the shampoo saga, the products were actually identical. Customers were given the Japanese brand and the American issue and told to rate them. Perhaps you’ve already guessed that the products sporting a Japanese label – never mind that in reality they were the same – were rated much better.  Consumers made comments like, “The Japanese model just rode quieter,” or “the picture and the sound were markedly better.” Had you performed the experiment in the early 1950s the products with the US nameplate would surely have won by a landslide. 

Now what does all this have this do with the art and science of psychotherapy?  I thought you would never ask. A number of years ago I was at a conference where one of the top-guns in the world was not only lecturing but was going to perform therapy with a real client for the audience. Since I was the program coordinator for an agency I brought several of my therapists with me. Anyway, Mr. Hot Shot top-gun therapist was kind enough to perform a therapy session for the audience. He spent most of the session yelling and screaming at the poor client. One of my therapists leaned over and said, "You'd fire us if we ever talked to a client like that. Well, wouldn't you?" I didn't answer.

When the brief session ended a counselor in the audience raised her hand and asked the client a question, "What would you think if you walked into an agency or private practice and the therapist treated you like this?" "Well," the client admitted, "I would think it was a bit odd or perhaps totally crazy." The counselor in the audience was now extremely perplexed. "But I don't get it. You seemed perfectly happy and even impressed when Dr. so and so just did it." "Oh that's different," replied the client. "I know he's one of the greatest therapists in the world. He did it for some complex theoretical reason. He knows what he's doing."

I leaned toward the therapist at my agency and whispered, "Yes, I would have fired you." So here's the quintessential question: If you said exactly (I mean precisely word-for-word) what a well-known therapist said to the same client would you get the same results? Since a world famous therapist is one heck of a placebo the best answer is: not on this planet.  Therapists, quite frankly, are a lot like brands of shampoo, electronics, and  automobiles.

Receiving Gifts in Psychotherapy

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What does your ethical code say about accepting gifts from clients? Is it ethical to do so? If you’re a psychologist, social worker, or marriage and family therapist, you’re probably not sure. That’s because your official code doesn’t address it. Surprisingly, there’s not a word about gifts in any of the codes pertaining to those disciplines. And yet, virtually every mental health practitioner has, or will, face a situation where some client offers a gift of some sort at some time in the course of their treatment. So what do you do? Do you have a well thought out approach or policy to guide you when a client is standing in front of you with an offer of a gift?
 
The truth is that most practitioners don’t have a clear idea of what type of gift would be acceptable, if any. Those who work in an agency or hospital setting might simply adopt the policy their employer already has in place, but those in private practice need to develop their own guidelines or they might find themselves one day standing face to face with a smiling client who is offering a small, or large, token of their appreciation, and who is wondering why there is a such a long pause going on.
 
Would you accept a poinsettia plant at Christmas time that your client brought as a gift for your office waiting room? How about a plate of cookies at Easter for you and/or your staff? Or a packet of special seeds for your garden since you once talked about growing and nurturing in an earlier session? Or a picture a child client drew for you, or a lanyard she made for you in her crafts class? How about frequent flyer miles? Or cologne? Or an item of clothing for your birthday? Or underclothing?
 
Surely you drew a line somewhere along that list of choices. Maybe right at the beginning or maybe at some point along the way. But why? What went into your decision to say, “That one’s not acceptable”? Why did you reject it? What factors did you consider?
 
The one major code that addresses the issue is the American Counselor Association Code of Ethics. It advises counselors to consider the therapeutic relationship, the cultural context, the value of the item and the motive of both the client and the counselor involved in the transaction when dealing with the issue of the appropriateness of the gift (ACA Code Section A.10(e)). Those are all excellent considerations that should bear on your decision of whether to accept or reject the offer.
 
We might, however, add to those factors at least three more: age and gender of the client, and the timing of the offer. For example, if a six year old boy brings a bouquet of flowers he’s picked for his 40 year old female therapist the situation is markedly different from the same bouquet coming in the hands of a 45 year old male client. Motive and intent would not appear to be the same in those two instances.
 
Also, the timing of the offer can be critical. Is it at the end of a successful treatment regimen, or is it at the outset? Saying goodbye with a token of appreciation would seem more straightforward at the end than at the beginning treatment in terms of motive, intent and the therapeutic relationship.
 
So putting together the ACA list of factors of therapeutic relationship, cultural context, value and motive, and adding the age and gender of the client along with the consideration of timing, should give you enough to think about when deciding whether a gift is appropriate or not. But it would be wise to do your thinking before you hear your client say, “Here, I brought this for you”.

Memories of Stonehenge, 1984: Conference of Women Family Therapists

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In the summer of 1981 I was traveling around Ireland with Lynn Hoffman who was at that time- and for a great many years- a tremendous supporter of the work of a numerous others in family therapy. She was at that time especially supportive of therapy teams in many different places in the world and was telling me a good deal about all the creative women she had run into in her travels. I began to think about the need of women mentors in our field and what a good mentor she was to so many others herself, including two Irish women to whom I became very close: Nollaig Byrne and Imelda McCarthy. By the end of our trip I had hatched a plan to bring together women family therapists for a conference. I approached my friend Betty Carter, who agreed it was a great idea and asked if we could present it to her group: The Women’s Project (in which her compatriots were Marianne Walters, Olga Silverstein and Peggy Papp). I agreed and soon met with them to discuss the idea. They were, much to my surprise, not enthusiastic and decided against the idea. For some reason, they could not see the value of a meeting of women in the field. They were not the only ones. Virginia Satir, Mara Selvini, and Cloe Madanes were all negative about the concept when invited, and Lynn herself said she could not see the value of it and did not in the end participate.

In any case, I went to my handy-dandy sisters, Froma Walsh and Carol Anderson, who I knew would support the concept and we decided to do the conference together. I knew of a wonderful hotel in Ridgefield Connecticut called Stonehenge and we decided that would be our venue. It had space for a meeting of about 40 people so that was the number we decided on. We then began the planning through networking. We contacted women we knew or whose work we knew of and asked them to recommend others they knew and through that method of networking we eventually had a wonderful group of very impressive women family therapists who agreed to come to Stonehenge to share work, personal experiences and ideas for 3 days in September of 1984. It was a most impressive group of women- the outline of presentations and discussion emerged pretty organically as I remember from different ideas presented by various women. One that stood out particularly for me was Ellen Berman’s presentation of the “Glory-Work Ratio,” a presentation in which she proposed that we as women often under-sold ourselves when invited to do a presentation and would agree to meager terms, happy to be included and not realizing how much work, time, and energy were entailed in such presentations. She recommended that we always sleep on any invitation and not agree to it for at least 24 hours, by which time we might have had a chance to decide how much effort should be expended for what return. We all laughed, recognizing how many times we had found ourselves traveling to faraway places for micro-fees, while the men in the field commanded much larger honoraria, even when they did not prepare for the presentation.

Another highlight for me was a comment by, I think Kitty LaPerriere, still one of the unsung heroes of our field, who said at dinner on Saturday night how amazing it was that for so much of our lives we women always wanted a “date” on Saturday night–which meant with a man—and here we were and we all seemed to want to be where we were at that time and in that place and were so fine with it! We had amazing experiences hearing new voices from the field and also from experienced senior voices. the Women’s Project had decided to participate and even sponsored the welcoming cocktail party on the opening night of the conference and all of them shared many of their experiences as women breaking the glass ceiling of our field.

There were also difficult issues and discussions about why our group was almost all white and how could we do it differently—how could we change our thinking so we could become a more diverse group of women. For me the struggles with how to deal with the intersection of race and gender took many more years—many years to appreciate that we could not discuss gender without taking race into account at the same time. And the intersections of race and gender , along with class and sexual orientation—which have become such important parts of our conversation in the decades since that time—were just in their infancy and not well understood or dealt with. In the years since I have learned a lot about the naiveté and inaccuracy of trying to consider gender by itself rather than within the larger cultural contexts of race, ethnicity, religion, class, and sexual orientation.

At the same time that we made many mistakes in our efforts, there was something amazing that happened for many of us at that meeting, I think. From that point on when we saw each other at other meetings there was a sense of solidarity and of collaboration and support:we had acknowledged to each other at that meeting how isolated we often felt, competing with each other for the attention of the men in the field, and how much of our sisterhood we lost in that competition process. And we came to stand by each other better, to help each other out informally with writing and presenting and thinking about the research and clinical practice of the field. I think wee listened better to each other after that—I know I did, realizing how often I had not really appreciated the other women in our field.

In the years after that we held one other Stonehenge networking meeting (1986) and then an international networking meeting of about 100 amazing women in Denmark a few years later, where, once again, we relied on networking as the organizing principle, learning from each other about other voices in the field. And at that international meeting with women from as far as Israel, Japan and Africa, I remember being totally in awe of the amazing women presenters, one after the other, who taught us about ourselves and each other and how to think more creatively about families and about their experiences trying to be family therapists in different contexts. I think these meetings helped many of us develop our voices in the field and I am grateful to all the women who participated and shared their stories and their work in those earlier days of our field.

Its the Psychiatric Meds, Stupid!

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I was getting ready to close up shop and leave my practice for the day when my secretary announced that one of my clients was in the waiting room in a hysterical panic pleading for a session with me. This came as somewhat of a shock to me inasmuch as I felt this client was actually progressing quite well.  I told my secretary to send her right in.

The client was crying so hard I could barely understand her verbalizations, but strangely enough the precipitating incident was a visit to her psychiatrist's office. As she calmed down I got the gory details. The client told her psychiatrist that she was doing extremely well.  That's a good thing, right? She then went on to explain that her therapy sessions with me were very helpful and thus she had turned her life around.

Her psychiatrist responded with a sinister chuckle and told her in no uncertain terms that her that the therapy sessions with me had done nothing. Instead, he suggested, she had been the victim of a nasty chemical imbalance and that the psychiatric medicines he prescribed had made all the difference. My client balked at the idea, stating that she made some cognitive and behavioral changes as a result of the psychotherapy and that his biochemical explanation was totally negating her work in the process. The psychiatrist's anger then began to escalate and he became louder and more belligerent. He insisted that the therapy and the client's volition had nothing to do with it.

The session reached a point of no return when the psychiatrist took her chart and physically hurled at her (wasn't that professional?) as he yelled, "If you really believe it was the therapy and not the psychiatric medication then go find yourself another psychiatrist." He then stomped out of the room. Since I'm a card carrying therapist in good standing please indulge me as I paraphrase the good doctor, "It's the psychiatric meds stupid!" This served as the trigger for my client breaking down and coming to see me. (Hmm? If you have a gander at one of your behavioral science dictionaries, I've got this uncanny notion the term iatrogenic illness will ring a bell here.)

I agreed with my client that counseling and therapy had been very valuable to her. Nonetheless, since I was the therapist at the center of this battle royale I just I had to know how she knew for sure—I mean 100% sure—that the medicine didn't make all or part of the difference.

"Oh that's easy," said the client as her face instantaneously blossomed into an ear-to-ear grin, "he's been giving me those pills for three years and I've never swallowed a single tablet."

Empowering Clients in Couples Therapy

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When I do couple therapy, I bring partners in on my concerns about what is happening in the session. If I am concerned that one partner might feel I’m siding against him or her, I might say, “Ben, I’ve just realized I spent more time today developing Lisa’s position today than I have yours. Is that your sense, too? And if so, do you feel left out or sided against or ganged up on?” The person (here Ben) often responds with something like, “Well, I was wondering when someone would start getting interested in what I have to say” or “Lisa doesn’t talk about any of these things at home. I’m just happy it’s all coming out.”
 
If I’m concerned that the partners are not getting at what they need to get at, I say, “Are we talking about what we need to talk about or are there other things we should get to today?” or “Will you suddenly remember on the way home that there was something you wish you’d brought up?” I am trying to decrease the likelihood that they will raise important issues as they walk out the door, that is, when there is no time to talk about them.
 
If I can’t tell whether the partners are repeating the frustrating conversation they have at home (in which case I need to do something about it) or are covering new ground, I ask, “Is this the kind of conversation you have at home or are you saying some new things?” or “Are you getting something out of this fight—a chance to say a few things or hear a few things? Or is it frustrating and the kind of fight that you’ve come to therapy to stop?" or “In what ways is this conversation useful and in what ways is it not so useful?” 
 
If I’m concerned that they are going to leave the session angry and alienated, I might say “We have only 5 minutes left and it looks like you are going to leave the session angry and alienated. What is it going to be like on the way home? How long is the bad feeling likely to last and how are you likely to work out of it?”
 
I get the partners’ help in figuring out what the session is about. At the end of each session, I ask, “What are you taking away from this session that’s useful, if anything, and what has been not so great about it?”
 
Some years ago Lynn Hoffman wrote about putting clients on the board of directors. That’s what I’m trying to do. I’m appealing to the partners as consultants in dealing with the problems I am having conducting the therapy. By appealing to them in this way, I am creating a perch (a platform, a metalevel) from which the three of us can look at what is going on in the therapy, providing a sense of safety (they’re not left wondering what I’m thinking; I’m telling them), modeling how they could confide in each other (a goal I have for them is to develop such a platform with each other), and doing something for myself (it’s relieving to be able to share the problem with the couple).

Ethical and Legal Issues in Telephone Therapy

Posted on by Psychotherapy.net Team

With today’s technology we are an ever mobile yet increasingly connected society. For example, a client who you have been treating in office and perhaps with a few phone sessions when he was stuck downtown at his office has now relocated out of state and wants to continue his therapy sessions. With telephone, Skype and e-mail, why not? Why not expand your practice and “see” patients across the country, especially if you have expertise in an area of treatment?

Over the past decade or so therapists have been warned of the pitfalls of telehealth. For example, bogus identities, unintended recipients, individuals lurking in group therapy sessions. There can also be misunderstanding or unavailability of the nuances of communication (verbal and nonverbal) through e-mail or the internet. In more recent years, various Codes of Ethics or statements from national organizations (ACA, APA, etc.) have provided guidelines about the need for informed consent, maintenance of privacy and confidentiality, and billing issues.

Most recently individual states have started to enact statutes regulating telehealth. While all 50 states have laws regarding general telehealth, only few have laws specific to psychologists and therapy. Few state licensing boards also have enacted formal regulations regarding telehealth practice. However, it seems to be only a matter of time until more states enact laws to protect their residents and to hold therapists accountable to their residents. The APA Practice Organization recently published an article about legal basics for psychologists and telehealth that has a concise review of the current legislative actions regarding this topic (APA Practice Organization. Telehealth: Legal Basics for Psychologists, Summer 2010)

Telehealth can be viewed in two broad categories: practice within state and practice across state lines. Within state, the therapist need only refer to the state specific statutes and good clinical practices. Providing therapy across state lines is a little trickier. The APA article noted that there is a strong legal argument that the therapist should be licensed in both the state in which the therapist resides and the state in which the client resides. Most states allow nonresident therapists to obtain a temporary license to practice for a prescribed number of days a year (often 30 days total). Although this may be cumbersome, it will decrease the probability of licensing board sanctions for practicing within another state without a license. Another alternative, for psychologists, is to obtain an interjurisdictional practice certificate to facilitate temporary practice in other states.

Framework for risk management: (1) Review the telehealth laws in your home state and the state of your client. (2) Contact the psychology board of your home state and the state of your client to identify specific telehealth policies. (3) Confirm with your insurance carrier the limitations , if any, to your policy for telehealth for in-state and between-state clients.

Gottman and Gray: The Two Johns

Posted on by Psychotherapy.net Team

Walk into any bookstore in America —perhaps the world—head for the psychology shelves, and there bound together until sales do them part are the two gurus of relationships, John Gottman and John Gray.

John Gottman virtually invented the science of observing behavior in relationships and can predict future happiness with scary accuracy from groans and grimaces we're scarcely ever aware of. He's a very prolific writer, but most of his work appears in the academic literature. A couple of years ago he penned a popular book, Why Marriages Succeed or Fail. It sells respectably.

Of course, nothing like the books by John Gray: at last count six million copies of Men Are from Mars, Women Are from Venus. Even his several other books— his latest is Mars and Venus on a Date—sell in the hundreds of thousands. Hey, why save a hot concept for married folks, or even adults? The Mars/Venus juggernaut is readying a kids' version. We haven't even talked about the audiotapes. A run on Broadway. Celebrity Line cruises. CD-ROMs. Seminars, and now the first franchise deal to hit psychotherapy. For a few thousand dollars, plus a yearly renewal fee, you too can buy the right to call yourself a Mars/Venus counseling center. You lack the professional credentials to practice? Don't worry—so does Gray. For somewhat less, anyone with a pulse and a purse can buy the right to lead Mars/Venus groups in the nabe.

John Gottman and John Gray, side by side. The placement invites—no, commands—a comparison of the two. How does their information and advice stack up? The short answer is that Gottman is the gold standard while Gray is the gold earner. Gottman creates top psychology, while Gray mines pop psychology: Even that he's turned into "poop psychology," in the words of one Psychology Today reader. We've extracted the pith from their writing and sayings to compile a handy crib sheet. Judge for yourself.

 A Tale of Two Relationship Gurus

Issue John Gottman John Gray
Chief Motivating Force Research Revenge (first wife Barbara de Angelis taught him seminar biz then ditched him).
Formal Research Naturalistic observation of couples living in apartment laboratory, plus video and physiological monitoring. None.
Number Of Couples Actively Studied 760 0
Longest Period Of Follow-Up 14 years 0
Academic Credentials Ph.D., University of Illinois Ph.D., Mail order, Columbia Pacific U. (unaccredited institution).
License Psychologist Driver
Number Of Journal Articles Written 109 0
Cardinal Rule Of Relationships What people think they do in relationships and what they do do are two different things. Men and women are different.
Defining Statement The everyday mindless moments are the basis of romance in marriages. Before 1950 men were men and women were women.
What Makes Marriage Work Making mental maps of each other's world. Heeding gender stereotypes.
What Makes Marriage Fail Heeding gender stereotypes. Misunderstanding gender differences in communication style.
Heroes Men who put the toilet seat down Men who escape to their cave
Role Of Gender Differences Mark of an ailing relationship. Recipe for success in relationships.
View Of Intimacy Comforts men Scares men
View Of Humor Right up there with sex; communicates acceptance. "Men will tolerate humor. Women won't."
Signs Of Marital Apocalypse Criticism, contempt, defensiveness, stonewalling. Arguing
How Spouses Do Best Accepting influence from one another. On separate planets.
Key Gender Difference Men's and women's bodies respond differently to conflict Women talk too much about feelings.
Why Men Withdraw Their stress systems are over-activated during marital conflict. They can only tolerate so much intimacy.
Cause Of Conflict Virtually inevitable between two people. She hates Super Bowl Sunday.
Men's Big Mistake Failing to deep breathe during conflict. Solving her problems.
Women's Big Mistake Stating complaints with criticism. Giving advice.
Why Men Don't Help More at Home Their brain cells were not trained to notice domestic themes. They give their all at the office.
Marriage Math There must be 5x as many positives as negatives in marriage. Men and women keep score differently.
What They Say About Each Other "I envy his financial success." "John who?"

This article was previously published in Psychology Today, November 1997 (Vol. 30, No. 6), © Hara Estroff Marano. Reprinted with permission

A Psychotherapist Returning from Vacation

Posted on by Psychotherapy.net Team

It’s been twenty-plus years now of returning from some sort of summer vacation to resume seeing clients.  I wake up this morning, still unsettled from my dream life, reminded that my own anxiety, seemingly under wraps, is not too far from the surface. As I mentally ready myself to go back to work, images and memories seep in from prior years: early in my career nervously wondering whether any clients would return; other times eagerly anticipating seeing a specific client or two, looking forward to continuing our work; and now, a sinking feeling as I recall the years surrounding my divorce, wondering how I could possibly be useful when my whole world was a jumble.  In the San Francisco climate, where the summer fog is the strongest reminder of the changing seasons, August vacations serve as a marker of years passing.

My mind races back to my first clients: I was just starting out, not yet licensed, and had a small office at 20 Van Ness St., above Bull’s Restaurant.  The restaurant’s long gone, my office perhaps now occupied by a CPA or web designer, or vacant in this economy.  And my clients, where are they now?  How are they now?  Raza, or was it Rasha . . . a beautiful young Iranian woman telling me angrily yet excitedly that we had just launched Operation Desert Storm. This was pre-internet, and some information was still passed on via word of mouth.  Or Michael, still aching from his mother’s death, and trying to come to grips with being gay. I was pleased to discover that I could really empathize with his struggles, even though they were so foreign to my own. Or Joanne, whom I shepherded through memories of sexual abuse into a better relationship, and eventual marriage. When her memories first started emerging, we were both stung, confused, taken off guard.  But we both hung in there and plowed through somehow.  It was new territory for both of us, though I’m fairly certain she benefitted from our meetings. But how many of my clients did I really help?  The experience I brought to those sessions as a therapist and as a human being seems so limited as I look back now.  But perhaps that was partially compensated by my enthusiasm?  I would like to think so, to give myself the benefit of the doubt.

My dreamlife and the wisps of anxiety that remain if I allow myself to linger in bed suggest that I am still the same person as I was 20 years ago, and perhaps 20 years before that.  But I do know a few more things about myself, and about life, and that translates into being a better therapist….at least for most of my clients.  I know that significant change is really possible:  I’ve seen it; I’ve experienced it.  And yet I’m also humbled by the hardships that life can throw at us, that no amount of positive psychology or cognitive restructuring can easily neutralize.

This summer’s vacation has been broken into a few blocks.  This past weekend my wife and I had a quick getaway to the Delta region, just two hours away in current time, yet another world apart. We passed through “islands” surrounded by levees, pear orchards and vineyards below sea level, and the only surviving Chinese quasi-ghost town paying tribute to the first generation of farmers and miners who experienced hardships and loneliness unimaginable to most of the worried well of today.  No therapy couches to provide comfort; gambling parlors and liquor had to suffice as a distraction. 

But the morning’s coffee, nytimes.com, and the megabytes of emails provide a sharp transition back to life-as-usual.  Clients are calling.  Appointments need to be juggled. This is what I do.  I don’t grow pears, which in itself is no easy task, and subject to the uncertainties of nature . . . but hopefully I can help my clients grow.