Category: Blog

Its the Psychiatric Meds, Stupid!

Posted on by Psychotherapy.net Team

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

Posted on by Psychotherapy.net Team

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.

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.