What the APA Apology Means for Black Psychiatry

On January 18, 2021, the world of psychiatry experienced something historic when the American Psychiatric Association acknowledged and issued an apology for their part in a history of racism¹. There is no doubt it was time for this monumental moment, which markedly took place on this year’s celebration of Martin Luther King, Jr. Day.

This apology doesn’t erase all of the history that is behind it, and it doesn’t solve everything that may come. Yet after the history that has led to the APA’s need for an apologetic statement, this is an important step forward. This is a milestone for Black psychiatry and for all of us, really, in the African American community. I believe it may even deserve its own place in the history books.

For Black American, the history of our country has been paved with injustices, many of which have had a lasting effect on every facet of mental health, from assessment to treatment. The trauma of the African American community goes back many generations to slavery. The history behind the need for the APA’s apology goes deep into our past and can still be seen in the current practice of psychiatry². Going back all the way to the very beginning, the necessity of this apology is painfully clear.

The roots of racism in the psychiatric field go back a very long time. Diagnoses of mental illness were used to justify the view of Black slaves as inferior human beings. A supposed mental illness invented by Samuel Cartwright called “dysaethesia aethiopica” was used to explain a slave’s “laziness” and disinterest in their forced lifestyle³. In those days, the work of mental health professionals was only used to harm Black Amercians, not help, as it is meant to do.

The APA was meant to be an institution that kept racism from being fully actualized. The organization should have been there for the mental health support of all Amercians. Instead it was founded on principles that allowed Black patients and White patients to receive separate and vastly different levels of quality in care. It should be clear who was given real support, and who was left to suffer.

Time and time again, injustices were suffered by the Black community, and APA was among those who remained silent. Again and again, the mental health of Black Americans was both damaged and neglected while society stayed silent. Racism remained an issue within American psychiatry and someone should have spoken up, but APA didn’t.

APA repeatedly did not support civil rights legislation meant to improve psychological conditions for Black people. They neglected at the most crucial of times to do anything more than offer mere consolation to the people who were really hurting. Regardless of how widespread race-related inequality was at the time, the APA has missed many opportunities to speak up before this recent apology.

This history has piled onto the state of mental health for Black patients today, and it is about time that we hear the APA take accountability for its actions and inaction. Racist beliefs were integral to the damage that has been caused in the long history of Black psychiatry in this country. African Americans were declared biologically inferior, and that bias never fully went away. From Cartwright’s categorization of an entire race of people as simple and lacking emotional complexity, to the still very recent disproportionate diagnosis of schizophrenia in the BIPOC (Black, Indigenous, and People of Color) community?, systematic racism runs through the field of mental health and has done so for a very long time.

The APA’s apology is a small step in the right direction. The damage done has been far too great, but this is not insignificant. Truly, it represents something incredible. Mental health treatment is so important for people, especially for those in the Black community. This is the work that helps people heal from trauma and address the disorders and mental struggles that make everyday life difficult. With the apology we have received from APA, we can gladly find ourselves so much closer to reaching what the mental health system in this country should be.

What this represents is hope. We have made it a great deal forward, and now we can continue to find hope for better in our future. On the day that I saw this apology, I celebrated, not just for the moment itself, but for what this means for what may come. While I’m glad for the APA’s apology, I’m excited to see more medical organizations stepping up to do the same. I have hope that this is only the beginning, and that this apology truly represents a positive move towards improved mental wellness in our community.

References
American Psychiatric Association. (2021, January 18). APA apologizes for its support of racism in psychiatry. American Psychiatric Association. https://www.psychiatry.org/newsroom/news-releases/apa-apologizes-for-its-support-of-racism-in-psychiatry.

American Psychiatric Association. (2021, January 18). Historical addendum to APA's Apology to Black, Indigenous and People of Color for Its Support of Structural Racism in Psychiatry. American Psychiatric Association.
https://www.psychiatry.org/newsroom/historical-addendum-to-apa-apology.

In 1851 a scientist “discovered” a disease that caused slaves to run away, this was the prescribed cure… (n.d.). Watch the Yard. Retrieved 16 March, 2021, from https://www.watchtheyard.com/history/drapetomania-dysaesthesia-aethiopica/.

Schwartz, R. C., & Blankenship, D. M. (2014). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World Journal of Psychiatry, 4(4), 133–140. https://doi.org/10.5498/wjp.v4.i4.133

COVID, Counseling, and Caution: Ethical and Relational Concerns

It was a typical session on a normal day in late September; as typical and normal practicing therapy can be during a global pandemic.

Jonny, a Black male in his mid-50’s who worked in law enforcement, was referred to me by a former client. He was skeptical of therapy and the process. He decided to attend after several years of being cut off from his adult son, after his long-time partner gave him an ultimatum about committing to their relationship, and after his co-worker’s convincing him that the process could be useful for him. On this day in late September, it was our fourth session together.

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I don’t recall anything especially memorable about that session. We explored his beliefs on parenting and delved into some of the history with his son. We paralleled this relationship to the one he had with his own father, discussed the type of relationship he wanted to have with his son and what was holding him back from doing so. Of course, we followed all the guidelines for COVID that we had previously agreed to. Jonny did not sneeze, cough, or exhibit any symptoms of illness during this session.

I have a small private practice in a community where the COVID positivity test rate had been under 3% for about 6 weeks, considered low community spread. The city has a population of 95,000, and the number of people in the city who tested positive had remained at 10-15 cases per day during this timeframe. Despite the low risk of encountering a client who was positive with COVID, all my clients were offered the choice of telehealth or in-person office sessions. Jonny would not have participated in therapy if the only option was telehealth, as he clearly explained to me, because he needed to be able to “read people.” For our office visits, we sat six feet apart and both wore face coverings. I have an air filter to ventilate the air, we keep the office door open for more air circulation, hand sanitizer is located in multiple sections of the office, and there are few other people in the office at any given time. Clients text me from their car when they arrive, and I text them back when it is safe to enter, so that they avoid mingling with anyone in the waiting room. I clean and sanitize the office between sessions, as well as have a weekly cleaning service. Clients and I both agree to inform the other if we are experiencing any symptoms, and they sign a separate COVID informed consent about the risks of conducting therapy in person during a pandemic. It was no different with Johnny.

About five days after that last session, I began to feel poorly. Although I did not experience the signs of COVID that we are generally taught to look out for, such as fever, cough, fatigue, and body aches, I did experience excessive nasal congestion, headaches and a sore throat. A few days after the onset of these symptoms, Jonny sent me a message to let me know that he had tested positive for COVID and was in the hospital receiving treatment. I made an appointment to get tested and learned 48 hours later that I was also positive. I experienced a mild case.

Ethical Dilemmas

The first ethical dilemma I encountered was that I needed to self -disclose my positive status to the clients who had potentially been exposed prior to learning of my status. I also needed to disclose to my other clients that any sessions while I was in quarantine would be done virtually. While therapists range in the amount of disclosure they do with their clients, I would rate my usual disclosure level at less than most therapists. I was fearful of disclosing to a few of them, as their anxiety about COVID had been high, prompting their seeking out services initially. How much information was necessary, and how much was too much? I prepared a basic speech with the facts and the importance of noticing symptoms and getting tested themselves. Some responded well; others less so. How to manage this anxiety? As clients check in with me about how I am doing, how much should I disclose? Will I feel differently towards clients who do not ask?

The second ethical dilemma I experienced occurred when the Health Department contacted me to gather basic information and begin the process of contact tracing. When they asked me to provide the name of the person whom I believed I had contracted the virus from, I was faced with the challenge of whether it was necessary to provide the client’s identifying information. Does this fall into the category of “harm to others,” one of the exceptions to maintaining client confidentiality? As my client was hospitalized, I felt confident that this information had already been sufficiently recorded, so I declined to provide identifying information and maintained his confidentiality. And yet, what if that had not been the case? When does public health outweigh the client’s right to confidentiality about receiving therapeutic services?

Relational Dilemmas and Further Questions

As of this writing, Jonny is still recovering, and I have not yet seen him again. I believe that he was unaware that he had been exposed and that he was in the asymptomatic stage of COVID prior to symptom onset. Due to this, I am not angry with him, I do not blame him for my exposure, and I am concerned about how he is feeling. And yet, what if I were less certain? Would I be able to continue working with him if I believed he suspected exposure or covered his symptoms and attended the session regardless? What if I viewed him as a “risk-taker” outside of our sessions, which prompted his exposure? If he experiences guilt over exposing me inadvertently, would that affect our relationship and work together?

Of the clients I contacted, only one family has tested positive, a 25-year-old daughter and 66-year-old mother who, ironically, were attending therapy because the daughter was concerned that her mother was engaging in too many risky behaviors regarding COVID and her health. Both are currently hospitalized. How will this experience affect our work together? Will they want to continue with me in therapy, assuming their health stabilizes? Although I have no way of knowing that I had been exposed at the time of their last session and was not exhibiting any symptoms, is there anything I could have/should have done differently?

Some of my colleagues believe that we should only be conducting telehealth sessions during this time, and many of them have not yet returned to live sessions. And yet, we are seven months into this pandemic, and the county is in Stage 3 of re-opening. At what point is it considered “safe enough” to resume? How many clients are not seeking services because telehealth fails to appeal to them? Black men as a group can be mistrustful of receiving therapeutic services, so what might be the ethics of refusing to offer these clients other format options? When do the benefits outweigh the risks?

* * *


We are encountering many ethical challenges during this time. As essential mental health workers, we are also on the frontlines of this crisis and play an important role in helping people to get through this time of uncertainty. These situations prompt few answers, only generating more and more questions to ponder.  

Robert J. Lifton on Political Violence, Activism and Life as a Psycho-Historian

The Psycho-Historian

Deb Kory: Robert Lifton, you’ve long been one of my heroes, and I’m delighted to be able to interview you and share your work with our readers. For those who may not know, you are a psychiatrist, researcher and writer, and have written many books on the psychology of political violence, the effects of such violence on both perpetrators and victims, totalitarian ideologies, the traumas of war, the threat of nuclear weapons, and much more.
I’m an early career psychologist and I started my doctoral program back in 2004, just before revelations emerged about psychologist’s involvement in torture at Guantanamo and other CIA black sites. It would turn out that the involvement went up to the highest levels of the American Psychological Association, but outside of a small group of activist psychologists, nobody in the field of psychology was talking about it. You were among the few mental health practitioners who publicly denounced this collusion with torture from the very beginning. When I wrote my dissertation on this subject, I drew heavily from your writings, particularly The Nazi Doctors: Medical Killing and the Psychology of Genocide, to help me understand and contextualize how seemingly normal, good people can commit evil acts.
As I came to learn through reading several of your books, your activism and commitment to social justice has been a fundamental and inextricable part of your professional work as a psychiatrist, researcher and writer.
Robert J. Lifton: Well, thank you.
DK: Your most recent book, Witness to an Extreme Century: A Memoir, weaves together your various works with your personal life, and the ways in which witnessing atrocities—you were a teenager during WWII, for example—impacted the course of your life. In it, you call yourself a “psycho-historian.” Can you explain what that means?
RL: It means applying a psychological approach to historical events, which requires a handling of psychology that is open-ended and sometimes outside of the orthodoxies within our field. The derivation is from Erik Erikson, who used the term as an adjective—he spoke of a “psychohistorical perspective.” It’s probably better to avoid the noun.
DK: When you say applying psychological methods, are you talking about research methods in particular?
RL: In my case, I’ve systematically used a psychological interview. I believe very much in the interview method. Though I haven’t spent much of my career doing psychotherapy, I have done a kind of equivalent by means of interviews. I think that the psychological interview is a beautiful instrument if one is careful and rigorous about the context. And it’s underused, even in the profession of psychology.
DK: How so?
RL: In terms of psychological research, the interview has become much less popular—the tendency is more toward questionnaires or statistical studies these days. The interview method that I have made use of is a modification of a psychoanalytic method. I was trained in psychoanalytic psychiatry, as we used to call it, and then had some training in psychoanalysis, but there was a kind of paradox for me. I thought then, as I still do, that psychoanalysis has been a great intellectual movement; but in its more rigid and dogmatic form, it can undermine the very historical approach that one wants to develop. So I modified it quite a lot.
DK: You talked in your autobiography about studying at the Psychoanalytic Institute in Boston and how you found some similarities between the kind of totalitarian mentality that you’d found among survivors of Chinese thought reform and the atmosphere at the institute. Can you say a little bit more about that?
RL: I was careful about how I wrote about that. I didn’t dismiss psychoanalytic training and, as a matter of fact, I learned a great deal from the psychoanalytic training that I did. But I found that there was an inherent problem in psychoanalytic institutes. Many others had spoken of it, but I had studied Chinese thought reform as well as the Cultural Revolution and so had that framework. The difficulty in psychoanalytic institutes at the time was that one was simultaneously a student, a candidate, and a patient. In a sense, the same people were one’s teachers, one’s therapists, and one’s judges in terms of whether one was accepted into the profession. There was a danger of requiring adherence to the existing doctrines as a necessary element for success, as opposed to originality or a creative perspective.
So I said those things, and I made the comparison with a thought-reform like environment. I did it carefully, but it was a fairly bold thing to do at that early stage of my own work.
DK: Were you ousted?
RL: No, no, I wasn’t ousted at all. There have always been within psychoanalysis people who are more open and more critical of their own group. Erikson was like that himself, as have been many other psychoanalysts whom I’ve known over the years. In fact, over time psychoanalysts have invited me to their programs—I’ve spoken at various institutes and groups. I chose to discontinue psychoanalytic training when I received a chair at Yale back in 1962, both because I had reservations about the dogma, but also because I had no need to become a psychoanalyst in terms of the direction I was going in my research. But, still, psychoanalytic tradition has a lot to offer and has been important to me in my work.
DK: You also wrote that breaking away from the Institute and the psychoanalytic framework allowed you to approach Freud in a new way and to connect to some of his more radical ideas.
RL: Yes, that was important to me. Back then, Freud had almost a deified kind of standing at the institute, and there were constraints on criticism and open-minded thinking that might find him lacking in any way. And so it was more difficult for someone like me to really engage with his ideas in a creative way. Later when I left the Institute, I was free to do that and did so in particular in relation to death and death imagery, which I was exploring after my study of Hiroshima survivors. I found that Freud had a lot to say about these things if one could translate the instinctual rhetoric into a rhetoric of symbolization. That’s what I tried to do in relationship to death imagery in one of the books that I wrote in those early years, in 1979, called The Broken Connection: On Death and the Continuity of Life. It was about those issues as they affected psychological and psychiatric thinking in general.

Hiroshima and the Symbolization of Death

DK: Can you explain what you mean by the symbolization of death? It sounds in some ways like an existentialist perspective.
RL: I don’t call it existential or phenomenological, but it resembles that kind of approach in many ways. What I mean by a symbolizing approach is that Freud did speak of symbols in his work, but it was more in terms of one thing representing another. A pen symbolizes a penis or whatever. But a broader approach to symbolization came through Ernst Cassirer and Susanne Langer, symbolic philosophers. Their idea of symbolization is that the mind can perceive nothing without recreating it, at least during adulthood and during mid and late childhood. We are inveterate symbolizers. And that means that every perception includes a recreation with this wonderful and sometimes dangerous gray matter of the human brain, so that we recast every perception and have no choice but to do so.
That’s what symbolization really is. And in that sense, although Freud rightly emphasized denial of death, I could evolve making use of his work and also the work of Otto Rank, a great early psychoanalyst, the idea of the symbolization of immortality—not as a denial of death, but as a symbolization of human continuity. Because we’re a cultural animal, we need to feel a continuity with those who go before and those who will go on after what we know to be our limited life span. And that is a symbolization of immortality rather than a literal claim to it, which of course is never realizable.
DK: It sounds like a non-religious way of thinking about what happens after death. Did these ideas emerge out of your study on Hiroshima survivors?
RL: Much of this research about death and death symbolism did evolve from my work in Hiroshima. And it’s my way of developing a secular perspective—because I remain secular—that takes into account some of the insights that have been developed in relationship to death, but also in relationship to what is thought to be immortality or some kind of afterlife.
My approach is a natural one. It’s never supernatural. But what I’ve learned is that the mind and the brain are extraordinary instruments that, in extreme situations, can go places that we find hard to imagine.
DK: You have been exposed to a great deal of death imagery not only through your research in Hiroshima, but with Vietnam vets, Nazi doctors, and other research you’ve done. What do you think drew you to this kind of work and to these questions?
RL: It’s not easy to answer that question, and I don’t think there’s any single characteristic or single experience that drew me to these events. I hadn’t probed the issue of death and death symbolism until my Hiroshima study, and I came to my Hiroshima work through a certain kind of activism leading to scholarship, rather than in reverse, as we usually think about it. It was through my exposure to a group called the Committee of Correspondence in Cambridge [MA] led by David Riesman in the late ‘50s. He was an early antinuclear academic, a sociologist who probed ways in which nuclear weapons were harming our society and our social institutions.
It was because of him and others in the group that when I was in Japan subsequently in the early 1960s to do a study of Japanese youth, I decided to make the trip to Hiroshima.
I was stunned to find that nobody had ever done a comprehensive study of that first atomic bomb. I developed a principle, which may not always hold up to scrutiny, that the larger a human event, the less likely it is to be studied. It’s difficult to study large events, and we don’t like to get out of our comfort zone, which a study like that certainly required.
I was then just beginning my chair at Yale and I was able to work out with the chairman of my department an arrangement to stay on in Hiroshima for six months to do the study. But it was the exposure to activism that led to the scholarship, and then I tried to do the work very systematically through interview methods in a modified way. The book I wrote from that study, Death in Life: Survivors of Hiroshima, was my scholarly contribution to antinuclear activism.

Combining Scholarship with Activism

DK: You say in your autobiography, “I was groping for ways of expressing in my work and in my life deeper opposition to what America was doing and becoming. The sequence involved for me consisted of first outrage, then research to deepen knowledge, and then protest in the form of writing and action.”

Most people don’t associate psychiatry and psychology with activism. Did you feel like you were forging a totally new path? Or were there other psychiatrists doing what you were doing?

RL: I was intent on combining scholarship and activism. I didn’t call it that at the very beginning, but I came to the realization that I wanted to combine them over time. There were a few others doing it at the time and I think there always are people doing it in any given field. I think each of us who tries to combine scholarship with activism does it in his or her own fashion.

There’s great value in obtaining good training for one’s profession, in deeply learning the trade we’re doing and combining that with activism. One can make certain kinds of contributions through professional knowledge that enhance activism in a way that contributions without that professional knowledge wouldn’t be able to do.

There are always some people, however few, who can look critically at their profession and yet see value in its tradition. In the case of psychology, as you know, there have been quite a number of very good psychologists who have spoken out passionately in opposing the American Psychological Association’s involvement with torture.

DK: Yes, like the folks at Psychologists for Social Responsibility who kept this in the media and fought against it for over a decade, finally getting a resolution through the APA to remove psychologists from all national security interrogations last year in 2015.
RL: They’ve always been there. And one no doubt has to seek them out and work with them and find ways in both one’s training and in one’s life to combine scholarship with activism. It can be done.

Of course, institutions can be backward and can, as we saw in the case of the American Psychological Association, take dangerous directions. But mostly if one is rigorously combining scholarship and activism, one is not really that condemned and on the whole one is honored for the effort. It’s demanding and it can lead to moments of conflict and difficulty, but it’s also rewarding.

DK: Well, it requires going against the grain, right?
RL: It’s going against the grain of the mainstream, but there is much in cultural experience that goes against the grain of the mainstream. One way of looking at it is that every profession has an ethical dimension as well as a technical one, and it’s a good thing to be well trained in the technical aspects of one’s profession, but not at the expense of ethics.

I was very aware of this in relation to studying Nazi doctors. Some of my friends warned me against doing it because they thought I would simply reduce them to psychopathology and lose sight of the ethical issues. I thought that was a fair warning and decided that whatever I did, I would look to both psychological and ethical elements, never leaving out the latter.

DK: That must have been difficult.
RL: In my work on Vietnam, I talked about the scandalous moment that we reached during the Vietnam War, where the duty of psychologists and psychiatrists was to help soldiers, traumatized by what they were seeing and doing, return to duty and daily atrocities.
DK: That reminds me of the army resilience training that positive psychologist Martin Seligman has been doing at the University of Pennsylvania. Among other things it’s designed to help troops better withstand multiple deployments in places like Afghanistan.
RL: When this was happening in Vietnam, I began to study the history of the concept of “profession.” It was originally a religious concept, a profession of faith, and then with our secular age it became more and more technical. Professions became learning technical details specific to that profession, and that technicization was highly overdone at the expense of the ethical dimension. We need to newly incorporate the ethical dimension to combine it with the techniques that we learn in our profession. That idea has been a common theme throughout my work.
DK: How do you imagine the ethical dimension being reincorporated into training? It strikes me that in the ethics classes that we take in psychology training, often times we’re dealing with thorny individual situations—when to break confidentiality, what’s the best way to protect yourself from lawsuits etc.—but we are rarely taught how to break free from toxic groupthink, how to stand up against immoral ethical transgressions like what happened in the American Psychological Association, how to dismantle unethical systems that might be contributing to the mental illness of the patients we see. We’re not often tackling these larger ethical issues that are deeply wounding and affecting the people we see in therapy. It can feel like a kind of resilience training we’re doing, helping people better navigate an unjust world without tackling the injustice that brings them to us.
RL: I think each of us can question things in the world around us, but there is no perfect answer to this problem. It’s not always possible to combine one’s activism with one’s professional work, sometimes they are things you do in parallel ways. Sometimes that means working with an institution that doesn’t live up to one’s activist principles, one’s activist desires, but I think it’s a constant balance one struggles for within oneself.

In work with patients, even if one doesn’t impose on them a full expression of all that one believes about how the world should be, every patient in psychotherapy has a strong sense of the ethical and political qualities of a therapist.

Even when things are not said. One’s holding to these principles does make its way into the relationship. And, of course, these are things that can be discussed in therapy, though one has to use one’s judgment about that. But I’m not one to give extensive advice about therapy. It’s not an area of expertise of mine at all.

DK: What went into your choice to not become a clinician?
RL: I was trained in psychotherapy and I did some of it early on, but relatively little. I began doing research and I found that the research I did was so involving and I was so intensely bound up with it that I wanted to deepen it and extend it. Doing individual therapy in a way was a distraction from that kind of research. Individual therapy requires one’s presence and a lot of one’s imagination. It’s very demanding and it’s also very satisfying. I felt its demands and I even enjoyed it, but I really preferred to develop the research, which I did with great intensity, and that required giving up the work in therapy.

The Nazi Doctors

DK: You’ve written many well-known books, but Nazi Doctors is one of your most well-known. When I read it, I was shocked that you were able to have so much face-to-face time with people I assumed would have been in prison. They had obviously perpetrated or witnessed a great deal of atrocity, some were still Hitler enthusiasts, and they were just living life in post-war-Germany like everything was dandy.
RL: It was the most difficult study I did. It was hard to sit down with Nazi doctors, you’re right. Most of them were not fanatical, but they tried to present themselves to me as conservative professionals who had experienced pressures during the Nazi era and tried to handle them as well as they could.

They knew I didn’t accept that self-presentation, but I worked from a standpoint of probing them and constantly asking questions and then asking more questions rather than confronting them and calling them evil or anything of that sort.

What happened in general with most of them was that they were surprisingly ready to talk to me, but behaved as though that person during the Nazi era was somebody different from the person sitting with me in the room, and that he and I were talking about that earlier figure as a third person—a kind of extreme dissociation.

I studied as much as I could about the particular person I was talking to, what people in his situation with the Nazis actually did, so I had a considerable knowledge of the context in most cases before I even sat down with them.

There were one or two who remained ardent Nazis in a way, but mostly they didn’t. Still, it was very uncomfortable and partly I could manage it because I knew I would have my say in the book I would write. And I deeply valued the research enterprise, its potential to say something that other studies of Nazi behavior couldn’t say.

DK: I researched those studies for my dissertation, particularly Stanley Milgram’s studies on obedience around the same time that Hanna Arendt was writing for The New Yorker about Adolph Eichmann’s trial in Jerusalem, both of them coming to the conclusion that normal people can, indeed, commit atrocities. It was a big scandal to say at the time that Nazis were human beings, not monsters. Were you worried that your work would humanize them too much?
RL: Some people were worried about that. But, you know, they were human and that was the problem. They were human beings. They were human beings who did evil things.

Evil things are only done by human beings in my view, not by god or by the devil, but by fellow human beings. And in that sense, yes, I had to encounter all of their sides. Not humanizing them to the extent of leaving out or negating their evil, but rather recognizing and trying to probe ways in which human beings are capable of evil, or what I came to call the psychological and historical circumstances that are conducive to evil.

DK: What you call, “atrocity-producing situations?”
RL: Yes, atrocity-producing situations are those in which ordinary people may be socialized to evil. They come to belong to a group in which the norm is destructive—murderers in Auschwitz, let’s say. Or even in Vietnam. And since we are social animals and we all belong to groups, we never work totally in isolation intellectually or emotionally. If one enters into a group which holds an ideology of genocide or mass killing, one tends to internalize much of that ideology. That is a way in which human beings carry out evil projects and, of course, do so as human beings.
DK: Was one of the difficulties of doing this work that you could sort of imagine yourself in their shoes?
RL: One has to wonder that. If I had been a German, would I have done some of the things that they did? I wouldn’t necessarily condemn myself and say I would have, but one has to ask oneself that kind of question. And one has to also come to value, as I did, those who opposed the Nazis. For instance, I became a friend of two of the few psychoanalytic heroes I know of, Alexander and Margarete Mitscherlich, a husband and wife who were anti-Nazis and were part of the underground during the Nazis era at great risk. He reintroduced Freudian psychoanalysis into Germany after the war and was the first to expose, on the basis of the Nuremburg medical trial, the deeds of Nazi doctors.

I also met Jewish survivors of Auschwitz who had managed to remain healers while in Auschwitz. So there were people one could admire in those extreme situations and one could at least hope that one would have been among them, should one have been exposed to that sort of pressure. But who can be sure?

DK: Do you hope through this kind of research to prepare people to be among the helpers, the healers?
RL: Yes, the research is very much meant to expose the destructive behavior, the killing, and assert its opposite, the healing. In all of the studies I’ve done, I’ve looked at the alternative to the extremity of behavior that I was studying. Even in my first study of Chinese thought reform, which applied great pressure in coercing change in people, I had a long concluding section on what I called “open personal change.” All of my work is in the service of openness and healing and ultimately justice, even though—or particularly because—it studies the opposite.
DK: Do you think that people who deny their own darkness are more likely to act out in evil ways?
RL: I think we all have a potential for destructive or evil behavior. When I completed my work on Nazi doctors, people would say, now what do you think of your fellow human beings? And most people expected that I’d completely lost my faith in humanity, but what I said was, “We can go either way.”

I haven’t lost my sense of possibility in human beings. And, yes, we do have a potential for destruction. Somebody wrote a book called We Are All Nazis and I didn’t like that kind of approach because it ceases to make distinctions. Having the potential for evil is very different than actually engaging in evil behavior. But we all have a potential for destructive behavior and it’s well to look at that.

I think that the relationship to ideology and groups that form around ideology has a lot to do with which direction we take. By ideology, I mean idea structures that have intensity and which explain aspects of the world to us. This is something we all engage in, even though we Americans like to think we’re non-ideological. The kind of idea structures we embrace and the groups that we immerse ourselves in have a lot to do with which aspects of the human potential we find ourselves expressing.

DK: Is your concept of the “protean self” a counter to this more strictly ideological way of being?
RL: Well, the protean self is a counter to the more rigid, fixed self and to the totalistic tendencies that I am averse to or even allergic to. The all-or-none kinds of totalism that I studied and wrote about in my first study of Chinese thought reform in particular. What I found is that the reverse of totalism is a kind of proteanism, which has surprising capacity for change and transformation and for a multiplicity of elements in one’s character or personality. This has its vulnerabilities, too, but at least means that we needn’t be stuck in totalitarian dogma. To the extent that we are protean, there are constant opportunities for new beginnings.
DK: Does it mean just being a flexible, open person?
RL: Yes, it does, but also more than that. It’s consistent with flexibility and openness, and a capacity for change and transformation.

Apocalyptic Violence

DK: In your book, Destroying the World to Save It: Shinrikyo, Apocalyptic Violence, and the New Global Terrorism, you do a study on the Japanese cult that released sarin nerve gas in the Tokyo subways. We’re certainly living in a time of apocalyptic violence and I’m wondering what your study in this book has to teach us about it more generally.
RL: The Japanese cult, Aum Shinrikyo, was notably apocalyptic. The guru and his close disciples believed passionately in the end of the world, and in actively contributing to that end. It was an example of what the ancient Rabbis called “forcing the end.” I write of an ancient rabbinical dialogue about whether it’s correct for people, for rabbis, to advise joining in the violence to force the end of the world and help bring about the appearance of the messiah. The rabbis decided against it, saying that only god kept that timetable.

But some of the most extreme groups do embrace violence to bring about the end of the world, as did Aum Shinrikyo. And there are certain American right-wing groups that have that intent, who have tried to destroy the government through acts of violence, and contribute to an apocalyptic vision, as well as to forcing the end.

But there’s also a lot of apocalyptic thinking in this country without necessarily resorting to violence. There are confused, highly fundamentalist groups in America with an element of apocalypticism who, for instance, deny climate change. They say that only god could change the climate, that it would be impossible for human beings to be responsible for it. And some of those people are in the mainstream of American political life in the Republican Party. That’s a fundamentalist approach that can also be apocalyptic. It isn’t necessarily violent, but it can be highly dangerous.

DK: Do you think that the war on terror, particularly as it was waged by George W. Bush, had elements of apocalypticism in it?
RL: Yes, it did. I wrote about this in my book, Superpower Syndrome: America’s Apocalyptic Confrontation with the World. George W. Bush saw it as a war against evil and that takes on something close to an apocalyptic tendency. To destroy evil is to create an endless war against an enemy that can never be destroyed. It also is to polarize the world into one’s own good and the evil of the other. It’s that tendency that we’re seeing now with regard to terrorism.

Terrorism is real. And ISIS is a real danger. And it’s a highly apocalyptic and murderous movement. But there’s a tendency among some groups in this country to view it the way that communism was viewed in the past as absolute evil in contrast to our absolute good. That radical polarization of the world is enormously harmful and can feed violence ultimately rather than diminish it.

DK: Is that the kind of historical issue that you bring your psychological methods and moral complexity to, for purposes of understanding the “other”?
RL: That’s right. Moral complexity becomes extremely important. That’s where we psychologists and psychiatrists can have something to say.

Climate Change and the Nuclear Threat

DK: Right now you’re working on a book about climate change and you are also making a connection between the antinuclear movement and the climate change movement. You basically never hear about nuclear proliferation these days and I’m wondering why people aren’t more freaked out by it. To my knowledge, the world’s arsenals have only gotten bigger.
RL: Yes. The nuclear threat is still very much with us and there are people who are saying this, but it has lost its visibility in a larger society. So there’s a gap between mind and threat. During the ‘80s, the heyday of the antinuclear movement, when there was the million-person demonstration in Central Park and the nuclear freeze or moratorium, there was a certain amount of fear that was useful. And there was a closer relationship between mind and threat.

I don’t equate nuclear threat with climate threat, but I look at the nuclear threat and the antinuclear movement for both parallels and differences in order to think more critically and understand the challenges of climate change.

They both are realities that threaten the human future; they both have world-ending possibilities—yet they both are movements that the human mind is capable of addressing. We haven’t figured this out in time to prevent enormous amounts of suffering because of climate change, and there’s a great amount of work that has to be done even to limit that suffering. Nonetheless, there is a demonstration of what I call “formed awareness” about the nature of climate change that has great value to us because it’s the basis for anything constructive that we do in that area.

DK: But there’s not that sense of imminent crisis that the threat of nuclear war gives us.
RL: The comparisons are complicated because, yes, there’s something about a bomb—it’s an entity, it’s a thing that explodes and destroys a city. We saw that in Hiroshima and Nagasaki and I’ve experienced it viscerally by studying it in Hiroshima. Climate doesn’t do that. It’s a slower incremental series of changes, but what’s changed now in relation to the climate threat is that it’s become more active. We’ve had hurricanes and floods—
DK: Super storms.
RL: We’ve had coast lines being destroyed. It’s closer to us. The gap between mind and threat is narrowing. Climate change has become not just something that will become much worse in the future—it will if we don’t do more about it—but also something that’s now affecting and threatening us in profound ways at this moment. So, that distinction between the two is still there, but it’s lessening. And climate change is closer to us as a real threat.
DK: Well thank you so much. This has been such an interesting conversation.
RL: You’re very welcome.

Ethics of Treating Two Psychotherapy Clients who Know Each Other

A question was recently posed to us about what to do when you discover in an early session with a new client that they are the former partner of another well-established client. Well, for those of you who actually stopped to think, “Oh, this may be a problem,” then you are certainly one step further away from sliding down the slippery slope of unethical behavior than those who did not recognize that this situation may pose a potential ethical dilemma. Professional codes of ethics (e.g. APA 3.06, NASW 1.06) ask us to be mindful of conflicts of interest that arise and to take steps to resolve them. The best resolution is to refer the new client to another therapist (if possible).

For those of you who can refer this new client to another therapist, then the question arises as to how to do so in an ethical manner. First, remember that you cannot ask permission to disclose your relationship with the other client because this will breach patient confidentiality. You can, however, simply express that in reviewing this new client’s case you believe he/she would be better served by a different therapist who is more closely matched or specialized with his/her needs. Remember, you are not mandated to treat every client who seeks treatment from you. Second, provide the names of two or three therapists who currently have openings for new clients in their practice. It is important that these referral therapists have the capability to accept new clients at the time so that continuity of treatment is maintained and the client’s (potential) feelings of abandonment are diminished. Third, if you terminate in a responsible clinical manner then you will likely be terminating in a responsible ethical manner. Thus, if you terminate in accord with the standard of care for your theoretical orientation, using good clinical skills to transition the new client and allowing them to feel heard about your decision, then you again decrease the probability of the client feeling abandoned which often leads to board complaints. Last, provide a written termination letter confirming the termination of treatment and the referral therapists contact information. Keep a letter in your file as part of the clinical record.

Earlier I mentioned that this situation “may” pose a dilemma because if you practice in a small or rural town then you may encounter this situation frequently since you are one of the few practitioners available. In those situations, if you cannot refer out then it is best to have a clear plan as to how you will keep from falling down that slippery slope of potentially unprofessional conduct. For example, how will you handle information you learn from your well established client from seeping into your sessions with your new client, and vice versa? How will you identify and handle information learned from one client inadvertently influencing how you think about the other client? Consultation, and of course subsequent documentation of decisions and rationale, is a good way to keep your own personal biases and such influences in check.

As a general rule of thumb remember that our professional codes of ethics require us to be mindful of conflicts of interest that arise and to take steps to resolve them. While the best resolution (especially in this scenario) is to refer the new client to another therapist, if this course of action is not possible, and refusing service to a client is clearly detrimental to the client’s welfare, then chart and note the steps taken to minimize potential conflicts and difficulties that arise in the course of treatment. Such documentation is part of good (and mandated) record keeping procedures but also demonstrates your contemporaneous judgment, which is always your best proactive defense.
 

Ethical Guidelines: Do We Really Want What Is Best For Our Clients?

Most therapists are familiar with the affliction of Seasonal Affective Disorder (SAD). SAD impacts approximately seven million people each year in America, mainly women.

At one point in my career I shared a private practice office with a psychiatrist. She would use the office on some days and I would use it on others. When I entered the office for the first time I was struck by the fact that she had a phototherapy apparatus in the room. It was physically huge and was much larger than any commercial unit I had ever seen. Many experts believe that SAD is caused (or at least intensified) by a lack of sunlight. Hence, when the sun is not shining very often or the days get shorter depression sets in. Phototherapy devices fight the depression and emit massive amounts of full spectrum light. The phototherapy simulates or mimics the sunlight you would receive if you more spent time outdoors.
My initial reaction to this situation was beyond positive. I was elated that this psychiatrist was utilizing cutting edge technology. I thus decided to praise her and let her know in no uncertain terms that I was impressed.

The good doctor's reaction, nevertheless, was hardly what I expected. "Oh my gosh, no, I don't use it for my clients. That's fringe psychiatry. Somebody might think it was unethical. I might even be sued or reported to the Board of Healing Arts. I might be branded as a quack."

"Well what in the world is a light therapy lamp doing in your office?" I asked inquisitively.

"In the dreary short days of winter I am stuck in this office all day and I generally become extremely depressed, so I had an engineer build me a phototherapy unit that is stronger than anything you can purchase. As soon as my current patient exits the treatment room I flip on my phototherapy device. I then turn it off before the next patient enters the office."

Oh, so now I get it: It's good enough for you, but not for your patients. Go figure.

In one of my recent books, Favorite Counseling and Therapy Techniques, I share a fascinating story about a young man I treated who had such low self-esteem that he walked bent over like an ape. The kids at school thought it was hilarious and made the situation worse by calling him the Ape Man.

One reason for the young man's Ape Man posture was that he believed he was extremely ugly and could never date a nice young woman. To counter his feelings I set up a contrived situation in which a female colleague walked in the room and said, "Gosh, is that your client, he's really cute." He seemed shocked (exactly the reaction I wanted). I told him we weren't going to discuss his looks because we both knew he was an exceptionally good looking guy and there were serious issues of his we needed to work on. He walked out with the finest posture he had displayed in years. Cured, no. Improved, yes.

Unfortunately, I also point out in my book that today's ethics which stress informed consent would not permit an intervention of this ilk. The female colleague who gave him the compliment would need to be identified as part of the treatment or therapy team up front and there is a 99% chance he would have totally discounted her remarks as being staged. (The young man's mother had repeatedly told him he was a good looking guy many times to no avail.)

Along these same lines a client I shall call John came to see me who severely depressed. John's brother was a very well-known psychiatrist. Now I was aware of the fact that ethical codes frown on (or downright prohibit) dual or multiple relationships, but certainly John's brother knew another top notch psychiatrist who could help. Why was John seeking my little old services?

When I asked John why his brother did not provide a psychiatric referral John quoted his brother verbatim. "Look I give those dangerous psychiatric medicines to my patients, but I'm not going to let my family take them. You need psychotherapy."

I so I get it. It's not good enough for your family, but it's okay for your patients. Oh sorry, I think I said something similar to that that before.

I remember hearing a presentation given by Jay Haley once. He told a powerful story regarding a difficult client he had successfully treated. I raised my hand and asked if his psychotherapeutic intervention was in violation of the ethical principle of informed consent. It certainly seemed like that was the case.

Haley was silent for a moment and then grinned. "I never let ethics get in the way of good treatment."

The problem for those of us who are mere mortals is that Haley's philosophy might leave us without a therapist's license and standing in a long unemployment line.
 

Receiving Gifts in Psychotherapy

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”.

Ethical and Legal Issues in Telephone Therapy

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’s Guide to Facebook and Twitter: Why Clinicians Should Give a Tweet!

It seems strange today, but when I was a graduate student, nobody brought a laptop to school. I was lucky if my practicum sites had a computer that the office administrative assistant might permit me to use. I was the intern in the group who would beg whoever was working at the front desk to let me sneak on during our lunch hour so that I could check my email, write a quick blog post, or see what was happening on BMUG (Berkeley Mac Users Group). This was in 1998, which seems not very long ago, but which was eons ago in cybertime.

I’d been on the Internet since 1993, and I’d been a computer consultant for almost as long. By the time I enrolled in my PsyD program in 1996, I’d Internet dated, I’d connected with friendly folks across the country, and, I’d been on Craigslist when it was just a small email list sent out by Craig himself. I accessed Usenet before the World Wide Web was browsable, and “I spent much of 1994 lurking on support boards for polyamory and multiple personality disorder just because these forums allowed me to be a virtual fly on the wall and learn about the experiences of people whose lives were very different from mine.” The Internet was still a place that offered anonymity at that time, a land of pseudonyms and no powerful search engines to track the gingerbread crumbs back to your door. I can still remember what it sounded like when my 2400 bps modem connected to AOL: the distinctive sound of rubber band meets static as the modems on each side negotiated their connection.

I also remember becoming a psychology trainee a few years later and listening awkwardly when supervisors and professors spoke with confidence about people who were addicted to the Internet. Many of them made assumptions about those “Internet people." They were lazy couch potatoes who never left the house, or worse: antisocial porn addicts. “I seemed to be entering a field in which maybe my own Internet habits were a bit suspect.”

It’s now 2010 and it’s rare to find someone who isn’t on the Internet in some fashion. While many therapists may not have a social networking presence, most have email addresses and have used the Internet to locate a business, view a family member’s photos, or to watch a funny video on Youtube.

When I started my private psychotherapy practice in 2008, I made the shift from using the Internet for my personal life to using it in my professional life. An integral part of that shift entailed creating a website and a blog. In 2009, I expanded my professional Internet presence to include a Twitter account and a Facebook page for my private practice. Some other mental health professionals have been doing the same. It’s certainly a new era.

What is Social Media?

What is Facebook?

The main page of your Facebook profile is called a Wall and depending upon the privacy settings you select (which might limit who can post on your Wall, or who can even view the Wall itself) people can view things you post to your Wall or post items of their own onto your Wall. The sorts of things that get posted include Status Updates, which are brief comments you add about what you’re doing or something you care about. These Status Updates show up on the News Feed which is a constantly refreshing stream of what only an extremely social person could consider news: John just Liked a photo, Penny wrote on David’s Wall, Molly posted four pictures to Flickr (a photo-sharing site), Evan just overheard something funny. People also share news articles and Youtube videos or longer Notes, which are essays they write (or essays someone else wrote that someone wants to Share).

“Some people post incredibly personal updates on their Walls. I have been surprised more than once to learn of engagements, deaths, and divorces via Facebook Walls.” I sometimes discover this information reported on Facebook before ever getting a note or phone call from the person who posted the update. People have also used the Wall to share information about missing persons in their friend networks. News can travel fast, especially when people click the Share button and immediately are able to take a post from one user’s Wall and transmit it to everyone who reads their own Wall. When you have friend networks of 100–1000 people, you can imagine how this has become quite a tool for disseminating information.

This quick circulation of information has inspired some therapists to consider using Facebook as a platform for advertising their practices. Some do this directly from their Facebook profiles and others have created a separate business listing, known as a Page. If you can get friends, families, and strangers to Like your page (prior to April, 2010, they became a Fan of your Page), then others in their network can see this action and click through to your business to learn more.

Other therapists first get onto Facebook because they want to view family photos or find friends from high school or college. It’s a social networking site allowing you to connect to your friends and interact with them and their online profiles in a variety of ways. Where Facebook gets tricky for mental health professionals is that it is a personal space that exists in public.

Personal vs. Professional Space

Managing Friend Requests

Some therapists using Facebook have received requests from their current or former clients to add them as Friends. It is wise to think through how you plan to manage Friend requests from clients. Be mindful that inviting clients to your personal profile can be perceived as inviting them into your personal life. This can send mixed messages to clients, especially if they are unclear about therapeutic boundaries to begin with. “If you would never think of inviting a client to a cocktail party at your home with your friends and family present, then you may want to think twice about inviting them to be your Friend on Facebook (or approving their Friend requests).” It can be the online equivalent of inviting them into your social circle. It may also make them wonder who else in this social circle is in treatment with you. If clients try to add us as Friends on Facebook, or we try to Friend them (yes, thanks to Facebook "Friend" has become a verb)—even by either of us accidentally clicking on a link to invite everyone in our address book—the boundaries can become even more complicated. This suddenly brings up issues of confidentiality, dual role conflicts, and feelings of trust, boundaries, safety, and rejection. It can also create questions about whether you are responsible for attending to the information a client shares on her own profile and utilizing it in treatment.

Friends You Share

Pages vs. Profiles

The biggest problem with having a Page is that you will still have to decide how you feel about who Likes your practice. Will you want your family members listed on that Page for others to see? Will you accept current or former clients as people who endorse your Page? Having or allowing your clients to be connected to your public professional profile brings up issues of confidentiality. There is also the question of whether someone Liking your Page could be perceived as a testimonial. All Ethics Codes for psychologists, marriage and family therapists, and social workers prohibit us from requesting testimonials from current clients due to their being vulnerable to our influence. Is a Facebook Page a passive request for an endorsement or testimonial? This is one of the gray area questions that social media is raising for clinicians.

So What is Twitter?

Why, you may ask, would someone want to share 140 characters of information? Well, it’s a great way to direct people to news stories or make short announcements. Most people use it to share tidbits from their day and there are a lot of mundane Tweets about people’s life activities. But Twitter can get a lot more interesting if you search for news items or want to follow a conversation. For example, “some people have noticed that Twitter is the first place that they can find out if there was an earthquake in the San Francisco Bay Area and that those updates sometimes refresh more quickly than some of the well-known earthquake websites.”

If you’re presenting at a conference or offering a CE workshop or you have openings in a therapy group, Twitter can be one way to get that information out to your Followers. Yes, your Followers. That’s the cultish name Twitter gives to what others might refer to as subscribers of your content. When you sign up for a Twitter profile, you can start looking for others whom you might want to Follow, as well. You can search your address book to see if people you have exchanged email with are on there. This means that friends, family, and that random person you bought a futon from on Craigslist ten years ago will all show up if they have a Twitter account and if they’re in your contact list on your email account. But you can also browse Twitter’s suggested users to find people Tweeting on the topics you care about, and there are also Twitter directories if you want to search for more specialized information.

You can also have conversations with people on Twitter. You do this by @replying them. Your responses will show up on your Twitter profile page, and people can look at their @replies to see if others have responded to their messages. Twitter offers the ability to have either a public or private profile. Private profiles mean that only people you approve get to see your Tweets. If you have a public profile, anyone can read or reply to what you’re posting. Twitter also employs hashtags, which help people to find and follow conversations about a particular topic. Sometimes, people at a panel at a conference will assign the panel its own hashtag. For example a speaker may say: "This session has the hashtag #facebook_psych." When the hashtag is given, you can add the hashtag at the end of your Tweets so that others can click on it to find other public Tweets from people in the session. It also allows people outside the session to still participate in the conversation or ask questions of those who are there.

Why Would You Have a Professional Twitter Account?

My awkward moment occurred when I tried to use my friend network to publicize my practice on Twitter. I Tweeted on my locked, personal account that I was running a support group. A friend Retweeted it to his group of several hundred followers. While I appreciated his publicizing it to so many people, “I felt exposed and I realized that I didn't want my online pseudonym linked to my private practice.” I called him and explained and he deleted it immediately. This was how I recognized that maybe I couldn't have it both ways: using social networking to expand my reach but not allowing people to repost things. I wondered if it was time to create a Twitter account solely for my professional practice. But I wasn’t sure if anyone would be interested in what a psychologist had to say on Twitter.

Weeks later, in February 2009, I met with a friend for one of our co-working dates and I batted the idea of the professional Twitter account back and forth with him. Within the hour, I created my @drkkolmes Twitter profile, used it to link to a few of my blog posts, and then sent an email out to a bunch of friends. In the email, I let them all know that I would not be following friends back on the Twitter account, as it was my intent to only follow other mental health organizations. But I asked if they would be kind enough to follow or publicize the account to others. About 15 people did.

That’s how it began.

By the end of 2009, my Follower count was over 800 people, and more importantly, I’d forged a number of fruitful collaborative projects with other mental health Tweeps (people who Tweet) on Twitter.

Branding & Marketing

I make sure to only use my professional name to post psychology related news, news about my practice, or to respond to others who are talking about these matters. I want to be sure that people know what to expect when they see my name float across their screens, and what I’d like them to expect are thoughtful posts about professional topics of interest to me. I also want them to think of me when particular subjects come up that are related to my expressed interests, since then, they can also alert me to these items if they see them first. Occasionally on Twitter someone may Tweet: "@drkkolmes, you might want to see this post about therapists Googling their clients," and I am pleased that they are sharing something interesting with me. But I’m especially pleased that they know what my professional interests are and that they can quickly let me know where I can find out more.

Professional Collaborations

Transparency

I blog about psychology-related topics that interest me. Since I do not allow comments on my blog and I do not wish to spend my online time moderating comments or worrying about the identity of people posting on my site, I invite readers to comment via private email and on Twitter. Oftentimes, people will Retweet my blog posts on Twitter or briefly respond to them and we might have a brief chat about it.

Another example of utilizing social media transparency is my Facebook Private Practice Page which I experimented with last May and later disabled the following April. I never had clients become Fans of the Page and I was fairly clear in my policies and blog posts that I felt this would be a confidentiality concern. But I finally decided the Page provided more risks than benefits. I discussed my reasons to disable it (summarized below) on my blog and on Twitter. In this way, social media through blogging, Facebook posts, or even Tweets can provide a platform to convey your thinking on topics when it may not always make sense to bring these topics into each and every therapy session. But it makes your process of thinking about such things available if and when clients get curious to know more about how you came to particular decisions. I did a similar thing with the development of my Private Practice Social Media Policy, blogging about it as I wrote it, so that those who cared to could understand how I came to my conclusions.

Cautionary Tales

The biggest potential problem with Facebook tends to be around managing Friend requests and controlling who posts on your Wall. Clinicians vary on their attitudes about handling Friend requests. Some feel strongly that it’s important to welcome any clients who want to endorse their Pages. Others feel strongly that it’s a huge HIPAA, confidentiality, and dual-relationship can of worms, which isn’t worth the potential headaches.

When I experimented with my own Facebook Page for my private practice, I was very clear that I would not allow clients to become Fans or to Like the Page. This invited criticism from other professionals who felt I was conveying mixed messages by having a Page that clients could not Fan if they wished to do so. My office policies stated that I would remove clients if they became Fans and some professionals expressed concern that this could be experienced as hurtful and rejecting to my clients and that it was too harsh a response.

Ultimately, I chose to delete my Facebook Page because monitoring the Wall postings and scanning to see who had followed the Page felt like more time and energy than I wanted to spend. It was time spent on worry and risk management, rather than pleasure. Ironically, I never had a single negative experience with clients on my Facebook Page, but I did have a couple of situations in which supportive, well-meaning friends posted comments that were too personal for my own comfort. This is always a risk on any social media page that allows others to post or comment. You cannot control what others write. But you can hit Delete. And Deleting people’s comments may make them feel hurt or censored. It’s one thing when it’s your friends or family who are experiencing this. But when it’s your client, you have a clinical dilemma of your own making.

Pitfalls of Twitter

There are times when you may find yourself tempted to get caught up in passionate exchanges on Twitter on issues that are meaningful to you. The conversation can be experienced so quickly as Tweets refresh that it’s compelling to respond immediately. But it’s hard to make a strong argument and fine-tune one’s tone in 140 characters. I try to keep the focus on lively conversations but there have been times that I felt baited by provocative Tweeters. I have sat with my fingers hovering over my keyboard, trying to compose a Tweet that I’d feel comfortable with any and all of my clients finding at some point down the line. And I will admit to a handful of times that I’ve deleted Tweets when I wasn’t sure I wanted to live with them forever. This has happened when I wasn’t sure if I’d expressed myself well or when I felt a corny joke fell flat. (Note that these will still show up in RSS readers and be archived if you have posted them under a public account. There also used to be a website called Tweleted that allowed you to view Tweets that had been deleted by users with public accounts.)

As your number of Followers increases, you will have more random comments, questions, and spam directed your way. I've had to learn to resist the impulse to reply to every question or comment. It is wise to conserve your time and energy and focus on conversations that have high value to you, but being more selective may bump up against your own worries of being rude or ignoring folks.

There was a time when I felt that I should try to confine my Tweets to "normal" waking hours. I have a tendency to stay up late at night. I like the quiet hours when I do most of my inspired writing and when I’m least likely to be interrupted. Sometimes I wake up at night and I may wind up online where I’ll find an interesting psychology-related news item that I want to Tweet. For a while, I worried that clients might know too much about my habits if I posted late at night. At some point, I gave up on worrying about the timing of my Tweets and decided to allow myself to do what felt natural to my own rhythms. What a relief. Now I feel that so long as I'm fully showing up for client sessions, giving my patients my full attention, and keeping good boundaries about the content of my Tweets, when I Tweet is really my own business. But it is an interesting conflation of both personal and professional space. In a similar vein, clinicians with public Twitter accounts may want to be aware of the effect it may have on clients if you are busy updating your social media profiles before responding to a client’s phone message or email. We may be unwittingly conveying a hierarchy of priorities that can leave clients feeling less important.

Another challenge of Twitter in regard to clinical care is the need to be aware that it’s not just our own therapy clients who may follow our postings there. In some cases, others in our clients’ lives may also follow us and this may have an impact both on the client and on our clinical relationship. For example, a client may share with one of his friends, family members, or relationship partners that he sees a therapist and that his therapist is on Twitter. These people may wind up with strong opinions about our social media presence or react to things we post, and this may put our client in the position of either feeling protective of us or feeling uncomfortable. Even clients who don’t tell others who their therapist is may have such feelings if and when they see us engaging with others on social media. And what of clients who have friends who follow our updates but who don’t know their friend is in treatment with us? By making ourselves public figures in this way, we’re certainly introducing some non-traditional dynamics into the traditional therapy relationship. Of course, this potential tension has always existed with therapists who write books or are public speakers, but social media increases the ability to immediately access a therapist’s public presence.

Conclusion

I see one’s professional online identity—so long as the interactions are professional and not personal—as a form of community outreach. I have compared it to working in a college counseling center and then visiting a class that your client may be a student in, such as when a community event affects the campus and you provide information or do a presentation. Sometimes we are visible in the community as mental health professionals and clients may see us acting in this role outside of therapy sessions. An online professional presence can be similar. Some of us are teachers, writers, and lecturers, as well as clinicians. This is our professional life. Perhaps we do not have to exist in a vacuum, only functioning as clinicians in our therapy sessions. Existing online does not have to mean we cannot hold the frame with our clients, nor does it have to mean we are incapable of boundaries or talking about the effects of our online visibility on clients, when necessary. But we are going to have to develop tools and systems to learn to take care of boundaries in new ways and be present to talk with clients about the effect our online lives have on the clinical relationship.