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The world has long been titillated by the extramarital transgressions of the high and mighty, from emperors to queens and presidents to movie stars. The theme has threaded itself through history, art, literature and, certainly, Hollywood.
Here are some of the most common myths about marital affairs and infidelity followed by the facts.
Myth: An affair inevitably destroys the marriage.
Fact: Many marriages survive affairs. Most marriages, where both partners are committed to the marriage, emerge stronger from the infidelity crisis.
Myth: Infidelity is rare in the animal kingdom.
Fact: Only three percent of the world's 4,000 species of mammals are pre-programmed for monogamy. According to many scientists, Homo sapiens is not one of the 3%. Monogamy in the animal kingdom is so rare that those romantic Hallmark cards with images of doves, swans or other types of lovebirds should more accurately feature the flatworm.
Myth: Infidelity is not a norm in our, and most other, societies.
Fact: Men's infidelity has been recorded in most societies according to anthropologists and archeologists.
Myth: Society, as a whole, supports monogamy and fidelity.
Fact: Society gives lip service to monogamy/fidelity, but actually supports affairs (the way they do with violence) through obsession with sex and role modeling by presidents, celebrities of all sorts, especially actors and actresses, and through advertisements, TV, news media, literature and the movies.
Myth: Men initiate almost all affairs.
Fact: Unlike in the past when women could lose everything, including their lives, infidelity has become an equal opportunity issue in the West. Women are catching up to men's infidelity stats rapidly as they are less dependent on men for physical and financial support and, therefore, are willing to risk more by having an affair. Still, sexual infidelity by a woman, either actual or suspected, can increase the likelihood of spousal battering and even spousal homicide.
Myth: An affair always means there are serious problems in the marriage.
Fact: Research has shown that some of those who engage in affairs reported high marital satisfaction. Others have reported that the secret affair has even spiced up their marriage and sex life. The ground-breaking research by Shirley Glass, Ph.D., ABBP, revealed that 56% of men and 34% of women who were involved in affairs reported that their marriages were happy.
Myth: Infidelity is a sign that sex is missing at home.
Fact: Some unfaithful spouses have reported increased marital sex during the period of their affair.
Myth: Infidelity always has to do with a bad marriage or a withholding partner.
Fact: There are many reasons that people may choose to have an affair and, therefore, many types of affairs. These include: 1. Conflict Avoidance Affairs; 2. Intimacy Avoidance Affairs; 3. Individual (Existential or Developmental) Base Affairs; 4. Sexual Addiction Affairs; 5. Accidental-Brief Affairs; 6. Philandering & Other Individual Tendencies; 7. Retribution Affairs; 8. Bad Marriage Affairs; 9. Exit Affairs; 10. Parallel Lives Affairs; 11. Online Affairs.
Myth: Full disclosure of all the details of the affair to the betrayed spouse is prerequisite to healing the marriage.
Fact: Most authors who advocate full and complete disclosure take the moralistic-puritanical view of affairs. The fact is that giving the uninvolved partner all the X-rated details of the affair can be haunting, traumatizing and can easily fuel obsessions. Sharing general information regarding when, where, with whom, how it started and who else knew, is often sufficient. Therapists must conduct a careful risk-benefit analysis before encouraging or instructing clients to disclose about their affairs. Some affairs are best kept secret, as such disclosures by women can increase the likelihood of domestic violence and even domestic homicide.
Myth: Extramarital affairs are never consensual.
Fact: Open marriages used to be popular in the 1970s and are still around. Some couples have reached a consensus regarding extramarital sexual relationships, as is the case in heterosexual marriage when one partner has decided to pursue gay relationships with the consent of the partner.
Myth: Concerns about AIDS and other STDs will reduce the frequency of affairs.
Fact: Statistics do not support this. Not only did AIDS not reduce infidelity, in fact less than one-half of individuals reporting sex outside the marriage use safe-sex with their primary and secondary sex partners.
Myth: Conducting couple therapy is the best approach to dealing with an infidelity crisis.
Fact: No one approach is the best with any psychological problem or crisis. Therapists must take into consideration the type of affair, the personalities, ages, culture, length of marriage and many other factors when constructing a treatment plan. Sometimes the combination of individual and couple therapy may be effective.
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Clinical Update, February 2006
Neuropsychology: The New Frontier
For an online course on Neuropsychology: Click here.
Neuropsychology is probably the fastest growing body of knowledge in psychology. This fascinating field brings back the focus of body-mind by exploring the intricate relationships between brain and behavior. To help clinicians get a sense of this important field we have just completed an introductory online course on Neuropsychology.
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Clinical Update, January 2006
What Films Can Teach Us About Therapeutic Ethics
For an online course on Movies and Ethics: Click here.
Movies have long exhibited fascination with sexual and other therapeutic boundaries. We have just completed an exciting and challenging course on ethics by using scenes from movies as a jumping off board for discussing therapeutic ethics. It turned out to be a rather comprehensive six (6) CE credit course on ethics that also fulfills the Ethics & Law Requirement in California and other states.
Following are a few examples that are discussed further in the course.
What About Bob: When clients rather than therapists violate therapeutic boundaries.
- In this comedy a client follows his rather neurotic analyst to the analyst's family's vacation.
- Most discussions about boundaries focus on the role of therapists in boundary crossings and boundary violations. However, in reality, as in this movie, clients are often the ones that violate therapeutic boundaries when they delay leaving the office at the end of the session, do not pay their bills on time or avoid paying them altogether, dress in sexually suggestive ways, use foul or vulgar language or threaten and even stalk their therapists.
- It is important for therapists to recognize the clinical and ethical meaning of such clients' boundary crossings or violations and respond appropriately.
- The exasperated psychiatrist in this comedy tries to manufacture an unethical, involuntary hospitalization in order to get the client off his tail. We must watch how we respond to clients violating our space and/or privacy.
- We use this movie to teach therapists how to deal with situations when clients, rather than therapists, violate therapeutic boundaries.
- Consultation with experts is highly advisable in complex and potentially violent or volatile situations.
Good Will Hunting: Leaving the office, aggressive touch and extensive self disclosure.
- This movie stimulates a discussion on the ethical complexities of going for a walk with a client, making extensive self-disclosure and using rather aggressive touch towards a client. This movie created an uproar among many therapists who viewed the film as depicting therapists in a bad light. The movie depicts the following three ethical or boundary considerations:
- Leaving the office for a walk has been reported to be effective with restless adolescents, depressed clients and those who prefer side-by-side rather than face-to-face conversation, such as the young client in this move. Clients who feel too confined, restricted or fearful in the office may also benefit from a walk by the river as depicted in this movie. Other reasons to leave the office are making a home visit; attending a graduation, confirmation or Bar Mitzvah; conducting in-vivo desensitization for fear of open spaces; adventure therapy; or attending a performance by a client who is extremely shy.
- Self-disclosure is probably the most common and therapeutically effective boundary crossing. Behavioral, Cognitive-Behavioral, Feminists, Group and Humanistic psychotherapists use it therapeutically, albeit for different reasons.
- Touching clients is the most controversial of all therapeutic boundaries. The impulsive and aggressive shaking of the client in this movie is clearly below the standard of care, even though the movie presents it as a highly effective intervention.
Antwone Fisher: Inviting a client to the therapist's home.
- Inviting a client for a family dinner at the therapist's home was initiated by the psychiatrist in the movie for the clinical reason of modeling and corrective experience. It is the first time that the client witnesses and experiences a "normal" family dinner.
Prime: Unavoidable dual relationships and unavoidable extensive self-disclosure.
- This movie invites us to explore the complexities of dual relationships when the client is also the lover of the therapist's son. This issue is close to my heart as I encountered a similar situation in my life and practice.
- Unavoidable Dual Relationships are very common in many small and rural communities, university campuses and small ethnic, spiritual and disabled communities. They are normal parts of training institutions and, apparently, as depicted in this movie, also occur in large cities. The movie portrays an appropriate use of consultation and flexible ways of handling unexpected, unusual and personally difficult situations with clinical and personal integrity.
- Unavoidable Self-Disclosure is another theme that is explored in this movie in regard to a home office. The home office setting always involves significant amounts of self-disclosure on the part of the therapist about the therapist's professional, personal and familial life. Therapists must be careful in screening clients and pay attention to the impact of the self-disclosure on different clients.
Basic Instinct, Bliss and Mr. Jones: These movies depict the ultimate boundary issue -- sexual relationships between therapist and client.
- The popular theme of sex is also depicted in movies, such as 12 Monkeys, Tin Cup, The First Wives' Club, Deconstructing Harry, Beyond Therapy and The Butcher's Wife.
- Sexual relationships between therapists and current or recently terminated clients are always unethical and often illegal. What is interesting about some of these movies is that they depict the sexual relationships as effective in promoting health and healing.
Prince of Tides: A social and sexual relationship between a therapist and the client's brother.
- Sexual relationships with a client's close relative are always unethical.
- Social dual relationships with a client's close relative are not necessary unethical. It all depends on if it impairs the therapist's objectivity and how it affects the clinical work.
House of Games: Therapist acting also as an investigator.
- This movie depicts a therapist who is both intrigued by the client's world and also takes on the unusual roles of investigator and savior to satisfy her need or impulse to help her client.
- Dual relationships, in which a therapist takes on additional roles to help a client, can be unethical if the therapist abandons his/her clinical role in the process or acts in a way that negatively affects the therapeutic relationship.
K-Pax: Questions about confidentiality.
- In order to learn more about his unusual patient, who pretends that he is an alien from another planet, the therapist takes his client to meet a group of astronomers.
- The psychiatrist shares his fascination about his client with a friend and with his wife.
- Confidentiality in psychotherapy is considered one of the cornerstones of the therapeutic relationship. If the clients do not sign an authorization to release information, talking about them with anybody without disguising their identity is unethical, illegal and potentially harmful for these clients.
This course uses movie vignettes to explore and discuss the following five areas:
Confidentiality, Self-Disclosure, Touch, Dual Relationships and Out-Of-Office Experiences (i.e., home visits, in-vivo exposures, attending a wedding, incidental encounters, etc).
Clinical Update, December 2005
The Professional Will
For an online course on Professional Wills: Click here.
- The Professional Will is the document all therapists should have prepared for the unfortunate case of unexpected or forced termination of their practices.
- Preparing a professional will serves to protect us, psychotherapists, ourselves, our estate or significant others in case of therapist's sudden death or disability or unexpected-forced closure of practice.
- Preparing a professional will for psychotherapists in solo private practice, in most cases, is neither a complicated nor a time consuming task.
- The online course provides a sample or prototype of a professional will that you can easily use.
- In the case of our unexpected death or disability our clients have ethical and/or legal rights, including continuity of care and appropriate handling of their confidential records.
- Having a professional will protects our family and colleagues from additional burden and ensures that the disposition of our practice will be performed according to professional standard and our wishes.
- A professional will can help to protect our estate from being sued.
- Most codes of ethics require therapists to prepare for the eventuality of unexpected death, disability or any other abrupt termination of treatment. Preparing a professional will is the ethical thing to do.
- The professional will should provide the executor with clients' contact information, information on where the records of current and past clients are located and how to access them. It should also provide information regarding computer passwords, answering machines access codes, keys to office and file cabinets, etc.
- The professional will should detail which clients should be contacted, how to contact them, what should be communicated and the referrals they should be offered.
- The executor should also have the contact information for the executor of the personal will and the attorney, and vice versa, as they may be required to work cooperatively in certain instances.
- Full access to all records, facilities and communication devices must be available to the executor.
- Contact information for others who have access to these facilities and records, such as practice partners, secretaries, business managers or facility managers, should be included.
- Directions should be included regarding how clients will be notified, including a list of former clients you might want included.
- The company providing professional liability insurance and your licensing board should also be notified immediately.
- The professional will should provide the executor with a list of contact information for clinical referrals and colleagues or organizations that you would like to have notified.
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Clinical Update, December 2005
ADHD: Fact or Fiction?
ADHD has been the object of study for over a century and has been considered a controversial condition for several decades. While some view it as a legitimate disorder, others believe that it is simply a diagnostic trend promoted by irritated parents and teachers and greedy pharmaceutical companies.
For an online course on ADHD: Click here.
ADHD: Basic facts and general recap of the complexities involved:
- This disorder has had many names, including "brain damaged syndrome," "minimal brain dysfunction (MBD)," "hyperkinetic impulsive disorder" and "attention deficit disorder (ADD)." The current term, ADHD (Attention Deficit/Hyperactivity Disorder), is the product of decades of study, which have identified a main syndrome with 3 specific "types" associated with it.
*An estimated 3-7% of school-age children are affected by ADHD -- roughly 1.5 million children.
- While historical research has suggested that boys have been more frequently affected than girls, current studies indicate that nearly equal numbers of boys and girls are affected by this disorder.
- Research suggests that of the children diagnosed with ADHD and learning disability, approximately 70% were treated with prescription medications.
- On one side of the debate the claim is that ADHD is a neurologically-based disorder that responds well to the combination of stimulant medication and behavioral intervention. Several studies evidence significant positive impact on social and family interactions as well as on academic performance. Current research suggests that the failure to treat ADHD may result in increased likelihood of drug addiction, school dropout and concurrent mental disorders.
- On the other side of the debate the claim is that ADHD is a made up diagnosis, nothing more than poor behavior resulting from a lack of discipline and structure. Proponents of this theory believe that disengaged parents become lazy and come to accept inappropriate behavior in their children. They jump at the diagnostic label and pharmaceutical interventions because little is required on the part of the parents. ADHD, according to this view, is a condition invented by the pharmaceutical companies to increase drug sales and corporate dollars. Proponents of this theory also assert that the pharmaceutical interventions cause most of the symptoms associated with ADHD and generally do more harm than good.
- According to Dr. Cheryl Barton, "The value of the ADHD market was $2.4 billion in 2004 and it is now the 9th largest segment of the CNS market by sales and one of the fastest growing (+40% year-on-year). Global sales of ADHD are forecast to reach $3.3 billion by 2010."
- According to Dr. Cheryl Barton, "approximately 50% to 70% of children with ADHD will continue to experience symptoms into adulthood," suggesting that big pharmaceutical companies will be reaping benefits that were formerly only stemming from pediatric pharmaceutical sales.
- While ADHD has historically been treated with psychostimulant medication, moderate benefit has been reported with new non-stimulant alternatives.
- Tom DeWeese of the American Policy Center contests that ADHD is not a biologic disorder but a financial jackpot. He not only points to the millions being made in big pharmaceutical companies but also by the school systems. "DeWeese points out that a 1991 change in eligibility requirements provided schools with $400 in annual federal education grant money for each child diagnosed with ADHD," equating to big dollars for diagnosis.
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Clinical Update, November 24, 2005
To Touch or Not to Touch: Clinical and Ethical Considerations in Non-Sexual Touch in Psychotherapy
For an online course on Touch in Psychotherapy for 6 CE Credits (also fulfills Law & Ethics Requirement): Click here.
Free extensive online article on Touch in Therapy: http://www.zurinstitute.com/touchintherapy.html
A woman patient of mine lost her first and only infant son in a drunk driving accident. At the time of this tragedy, the pain of her loss was, of course immense; she could not stop crying and was contemplating suicide. At the insistence of her family, she agreed to an emergency appointment with a psychotherapist expert in loss. In this grief-stricken state, barely able to stand, she entered the office and sobbed uncontrollably. In her desperation and isolation she begged him to hold her. True to his most recent Ethics and Risk Management continuing education workshops, he explained to her that therapy is about talking, not touching and citing something about professional boundaries. At the end of the session, he suggested that she get a prescription for Valium from her GP and set an appointment for a couple of days later. Eight years later, addicted to Valium and alcohol, divorced and with two failed rehab programs behind her, she began therapy with me. After an intense and tearful few months of therapy and long conversations we went to her son's grave. It was the first time she had ever visited the grave. There we stood, holding each other, and both weeping. We stood there for a long time as she cried and I cried. She had finally begun facing her baby's death and mourning for him and grieving for the years lost in drugged denial. That therapist followed risk management guidelines to perfection. He took the "safe" path that forbids touch. However, by practicing risk management, adhering to the "no touch" dogma, he inflicted needless additional suffering on this woman. He sacrificed his humanity and the core of his professional being, to the demands of a heartless, paranoid and destructive protocol.
We have been told by ethics experts, attorneys, continuing education instructors and supervisors never to touch our clients. Touch has been increasingly perceived as a risk management issue to be avoided rather than as one of the most powerful tool of healing. Non-sexual touch, we have been told, is very likely to lead to sexual touch. In spite of the almost half century of knowledge of the emotional, physiological and behavioral benefits of touch, most therapists still shy away from appropriate non-sexual touch due to fear of boards, attorneys and lack of training. This Clinical Update summarizes the significant, ethical and clinical utility consideration of non-sexual touch in psychotherapy.
The General Significance Of Touch
- Touch is one of the most essential elements of human development: a form of communication, critical for healthy development and one of the most significant healing forces.
- In his seminal work, Touching: The Human Significance of the Skin, Ashley Montagu (1971) brought together a great array of studies demonstrating the significant role of physical touch in human development.
- The effects of touch deficiencies can have lifelong serious negative ramifications.
- Bowlby and Harlow, among many others, concluded that touch, rather than feeding, bonds infant to caregiver.
- Touch has a high degree of cultural relativity. People of Anglo-Saxon origin place low on a continuum of touch while those of Latin, Mediterranean and third world ancestry place on the high end.
- The general western culture and its emphasis on autonomy, independence, separateness and privacy have resulted in restricting interpersonal physical touch to a minimum. America is a "low-touch culture."
- In Western society, sex, love, power and dominance are dangerously confused.
- Americans tend to sexualize or infantilize the meaning of touch and as a result tend to avoid touch. Watson, parenting expert of the early 1900's, cautioned mothers not to sexualize their infants by kissing or hugging them affectionately.
Touch And Healing
- The medicinal aspect of touch has been known and utilized since earliest recorded medical history, 25 centuries ago.
- Touch unleashes a stream of healing chemical responses including a decrease in stress hormones and an increase in seratonin and dopamine levels.
- Touch increases the immune system's cytotoxic capacity thereby helping our body maintain its defenses.
- Massage has been shown to decrease anxiety, depression, hyperactivity, inattention, stress hormones and cortisol levels.
- Massaged babies are more sociable and more easily soothed than babies who have not been massaged.
Types Of Touch In Psychotherapy (See articles for details)
- Ritualistic or socially accepted gestures
- Conversational Marker
- Consoling or reassuring
- Playful touch
- Grounding or reorienting
- Task-Oriented
- Corrective experience
- Instructional or modeling
- Celebratory or congratulatory
- Experiential
- Referential
- Inadvertent
- Preventing someone from hurting self or others
- Self-defense
- Therapeutic intervention - A bodytherapy medical technique
- Inappropriate, unethical and mostly illegal forms of touch include sexual, hostile-violent and punishing touch.
Sources Of The Prohibition Of Touch In Therapy
- The general western culture and its emphasis on autonomy, independence, separateness and privacy.
- The cultural tendency in the USA to sexualize most forms of touch.
- The traditional dualistic Western mind-body or mental-physical split.
- Homophobia.
- Some fundamentalist religious denominations that have a highly restrictive view of all forms of touch.
- The litigious culture and the resulting risk management and defensive medicine practices.
- Psychoanalysis and its emphasis on neutrality, distance and rigid boundaries.
- Those feminist scholars who assert that most touch by male therapists of female patients is disempowering and injuring to the women.
- The fear-based, illogical slippery slope idea that non-sexual touch inevitably leads to sexual exploitation.
- The more recent crisis in the clergy and the not too distant day-care hysteria in regard to sexual exploitation.
Ethical Consideration Of Non-Sexual Touch In Therapy
- Touch in therapy is not inherently unethical.
- None of the professional organizations code of ethics (i.e., APA, ApA, ACA, NASW, CAMFT) view touch as unethical.
- Touch should be employed in therapy when it is likely to have positive therapeutic effect.
- Practicing risk management by rigidly avoiding touch is unethical. Therapists are not paid to protect themselves, they are hired to help, heal, support, etc.
- Avoiding touch in therapy on account of fear of boards or attorneys is unethical.
- Rigidly withholding touch from children and other clients who can benefit from it, such as those who are anxious, dissociative, grieving or terminally ill can be harming and therefore unethical.
- Sexual, erotic or violent touch in therapy is always unethical.
- Stopping therapy in order to engage in sexual touch or sexual relationships is unethical and often illegal.
- Ethical touch is the touch that is employed with consideration to the context of the therapeutic relationship and with sensitivity to clients' variables, such as gender, culture, history, diagnosis, etc.
- Seeking ethical consultation is important in complex and sensitive cases.
- Ethical therapists should thoroughly process their feelings, attitudes and thoughts regarding touch in general and the often, unavoidable attraction to particular clients.
- Critical thinking and thorough ethical-decision making are most important processes preceding the ethical use of touch in therapy.
- Documentation of type, frequency and rationale of extensive touch is an important aspect of ethical practice.
Clinical Considerations For Touch In Psychotherapy
- The meaning of touch can only be understood within the context of who the patient is, the therapeutic relationship, the therapist and the therapeutic setting.
- Touch, like any other therapists' behavior and interventions should be employed if they are likely to help clients.
- Touch increases therapeutic alliance, the factor found to be the best predictor of therapeutic outcome.
- Touch can help therapists to provide real or symbolic contact and nurturance, to facilitate access to, exploration of, and resolution of emotional experiences, to provide containment, and to restore significant and healthy dimensions in relationships.
- Clinically appropriate touch must be employed with sensitivity to clients' variables, such as history, gender, culture, diagnosis, etc.
- Sensitive, attuned touch gets etched into our developing neural pathways enabling us to feel of value, and to connect emotionally with others. As such, touch can be a powerful method of healing.
- Language never completely supersedes the more primitive form of communication, physical touch. As such it can have a significant therapeutic value.
- The unduly restrictive analytic, risk management or defensive medicine emphasis on rigid and inflexible boundaries and the mandate to avoid touch interferes with human relatedness and sound clinical judgment.
- Due to the absence of attention to touch in most training programs, clinical supervision, research and testing, the majority of therapists tend not to incorporate the use of touch in therapy.
- Fear, misguided beliefs and lack of training often lead to therapists employing an approach of "touch but don't talk."
- Touch that is inappropriate, sexual, cold or abusive can be harmful.
- Traumatic memories are encoded in our sensorimotor system as kinesthetic sensations and images, while the linguistic encoding of memory is suppressed. Therefore, appropriate touch can have a significant therapeutic value.
- Disturbances in non-verbal communication are more severe and often longer lasting than disturbances in verbal language. Using touch in therapy may be the only way to heal some of these disturbances.
- To disregard all physical contact between therapist and client may deter or limit psychological growth.
Guidelines For Clinically Appropriate And Ethical Touch In Therapy.
- Touch should be employed in therapy if it is likely to be helpful and clinically effective.
- Avoiding touch due to fear of boards and attorneys is unethical and a betrayal of our clinical commitment to aid clients.
- Touch in therapy must always be employed with full consideration to the context of therapy and clients' factors, such as presenting problems and symptoms, personal touch and sexual history, ability to differentiate types of touch, the clients level of ability to assertively identify and protect his or her boundaries as well as the gender, and cultural influences of both the client and the therapist.
- Touch should be used according to the therapists training and competence.
- Extensive touch should be incorporated into the written treatment planning.
- The decision to touch should include a thorough deliberation of the clients' potential perception and interpretation of touch.
- Therapists must be particularly careful to structure a foundation of client safety and empowerment before using touch.
- Factors that are associated with congruence are; clarity regarding boundaries, patients' perception of being in control of the physical contact, the patient's perception that the touch is for his/her benefit rather than the therapists.
- The therapist should state clearly that there will be no sexual contact and to be clear about the process and type of touch that will be used.
- Extensive use of touch, as utilized in some forms of body psychotherapy, is likely to require a written consent.
- Touch is usually contraindicated for clients who are highly paranoid, actively hostile or aggressive, highly sexualized or who inappropriately, implicitly or explicitly demand touch.
- Special care should be taken in the use of touch with people who have experienced assault, neglect, attachment difficulties, rape, molestation, sexual addictions, eating disorders, and intimacy issues.
- Therapists should not avoid touch out of fear of boards, attorneys or dread of litigation. Therapists are paid to provide the best care for their clients not to practice risk management.
- Consultation is recommended in complex cases.
- Therapists have a responsibility to explore their personal issues regarding touch and to seek education and consultation regarding the appropriate use of touch in psychotherapy.
Online courses for CE credits: http://www.zurinstitute.com/homeonline.html
Happy Thanksgiving,
OZ
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Clinical Update, October 2005:
Home Office: When the therapy office is at home
For online course, Home Office, Click here.
Guidelines: Home Office:
- Home offices present therapists and clients with several challenges, advantages and burdens to therapists, clients and therapists' family members or co-inhabitants.
- The home office significantly increased the crossover of the therapist's professional and personal life.
- Home office practice dates back to the time when Freud, Mahler, Jung, Winnicott, Bettelheim and other forefathers and foremothers practiced, at least sometimes, from their homes.
- Home offices come in different formats and arrangements. Some offices are located in detached units with separate driveways and entrances, distanced from the main residence. On the other end of the spectrum are the offices that are located in the therapists' living rooms, offices or designated bedrooms within the homes. In between these two arrangements, there are many variations in regard to which entrances or which bathrooms clients use and what part of the therapists' private home they get to see.
- Although many therapists work from their homes, there have been no formal studies on the impact on therapy, the motives of the therapist and the emotional and other consequences to the therapist and their families.
- Woody Allen's movie, Deconstructing Harry, while true to the producer's exaggerated style, illustrates the complexities of a home office and how the close proximity of office and home may affect therapists, clients and spouses. In this particular movie Woody Allen is married to a psychoanalyst working out of their home. When she discovers her husband had an affair with one of her female clients (whom he had originally met in the living room-waiting room), she, understandingly, cannot contain herself. She leaves her client on the couch in the middle of an analytic session, bursts in on her husband in another room and roundly curses him for his transgression. The client, of course, can hear the screaming and every word of the argument from the couch. The therapist intermittently returns to the therapy session and makes a poor attempt to appear concerned and focused on the well being of the client. Although grossly exaggerated for effect, the movie illustrates how private information about a therapist's marriage and emotional life, especially at times of crisis, can more easily be revealed to clients in a home office environment. It highlights the issue of greatly diminished role transition time for the therapist working in a home office setting and clearly illustrates how therapists may sometimes be so distracted by their personal issues that thoughts of the clients' well being recede into the background.
Advantages for therapists:
- Therapists who work out of their homes have the ability to flow more easily between the personal-familial and the professional realms.
- No need to commute.
- Avoidance of high-density population areas.
- Financial benefits (no rent).
- Supports ease in household management.
- Access to the comforts of home.
- Therapists are in closer proximity to family and community obligations, children's schools, etc.
- Can increase the amount of time with significant others.
- Advantages for clients
- Usually a friendlier and warmer environment than the standard professional office.
- Provides a focus for processing of boundary issues.
- Provides additional information about the therapist.
Clinical concerns:
- Unavoidable, significant therapist's self-disclosure.
- Issues of privacy and confidentiality.
- Safety and containment issues for volatile and violent clients.
- Pre-therapy screening concerns.
- In-person interruption by family members, pets, neighbors.
- Interruptions by music, children's play, screaming, etc.
- Concerns for therapists' family
- Sense of intrusion.
- Potential issues of safety.
- Need to be discrete or quiet at certain times.
- Can overhear crying, yelling, pounding in the therapy room.
- Role confusion -- not knowing how to interact with clients.
- Complications regarding scheduling home based activities around the need to be quiet while therapy takes place.
- Providing boundary guidelines for visiting guests.
- Confusion for young children regarding why a parent is at home but unavailable.
Additional considerations:
- From an ethical point of view, there is no injunction in any of the major professional organizations' codes of ethics against home-based practice. Such practice conforms to the standard of care.
- When practicing from a home office, a therapist has a responsibility that involves a series of conscious decisions that involves what is communicated through non-verbal self-disclosure and how these communications affect the clinical issues of their clients.
- Screening and safety considerations are of paramount importance as there are fewer external safety systems than one might find in a traditional office practice.
- Average and highly functioning clients and those who can benefit from the warm and casual ambience and the self disclosure involved in a home office are likely to be good candidates for this setting.
- Informed consent with regard to home office practice involves informing clients and family members, in detail, about specific physical and relational boundaries. Negotiating these boundaries is not a one-time event prior to therapy; it is often a continuous and dynamic process and as such can also be part of the clinical process
- Issues of parking, which bathroom to use where one waits, where one can wonder, etc. must be discussed and clarified.
- Consult in gray area cases, in complex cases and in cases where therapy may need to end or be changed to a traditional office.
- The highest level of satisfaction for those who work at home and their family members involves successfully managing time, places and people along a continuum of segmentation and integration with careful attention to the unique personal preferences of clients, therapists and therapists' family members.
- Discuss the concern of boundaries, intrusion, etc. with family members. Obtain input from those involved and provide clear guidelines. Make this an ongoing, dynamic process.
- Running a home-based practice often involves additional attention to zoning, tax and insurance considerations. Tax implications often mean that therapists may be able to deduct a portion of their house and related expenses as a home office deduction. The IRS has a publication to help with this information called Publication 587, Business Use of Your Home, available at www.irs.gov.
Risk Management for those who practice outside their homes:
- If you are practicing in your home, getting informed by taking this online course is a simple and solid risk management strategy.
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Clinical Update, October 2005
The Dreaded Subpoena: How to respond
Online course on Subpoenas and How to Handle them, Click Here.
Sooner or later in their careers, most psychotherapists and counselors are likely to receive a subpoena requesting client records. Therapists often react with dread. They often react with a fight or flight response when served with a subpoena and either ignore the subpoena or simply provide the requested records. Either response may be illegal, unethical and counter-clinical. Responding to subpoenas can be complicated and complex since legal requirements sometimes conflict with ethical guidelines and copyrights laws.
Guidelines: How to Respond to a Subpoena
- A Subpoena is a legal document or order requiring an individual (psychotherapist) to appear and testify in court and/or to produce documents. Subpoena duces tecum is an order requiring a witness (psychotherapist) to bring specific documents, reports, tapes or any other specified records that are in the possession or under the control of the witness to a certain place at a certain time.]
- When receiving a subpoena, neither ignore nor send records. A therapist does not need to automatically respond to the subpoena and uncritically send the records.
- Therapists should not release confidential and/or privileged information or surrender any documents or records to the person serving the subpoena no matter how aggressive the request is. The subpoena document should be accepted, and the psychologist should then evaluate the situation and, when necessary, obtain legal counsel regarding applicable law and resulting obligations.
- When being served with a subpoena, therapists should not acknowledge that they know or treated the person whose records are being subpoenaed.
- Do not attempt to avoid being served a subpoena.
- After receiving a subpoena therapists should carefully determine its validity and, most importantly, who initiated it.
- Find out if the subpoena was initiated by a judge/court, attorney, etc.
- Obtaining an authorization to release information from clients is one of the better and simpler ways to deal with subpoenas.
- Contacting the clients, when appropriate, is very important. Sometimes clients are willing to sign an authorization to release information and want the therapist to respond fully to the subpoena.
- Unless therapists obtain either an authorization from the patient or an order from a judge, therapists are advised to consult with an attorney before releasing any information.
- If there was more than one person/client involved in treatment, seek authorization to release information from each patient before releasing records.
- Before responding to a subpoena consider the source of the subpoena, client's welfare, other people's welfare, state and federal laws (e.g., HIPAA, Patriot Act, copyright laws), codes of ethics and, where applicable, your contractual relationships to test publishers.
- Sometimes providing only a summary of the treatment rather than appearing in person or providing the entire file may be acceptable to clients, attorneys and courts.
- Whenever possible, provide the minimum information necessary. However, some situations may demand that you release the entire file.
- Never alter records.
- If a signed authorization to release form is included, but the therapist believes that the material may be clinically or legally damaging, s/he should discuss these issues with the client before releasing the records.
- When the subpoena request includes tests' protocols, record forms, raw data or entire test kits, be aware and cautious of copyright laws, your contract with the publisher as well as federal and state laws. Consult with expert counsel and/or explain to the judge, if and when necessary, about the potential conflict between the subpoenas, professional codes of ethics, state and federal laws and copyrights laws.
- Be aware that the Patriot Act may force you to disclose any or all clinical information while at the same time forbid you to inform your client about the disclosure. This can create a very complicated situation where therapists act more like informers rather than psychotherapists. Consult, consult and consult.
- Do not release the HIPAA's Psychotherapy Notes (if you have any) unless specifically ordered by the court or have received a written authorization to release this part of the records. It is my general recommendation that therapists do not keep Psychotherapy Notes (as defined in HIPAA regulations). (For more HIPAA information, go to: http://www.zurinstitute.com/hipaa.html.)
- Each situation is different and these general guidelines are neither a substitute for legal consultations nor apply to all situations. When necessary, consult with knowledgeable experts, attorneys or the attorney of your malpractice insurance.
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Clinical Update, October 2005
Cinema Therapy: Harnessing the power of movies for therapeutic gain
Online course on Cinema Therapy, Click here.
In the last year I have watched a couple of movies that affected me significantly. I fell into an existential funk after watching Motorcycle Diaries that made me feel like a "middle class sellout." As I was emerging from the funk, I happened to watch The Constant Gardener, which takes place in Kenya. Kenya was my old stomping ground, where I was a fish researcher determined to save the third world from starvation, but barely survived my naiveté and grandiosity. These two movies have launched me into deep questioning about the direction and the meaning of my life.
Most of us, and most of our clients, have similar stories of movies that have deeply impacted us. This clinical update is about how we, as therapists, can harness the power of movies to help our clients grow and change. Appreciating the power of movies, I also thought that an online course on Cinema Therapy, developed by Dr. Birgit Wolz, a pioneer and top expert in the field of Cinema Therapy, would be an exciting addition to our innovative online courses.
Guidelines: Cinema Therapy (CT):
- Movies affect most of us powerfully because the synergistic impact of images, music, dialogue, lighting, camera angles, sound and special effects can elicit deep feelings and help us reflect on our lives.
- Movies can help us to better understand our lives, provide catharsis or perspective and may suggest new ways of thinking, feeling and pursuing our lives.
- In Cinema Therapy (CT) clients learn to watch movies consciously and reflectively and to pay attention to the story and to themselves. Clients then learn to understand themselves and others more objectively in the big "movie" of their lives.
- Clients who hold their feelings back by over-intellectualizing may find it easier to let go of their defenses and access feelings that arise during and after watching a movie.
- Conscious watching of films can enhance perspective, insight and empathy.
- Movies have been successfully employed in conjunction with depth psychotherapy, cognitive, humanistic-existential, feminist and narrative therapy, hypnotherapy, psycho-education, EMDR and systems-oriented therapies.
- CT can be incorporated into individual, couples, family and group therapy.
- CT can help with assessment: In addition to the standard biographical questioning, clients may be asked to name a few films they have found to be personally meaningful and explain why they found them of importance.
- Client resistance can dissolve because: 1. Clients become curious when the therapist suggests that they watch a movie, especially if they don't expect this kind of intervention. 2. Rapport develops faster and is stronger because movies speak a language that is familiar and less intimidating than psychological jargon. 3. Watching and discussing a movie can help clients to see their situation from a bird's eye perspective. 4. Movies can demonstrate behavior change, enabling clients to envision how their own problems might be solved.
- Some suggestions for client viewing are: 1. Watch certain movies at the theatre or at home. 2. Watch certain clips during a session (on a laptop or DVD Screen). 3. Watch an entire movie with a client during a longer scheduled session.
- More information: Much more information is available in the 80 page document that composed the online course.
Examples of how CT can be used:
- Addictions: Leaving Las Vegas (1995) demonstrates how addiction can ruin a life when untreated. Postcards From the Edge (1990) and 28 Days (2000) demonstrate how addictions can be successfully overcome, even though the recovery process is challenging.
- Trauma: Clients can get in touch with and successfully process unresolved trauma through such movies as Affliction (1997) and Mystic River (2003).
- Depression: Movies, such as About Schmidt (2002), can serve as a psycho-educational tool in cognitive work with depression.
- Grief: In America (2003) is an excellent for clients who tend to hold back emotions while grieving. Frida (2002) demonstrates courage, determination, endurance, acceptance and the potential for transformation.
For listing of therapeutic themes and relevant movies: click here.
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Clinical Update, September 2005:
Fees in Therapy
For the Online Course, Fees in Therapy: Click here.
Guidelines: Fees in Therapy:
- People's relationships to time, money and sex are the three most revealing aspects of their lives in our time.
- Money is one of the more complex issues facing therapists and clients, especially at the beginning of treatment.
- As with issues of sex, many therapists tend to avoid exploring this important topic. As therapists, we choose to go to graduate school and study psychology or counseling rather than business, which is a reflection that our focus is on healing rather than on money and fees.
- Money is one of the parameters that defines and differentiates psychotherapy from friendship and other intimate relationships.
- Therapists' Office policies should articulate fee structure and policies regarding billing, missed and late canceled sessions, insurance billing, debt and debt collection, etc.
- The most common fee arrangement options are:
- Full fee
- Sliding scale
- No fee
- Bartering for goods or for services
- Therapists should try to come to an agreement with their clients as soon as possible as to the fee structure. They should then document it in the clinical records.
- Therapists are advised to keep a log of sessions, charges, and payments by clients, insurance or others, insurance billing, etc.
- The clinical records should include copies of billing, invoices, communication with third parties, debt forgiveness and any other information pertaining to fees.
- The sliding scale is a very common and acceptable form of fee arrangement. This allows clients to pay according to what they can afford in a flexible, individually tailored way. The concern with the sliding scale is that it can put therapists and clients in a conflict of interest where clients may have an investment in presenting a scaled down financial picture in order to pay at a lower rate. If this negotiation takes place at the beginning of therapy, it can contaminate the therapeutic relationship. Some factors, such as retirement investments, anticipated inheritance, etc. cannot be easily factored into the sliding scale calculations.
- For a summary of the Codes of Ethics of major professional organizations on fees and payment issues go to zurinstitute.com/ethicsoffee.html.
- The self serving belief by therapists that the more clients pay for the therapy the more likely they are to benefit from it is not supported by research.
- It is important for therapists to be flexible in regard to fees as sometimes patients' financial situations change in the course of therapy due to illness, lost of job, etc.
- Therapists should not engage in misdiagnosis in billing for the purpose of securing insurance reimbursement (e.g., give an individual DSM dx and CPT code for couple therapy.)
- Fees are also a clinical issue. Different fee arrangements have different meanings for different clients that should be explored when appropriate. For example, no fee arrangement can elicit in a client feelings of gratitude, indebtedness, entitlement, etc.
- Therapists should allow for some free or very low fee sessions in their practices.
- Different theoretical orientations sometimes guide the type and extent of discussion regarding fees. Psychodynamic psychotherapists are more likely to focus on unconscious, transferencial and counter-transferencial dynamics regarding fees. Feminist therapists may focus on issues of justice and reducing the power differential between therapists and clients by reducing the fee.
- Different settings, communities and clients may require different approaches to fee setting. Agricultural and rural communities are likely to be more accepting of bartering for goods and other creative ways to pay for therapy. Art-rich but cash-poor artists are often used to bartering arrangements.
- Bartering for goods, especially when one can assess their fair market value, is generally less complicated than bartering for services. Unlike bartering for goods, bartering for services is always a dual relationship. (For extensive articles on practices and ethics of bartering go to: zurinstitute.com/bartertherapy.html.)
- Therapists may choose to educate their clients about the benefits of private pay and the concerns and risks of managed care in regard to confidentiality, privacy, future eligibility for health and life insurance, employment, continuity and control of care.
- Therapists should be flexible about missed sessions and late cancellations due to illness, transportation problems, etc.
- Contrary to what is commonly believed, HIPAA does not mandate electronic billing. For a summary of billing options under HIPAA go to: zurinstitute.com/billing.html.
- Therapists should try to be careful of the accumulation of debt by clients. Large debts by clients tend to be clinically very complex and burdensome. If therapists let clients accumulate debt, they should document the reasons (e.g., sale is pending for patient's house) and consult in complex cases.
- Therapists are advised to avoid using collection agencies because it significantly increases the likelihood of clients filing complaints with the licensing boards.
- Payment for referrals and fee splitting are considered unethical by some professional organizations' codes of ethics.
- Several professional organizations' codes of ethics, including APA, state that it is unethical to withhold release of records that are needed for a patient's emergency treatment solely because payment has not been received.
- It is of the utmost importance that therapists should try to explore their own personal thoughts, feelings and issues in regard to money. Many clinical and ethical complications stem from therapists' ambivalence about money and lack of training and education about how to handle it.
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Clinical Update, September 2005:
Confidentiality In Psychotherapy
For an online course on Confidentiality, Click Here.
Privacy, Confidentiality & Privilege:
Privacy, confidentiality, and privilege are different, but related concepts that are of great importance to every mental health professional and those we serve. Without an adequate understanding of these concepts we risk engaging in unethical, illegal, and potentially harmful behavior. Privacy is a basic right granted to all our citizens; confidentiality is an ethical concept pertaining to the psychotherapy relationship; and privilege is a legal concept regarding who has the right to release confidential information.
Limits to confidentiality:
While most consumers believe that everything they share with their psychotherapist is confidential, a number of limits to confidentiality exist to include mandatory reporting requirements for suspected child abuse and neglect; vulnerable adult reporting requirements that may include suspected abuse, neglect, self-neglect, and exploitation of the elderly and other individuals dependent on others for their care; and duty to warn and protect requirements regarding threats to harm others made in treatment. (For an update about the Tarasoff ruling in CA and how it effects clinicians, go to: zurinstitute.com/tarasoff.html.)
Informed Consent:
Just how we address the limits of confidentiality through the informed consent process is of great importance and has significant implications for how the therapeutic process transpires. Informed consent is an ongoing process that should begin at the outset of the professional relationship. The client must be competent to consent, consent must be given voluntarily, and we must ensure the client understands what s/he is agreeing to. This course includes the Office Policies Form. For Essential Clinical Forms, go to: zurinstitute.com/forms.html.)
Minors, Families, and Groups:
When working with minors, families, and groups, there are a number of special issues that must be addressed up front that concern confidentiality expectations. While minors may not legally be able to consent to their own treatment, we still must explain relevant treatment information to them in a manner they can understand. With families and groups, clients need to understand that one person cannot waive privilege for another.
Minors and Laws:
Understanding the relevant state laws is important when working with children and adolescents since their confidentiality rights may vary depending on age and other circumstances. In some jurisdictions minors over age 16 may consent to their own treatment and decide who may have access to treatment information. Additionally, 'mature' or 'emancipated' minors (typically those who are married or in the military) have the same rights as adults to consent to treatment.
Office Practices:
A thorough understanding of effective office practices is essential for preventing inadvertent breeches of confidentiality. Important steps include soundproofing, record storage and disposal practices, the use of technologies to include computers and fax machines, and the training of staff not to release confidential information without specific authorization.
Forensic Settings:
Knowledge of privilege rights and related procedures is essential when working in the forensic setting and in any situation involving the courts. While we must comply with a court order from a judge, psychotherapists do not necessarily need to comply with a subpoena. We also have the opportunity, through an attorney, to file a motion to quash a subpoena or to have a judge do an in-chambers review of records to see if they are relevant to the legal proceeding before ordering their release.
Technology:
The use of technology brings with it a number of important confidentiality challenges and concerns that each mental health professional should be aware of and address prior to using these technologies. The use of password protection and encryption are useful for protecting computer records. If our computer is networked or connected to the Internet, the use of firewall and virus protection are important to help prevent unauthorized access to, and release of, confidential materials in our computer. Ensuring care when punching in fax numbers and the use of a cover sheet stating the confidentiality of the materials being sent are useful as well. (For an online course on Telehealth that discusses confidentiality consideration in e-therapy, go to zurinstitute.com/telehealthcourse.html.)
Insurance and Managed Care:
Working with insurance and managed care companies brings with it additional risks to clients' confidentiality. Understanding how insurance carriers may share and release information sent to them has a great impact on how we document our services and just what we share with them. We should share only the minimum amount of information needed to meet utilization review requirements knowing that once we share the information the ability to control who has access to it is out of our hands.
Courts Rulings & Case Law:
Court rulings such as Nagle v. Hooks and Jaffe v. Redmond have significant implications for each practicing mental health professional who endeavors to protect a client's confidentiality. In divorce/custody situations in court a court-appointed guardian may be appointed who becomes the child's holder of privilege in the context of the legal situation. In Federal courts clients retain their privilege rights and one cannot be ordered to share information about or from their psychotherapy. Knowing this is vital for ensuring we do not violate the rights of those we are trying to help.
Consultations:
Consulting with experts can help you navigate the ethical and legal complexities of confidentiality and help you assure that you practice within the reasonable standard of care of your profession.
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Clinical Update: July, 2005
Record Keeping
For online course on Record Keeping, which includes 53 Essential Clinical Forms, Click here.
Guidelines for Record Keeping:
- Good records are the primary proof of quality of care.
- Keeping psychotherapy records is part of the standard of care.
- Assume that no records are immune from disclosure.
- The main reasons to keep records are: this helps therapists provide quality care; not keeping any records is below the standard of care, is unethical and, in many states, illegal; it is therapists' first line of defense in civil and administrative hearings; and finally, in case the treating therapist becomes disabled, dies or cannot continue to provide care, records can help the next treating therapist with information and the clients with continuity.
- Follow state, federal, professional organization, hospital, clinic or institution guidelines for record keeping.
- Never alter records.
- Store hard copy records in a safe, locked place that is reasonably protected from unauthorized access.
- Protect your computer records by use of password, virus protection and firewall. Backup regularly, and store your backup disks off site in a secure location. Print hard copies of very important documents and use access log if necessary.
- Assume that no records are immune from disclosure. Therefore, be careful in your documentation and do not include clinically superfluous details that can cause unnecessary harm for clients or others if they are disclosed or become public.
- Enter relevant information in the clinical records for each session and each meaningful contact including important phone calls. Include date, type of service and fees, payments and copies of third party billing.
- Make sure that the records include basic demographic information, mental status exam and diagnosis or presenting problem (does not need to be DSM diagnosis, can be familial, developmental, etc.), fee agreement and treatment plan. If relevant, include risk factors, medical and other issues relevant to treatment, collateral information and requests for information.
- Before treatment starts present clients with Office Policies and Informed Consent forms, which include information on limitation of confidentiality, fees, third party billing, client's rights, cancellation policies, etc. For detailed information on what may be included in the Office Policies and Informed Consent, go to: zurinstitute.com/tarasoff.html#policies.
- Update your treatment plans and report on progress or lack there of, as necessary. Treatment plans usually include: presenting problem; dx, focus of treatment; goals of treatment, interventions or means to achieve these goals; the theoretical, rational or research base for your interventions; and, if applicable, referrals. (For a complete Treatment Planning Manual, go to: zurinstitute.com/catalog.html.)
- Records should reflect your competence, thoughtfulness, decision-making ability, capacity to weigh available options, rational for treatment selection and knowledge of clinically, ethically and legally relevant matters.
- Appropriately document special occurrences, important telephone calls, emergencies, dangerousness, mandated and other reporting, consultations, testing, referrals, contact with family members, etc.
- Make sure that your records include forms, such as Office Policies and Agreement for Treatment; client's demographic information, emergency contacts; Treatment Plan; HIPAA forms, as applicable; consents to release information and consent to treat a minor, when applicable; test data, medical or educational reports and any relevant collateral data; informed consent in forensic and custody evaluations or any other situation that requires such consent
- Summary of termination, who initiated it, for what reason, what was achieved, any follow-up information and referrals that may be necessary.
- Document, as applicable, giving the clinical rational and, when appropriate, ethical considerations for gifts, bartering, extensive use of touch or self-disclosure, dual relationship, recording or videotaping of sessions, out-of-office experiences, such as home visits, E-therapy, phone therapy or any other telehealth practices, including a special disclosure if telehealth practices are the basic mode of therapy.
For Essential Ready-to-Use Clinical Forms: zurinstitute.com/forms.html
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Clinical Update, May 26, 2005:
Ethical Risk Management: Preserving Our Clinical Integrity
For an online course on Ethical Risk Management: Click here.
One of the worst professional or ethical violations is that of permitting current risk-management principles to take precedence over humane interventions. (Lazarus, 1994)
- We have been told, "Don't touch your clients!" "Minimize self-disclosure!" "Never venture outside the office with a client!" "Avoid bartering!" and "Avoid dual relationships at all costs!" These don'ts and many others whisper to us every time we emerge from one more risk management workshop or ethics and law seminar. They haunt us as we read with trepidation a bulletin from our malpractice carrier or review one more attorney's column in our professional organization's newsletter. Under the guise of risk management and self-protection, we are told, Beware! The slightest deviation from these ersatz commandments will set us on the 'slippery slope' to perdition.
- Risk management, the way it is often taught, means to avoid actions that may not look good in court or in licensing boards' hearings, regardless of their therapeutic value. It is my assertion that it is possible for us to protect ourselves while preserving our clinical and moral integrity. I believe we can touch our clients appropriately, self-disclose when helpful, barter when necessary, exchange gifts if it is therapeutic and engage in non-exploitative dual relationships without increasing the risk of being sued or losing our licenses.
Guidelines: Ethical Risk Management:
The complete guidelines are available at: zurinstitute.com/riskmanagement.html#guidelines.
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Clinical Update, May, 2005
Internet Addiction: The New Clinical Frontier
For an online course on Internet Addiction: Click here.
Guidelines: Internet Addiction:
- Studies estimate that Internet addiction effects 5 to 10 percent of the population.
* Internet addiction can be hidden by overt signs of depression and anxiety, masking how much time a client spends online. Therapists often overlook the symptoms of Internet addiction so that the disorder goes undetected making related problems worsen.
- Chat rooms and instant messaging are the leading reasons why people become hooked on the Internet. When asked about the main attractions of using these direct dialogue features, 86% of online addicts reported anonymity, 63% accessibility, and 37% ease of use made these interactive applications more attractive.
- In a recent survey of the American Academy of Matrimonial Lawyers, 63% indicated that the Internet played a significant role in divorce. Almost 80 % of the attorneys said that incriminatory e-mails had been part of divorce proceedings, while 65 % said computer and financial spending records had been incorporated into divorce records.
- Although online interactions are purely text-based conversations, the exchange of words empower a deep psychological meaning as intimate bonds are quickly formed among online users. In Cyberspace, the social convention of rules of politeness are gone, allowing personal questions about a person's marital status, age, or weight to be asked upon an initial virtual meeting. The immediacy of such open and personal information about oneself quickly fosters intimacy among others in the community.
- Among many online addicts, cybersex is perceived as the ultimate safe sex method to fulfill sexual urges without fear of disease such as AIDS or herpes.
- Those who suffer from low self-esteem, feelings of inadequacy or frequent disapproval from others are at the highest risk for developing an addiction to the Internet.
- Addicts report a sense of being able to "unlock parts of themselves which have been submerged" in their real lives, through online personas. The ability to unlock repressed aspects of the self can take on various forms. In Cyberspace, a shy person can become outgoing, a non-sexual person can be sexual, a non-assertive person can be forceful, or an aloof person can be gregarious. Addicts are able to play out parts of themselves that they fear or hate to consciously confront such aspects.
- Treatment for Internet addiction utilizes cognitive-behavioral techniques specialized to meet the needs for moderating appropriate computer use with a focus on abstinence from problematic online applications.
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Clinical Update, April 20, 2005
Termination: Clinical and Ethical Issues
For an online course on Termination: Click here.
Guidelines:
- Each client's treatment should ideally have a termination phase, even a very short one, regardless of the length of treatment.
- The process of termination requires thoughtful attention beginning with the process of informed consent.
- The process of termination should be articulated in the Informed Consent (or Office Policies) that each client must receive and sign before the first session (See Clinical Forms)
- When a client drops out of treatment or when treatment must be terminated due to managed care and insurance denials, lack of cooperation, failure to improve, and the like, simply tacitly condoning the termination sets the clinician up for ethical and legal difficulties.
- When a client drops out of treatment, if appropriate, follow up with letter respectfully offering to continue treatment, meet one more time for closure and/or to provide referrals.
- The main concern around termination is abandonment. Not only do not abundant your clients but also make sure that your records reflect that you indeed have not abandoned them.
- Arrange for appropriate coverage during periods of anticipated absence.
- Utilize a professional will to address any unanticipated incapacitation or absence from practice.
- Document all terminations. The records should include: Who initiated the termination, when and how it was conducted, which treatment goals were achieved, were referrals necessary and/or provided.
- Arrangements for clients to be able to have reasonable access to you between sessions are also important issues to address to prevent abandonment from occurring.
- If you are practicing Intermittent-Long-Term therapy, where clients and their families continuously come back to therapy throughout their lives, termination has a different meaning. Make sure you document your approach and how each ending of a phase of therapy is handled.
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Guidelines that are provided above are meant to be aspirational and general, as they may not apply to certain situations, clients and settings. For more details go to zurinstitute.com/privacy.html .
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