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What I learned from the Ethics refresher

Continuing education in counseling ethics is … Hey! Don’t nod off yet. Continuing ed in ethics is like tap water; flavorless and uninspiring, yet essential to our functioning. Caught short on ethics credits with license renewal slouching my way, I chose to go back to the basics.

An example of how exciting continuing education in counseling ethics is not.

I knew I would know most of the material. It meant passing up  advanced seminars with alluring promises of bullet-proof protection against lawsuits. But it’s too easy to get complacent about fundamentals. At risk of looking moronic to the more-recently educated, these seven points from Bruce J. Spencer’s “Applied Ethics” course caught my eye:

1. Bartering can be okay. 

Trading therapy sessions for goods or services has long been a no-no. There’s a high risk someone will wind up dissatisfied, and that will affect therapy. Spencer suggests it can be okay – in specific circumstances. If your client lacks health insurance or better options to pay, and the client likes the proposed deal, and a peer reviews it and agrees it seems fair,  and it’s written up in a formal contract,  then bartering might be appropriate. As unlikely as it seems, Spencer suggests that in impoverished areas with limited mental health services, bartering may be the most ethical choice.

2. How long to keep records? Maybe forever. 

State laws tell us to keep records between five to seven years. That may not be long enough. Per Spencer, there have been many cases where clients filed suit over years-old psychotherapy sessions.  With the documentation destroyed, the therapists had nothing in their defense except their word. Spencer suggests we save records of those dyspeptic clients who may grow disgruntled in future. Considering a career’s worth of electronic files can fit on a flashdrive the size of one’s thumb, one wonders if there’s a reason to dispose of any client’s records, ever.

3. Burn-out is a loss of faith.

If you can’t believe you can help others anymore, you’re probably right.

Most people view ideals and altruism as pleasant abstractions. Spencer sees them as essential to ethical practice.  To counsel clients, you have to believe (a) they can get better and that (b) you can help them do it,  (c) through therapy. When you’ve lost that confidence, you may play the role of a therapist, but you won’t perform effectively.

4.  Don’t put anyone else’s name in a chart.

You want to refer to people in your client’s life as, “The client’s second husband,” or “The client’s oldest daughter.” If the records ever get called into court and others are identified by name, those names will have to be redacted.

5. Not following up on homework could get you in hot water.

Spencer covers why we must set measurable goals to practice ethically. He also reveals therapists have been sued for not asking about progress on those goals – even for not asking clients whether they completed therapy homework.  Shocking? Not really. By relying solely on, “What do you want work on today?” the therapists floated aimlessly one session to the next. They failed to deliver services their clients agreed to and paid for. Since clients pay for our time and can’t be sure what they’ll need from one session to the next, it’s easy to regard treatment plans as busywork to satisfy insurance companies. Don’t.

6.  Void your safety contracts.

Are they this formal? It’s best to treat them as though they are.

Just because no-suicide agreements won’t hold up in court doesn’t mean “contract” is a metaphor. A contract is an agreement that ends when certain terms are fulfilled, or one of the parties breaks the contract.  Let’s say a client unexpectedly commits suicide months after signing a no-self-harm agreement. Concerned attorneys could point to the not-yet-voided contract as evidence the client was still in crisis and that we were negligent by not taking action. Spencer happily agrees this scenario is uncommon. Once a clients is out of crisis, we should document the safety contract is null and void, anyway.

7.  Clients can be scared to quit.

We all remember our first clients. They couldn’t have been scarier if they’d been nine feet tall with razor-sharp teeth.  It’s easy to forget licenses and degrees bring daunting professional authority, and that clients can feel scared of us. When we review our policies and the client’s rights in the first session, we need to cover their right to get a second opinion and to terminate therapy at any time. It’s hard for a client to get better if they don’t feel comfortable saying, “I think we’re done.”

@ 2012 Jonathan Miller All Rights Reserved


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California bans conversion therapy for kids

California has passed a law stating psychotherapists may not defraud their clients. Advocacy groups have filed suit to defend their right to be defrauded. Quick-witted readers have deduced I’m writing about the Golden State’s new law banning conversion therapy for children under 18.

Aren’t broken – Can’t be fixed

 Conversion therapy promises to convert homosexuals into heterosexuals. It’s persisted for years despite a near-total lack of success; Freud himself rejected it as unlikely and unnecessary nearly 80 years ago. In the United Kingdom, the British Association for Counselling and Psychotherapy formally declared conversion therapy to be unethical this month. Their decision came in the wake of a scandal sparked by an exposé of conversion therapists who insisted the reporter must be depressed, compared homosexuality to cannibalism  and showed peculiar interest as to whether his family members were Freemasons.

The Pacific Justice Institute and Liberty Counsel have filed suit in Federal Court, demanding therapists be permitted to offer these services to kids. They pose the issue as a matter of free speech and religious liberty. Here’s why they’re wrong.

1. What about the success stories?

Which success stories? In his 2009 review of extant studies, B.A. Robinson found conversion therapy’s failure rate ranged from 99.5% to 100%. He notes that Joseph Nicolosi, founder of National Association for Research and Therapy of Homosexuality, an advocacy group for conversion therapy, had a strange definition of ‘success’. Per Robinson, Nicolosi stated that one-third of his conversion therapy clients became celibate but remained attracted to same-sex partners. Another third limited their sexual activity with same-sex partners, and one-third didn’t change at all.  Nicolosi considered the first two categories to constitute success. You could call that “celibacy therapy”, but not “conversion therapy”.

Religious groups’ success has been minimal to non-existent as well. Two of the founders of Exodus International left the organization in 1979. They lived and loved together in a committed relationship until death parted them twelve years later. The Rev. John Smid, who spent more than 22 years with another ex-gay ministry, Love in Action, admitted, “Actually I’ve never met a man who experienced a change from homosexual to heterosexual.” As the former Executive Director, you’d think he would have.

2. What’s the harm in trying?

Suicidal depression, for one.  The American Psychiatric Association condemned conversion therapy in 1998 and again in 2000 because of the  considerable anecdotal evidence of emotional harm.

Bamboozlement, for another If a patient asks his doctor to cure him of lupus, the correct response would be, “There is no cure. Let’s talk about managing your symptoms.” To take the client’s money without stating plainly that lupus is incurable would be fraud – even if one’s faith teaches lupus is against God’s will. Lupus, of course, is (a) a disease that (b) causes pain and suffering in and of itself, and (c) can be eased with medical treatment. None of those things are true of homosexuality. For therapists to promise to treat a condition that has no effect on mental stability is exponentially more deceitful.

Consider the suits state boards  filed against L.Ron Hubbard in the early 1950s. They successfully charged him with teaching medicine without a license through his Dianetics Foundation. Hubbard kept peddling Dianetics, but repositioned it as a religion called Scientology.  Discomfited by allegations the Scientologist ‘church’ exploits and abuses its members?  How you would feel if your insurance premiums helped pay for it?

3. Isn’t this political correctness run amok?

No. Religious groups have the right to their view that gay sex is wrong. When they ask courts to rule that homosexuality is a treatable mental illness, they’ve long since left their bailiwick.


@ 2012 Jonathan Miller All Rights Reserved


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How far has therapy come since the 1970s?

Very far.

Note to clients: ethical therapists will not ask you to undress.

(thanks to V. Valenti)


@ 2012 Jonathan Miller All Rights Reserved

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Stress Management Blogging #3

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CBT by phone: Shorter-lasting effects for more.

There’s one kind of client no therapist can help – the one that doesn’t come in.  David C. Mohr, Ph.D, of the of the Northwestern University Feinberg School of Medicine, Chicago, IL,  has a new study that suggests they may not have to.

Alexander Graham Bell, inventor of the telephone.

In 2008, Mohr found clients will stick with therapy conducted over the phone longer than with therapy provided face-to-face. His latest study found that cognitive-behavioral therapy (CBT) for depression delivered over the phone was just as effective as the same therapy delivered face to face. Six months after treatment,  all the clients were still improved.

There was one catch:  the clients who met their therapists face-to-face were doing better at the follow-up than those who telephoned. 32% of those who came to their therapist’s office were depression-free compared to 19% of those who  phoned. Click the mp3 link on this page, and around the four-minute mark, you’ll hear Dr. Mohr describe the face-to-face clients as, “slightly better off.” This is an unnecessary understatement, considering the increased numbers who finished therapy.  Estimates of the drop-out rate in face-to-face therapy have ranged as high at 60%. Researchers have developed simplified feedback forms, helping some therapists reduce their attrition to around 18%. Mohr’s 2008 meta-analysis found the mean attrition rate for telephone psychotherapy was just 7.6%.

Sigmund Freud, father of modern psychology

Could coming to a therapist’s office for treatment increase the risk that a client will drop out?  Consider another industry whose consumers keep their customer status private: pornography. Reliable stats are rare, but it’s believed porn consumption exploded in the early 1980s, and did so again in the 2000s.  Changes in technology led the way. With the rise of the VCR, consumers could get their obscenity without visiting the seedy part of town. Once internet access spread, they didn’t even have to leave their home. There’s little reason to doubt most folks feel shame about going to a mental health center, just as they would about a grimy peepshow or massage parlor. Providing therapy by telephone would not only simplify clients’s busy lives, it would also remove low-level fears about being recognized at a therapist’s office.

Larry Flynt, pornographer. (Photo by David Livingston/Getty Images for COPE Health Solutions)

One can’t blame Mohr and Co. for trumpeting the effectiveness findings. Counseling someone you can’t see?  There have been long silences where I was grateful I could see my client quietly weeping or mulling things over. But  Mohr’s findings, and the number of successful blind therapists suggest visual contact’s importance may be overrated. Alexander Graham Bell invented the telephone in 1874. Sigmund Freud coined the term ‘psychoanalysis’ in 1894. In 2012, mental health therapy is still mostly conducted face-to-face in therapist’s office.  If combining Freud and Bell’s inventions would help more people, with only some decrease in the length of therapy’s effect, one is forced to ask, “Why not?”


@ 2012 Jonathan Miller All Rights Reserved


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Making therapy offices therapeutic

An interesting photo gallery here, where therapists muse on their offices. More than just decorating tips, they explore the thought process that went into creating a therapeutic space.  Author Jose Ribas MD explains:

An examination room in a North Carolina hospital or clinic probably appears quite similar to an examination room in a hospital or clinic in New York, South Dakota or Texas. Where this model departs is in Psychiatry, where the room itself plays an important role, as it becomes the physical “holding environment” where the therapist conveys to the patient that he or she is safe to explore those areas within him/herself that are threatening or causing distress.

My Tuesday-Friday office. The architects added on to the building some years ago, giving my clients and I a view of the billing area. (photo credit: Mrs. ‘Sphere)

Designing my own space, the aim was to balance professionalism and homeyness; to be colorful but not gaudy and warm without being oppressive. I realize now that all three posters show scenes from Europe. We Americans associate the continent with intelligentsia – perhaps it’s saying, “I’m smart enough to help you solve your problem.”


@ 2012 Jonathan Miller All Rights Reserved


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“Gay cure” study retracted.

“He struggled against an upsurging hilarity — that any reputable medical man should have lent himself to such an amateurish experiment! “— Señor, I must tell you that in these cases we can promise nothing.”

– F. Scott Fitzgerald, Tender is the Night

When a study is retracted, it usually gets a fraction of the attention it received when published. (just ask the parents who refuse to believe there is no connection between autism and vaccination.) This deserves to be bigger news than it has been:

In 2001 U.S psychiatrist Robert Spitzer conducted a study that claimed gay men and women could be turned straight through psychotherapy.

He has now retracted the highly controversial view.

Spitzer’s 2001 study earned extra attention because he led the charge to have homosexuality removed from the DSM in 1973 .  Back then, the reasoning was simple: homosexuality couldn’t be a disturbance in one’s psychological well-being.  Homosexuals and heterosexuals both scored in the normal range on tests of psychological well-being. When Spitzer suggested that orientation might be changeable, pseudo-scientific organizations such as NARTH seized on it as evidence that homosexuality was curable.

Conversion therapy” goes back to Freud’s time, but it was largely abandoned when the DSM dropped same-sex attraction as a mental health issue.  Conversion therapists’ success stories include gay people who stay celibate, and bisexual people who limit themselves to opposite-sex relationships.  None established a consistent track record of helping those exclusively attracted to the same sex become exclusively attracted to  the opposite sex – that is, “converting” them. The American Psychiatric Association condemned conversion therapy in 1998 and again in 2000; they found the anecdotal evidence of success was outweighed by considerable anecdotal evidence of emotional harm.

“Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation; it cannot be classified as an illness,” – Sigmund Freud, 1935

When one former conversion-therapy advocate estimates the failure rate at 99.9% and another states, “Actually I’ve never met a man who experienced a change from homosexual to heterosexual,” it’s safe to say conversion therapy is a sham. Spitzer’s retraction removes one of the last shadows of doubt from the question.

Shout this one from the rooftops: you can’t cure what isn’t a disease. Sexual orientation is fundamental.


@ 2012 Jonathan Miller All Rights Reserved

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Sorry Ben, Sorry Jerry

Much respect to you both, but there’s still no caloric cure for emotional ills.

… At least, I don’t think so. May need to do a few pints’ worth of research.

@ 2012 Jonathan Miller All Rights Reserved

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Stress Management Blogging #2

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Which 12-step group for your client with sex addiction?

Joe Kort, PhD, sexologist and founder of the Center for Relationship and Sexual Health has an useful article up at the Huffington Post on sex addiction treatment. Among other things, he categorizes the different 12-step groups available. Per Dr. Kort:

Various 12-step groups’ meetings are open to sexual addicts, but it’s vital to recognize the fundamental differences between them. Sex Addicts Anonymous (SAA) is most liberal, welcoming everybody — men, women, gay, straight, bisexual, and others — and lets you define your own sexual boundaries. Meetings tend to focus on paraphilias, in which arousal and gratification depend on fantasizing about, and engaging in, atypical and extreme sexual behavior.

Sex and Love Addicts Anonymous (SLAA) focuses on love addicts. People “in love with love” seek, and later crave, that lightning-bolt, blown-away kick of “love at first sight.” Again, everybody is welcome. This program helps those who tend to move on as soon as troubles arise, hoping a new relationship can supply what the last one failed to deliver.

Sexaholics Anonymous (SA) takes the rigid, orthodox approach that no sexual relations should occur outside marriage. They tell participants that “any form of sex with one’s self or with partners other than the spouse is progressively addictive and destructive.” Many gay clients tell me they feel excluded for this reason.

Sexual Compulsives Anonymous (SCA) was born after some gay men felt uncomfortable with SA’s fundamentalist, heterosexist overtones. Members have designed their own recovery program, where gay men can discuss their special needs and talk openly and honestly.

People who’ve never hear of this problem can scoff, “Sex addict? Who isn’t?” The answer is, “Thousands of people. Folks whose sex life causes buckets of shame, a thimbleful of pleasure, and still can’t make themselves stop.”  With the guilt and embarassment that comes with sex addiction, it matters we refer clients to a 12-step group where they will feel they fit in.  More articles like this, please.

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