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So, the most recently viewed entry of mine was ‘Why I don’t do free consultations’. Interesting. Perhaps it’s time to switch topics, write another blog in the spirit of…what? Consumer advice? Secrets from inside the therapist office? Well, maybe this entry will be along those lines, sort of.

If you’ve ever been in therapy (or if you are one) then you’ve probably come across the norm/ethos that therapists can and should work together with other professionals–doctors, other therapists–to provide optimal care for clients/patients. It’s a collaborative approach, a team approach. “Let’s see if we can get on the page”, someone might say, prefacing a discussion. There are procedural elements to navigate: each professional must obtain a signed consent form, from the client/patient, to speak to another professional, divulging confidential information, and must define the parameters of disclosure, such as categories of information, and a time-frame for the exchange of information (most consent to exchange information agreements don’t last longer than a year).

Given that a top priority, both legal and ethical, for any therapist is that of maintaining confidentiality, you might wonder the following: what are the specific pretexts for recommending an exchange of information with another professional? We surely can’t just employ the “isn’t is good to get on the same page” rationale with everyone, can we? Answer: of course not. So, what are the conditions that merit the so-called collaborative, or team approach? And when is it contraindicated (as we say in the biz) — as in not appropriate?

Well, to take the first category, I’ll start with one rule of thumb: I ask, ‘is this professional going to be working directly with my client?’. Meaning, are they the treating physician, someone who is overseeing medications, attending to physical needs, withdrawal symptoms from substances, for example. When working with someone who is either in an active phase of drug abuse or addiction, or in early recovery from substances, I will often agree to consult with a client’s physician, partly to determine if that client is compliant with their regimen, medically safe (BTW: I would have that reasoning understood by my client so as to avoid an air of secrecy or gamesmanship). Secondly, I would consult with a fellow professional if that person were working with my client in another format of therapy, say, couples’ therapy. In that situation, it may be helpful for the other treating professional to have my impressions of my client from an individual therapy, for example–impressions that may facilitate the progress of the couples’ therapy (again, for similar reasons, this would be explained to my individual client, who could of course block any such communication if having reservations). Finally, there are structural realities which determine whether therapists communicate with other professionals: if you see your therapist in a hospital-based setting, or as part of an agency, or if your therapist is a pre-licensed clinician, you should expect that he or she regularly consults with doctors, supervisors, peers, even teachers, as part of an established, collaborative team set-up.

But this is not the case in private practice, generally, and while private practice therapists often employ consultants so as to not be isolated in their thinking, they (including myself) don’t always agree to consult with another professional who wishes to exchange information about my client(s). A typical scenario is the following: a therapist for a partner of my client calls up, wanting to exchange information, having obtained consent from his or her client to speak to me. However, I don’t have a corresponding consent from my client, so I don’t return the call. I address the situation with my client, who may or may not object to the prospective exchange. I determine if my client is seeing the other professional in another context, such as couples’ therapy, or a doctor’s office, if a physician. If not, then the prospective exchange has not met the first criteria: the other professional is not working directly with my client. Secondly, I consider if there is a critical reason for such an exchange (like the aforementioned substance use issue, or another crisis that requires management). If that also is not clear, then that other professional’s call may remain unreturned, because confidentiality is more important than professional courtesy, basically.

When the value of a professional exchange is not clear to me, then I suppose the following: a savvy partner, and sometimes estranged parent, is looking to circumvent confidentiality barriers in order to infiltrate the therapy of my client, and effect an influence, by using their therapist, plus that zeitgeist ethic of collaboration. After years of facing such situations, I decided finally to articulate my opposition to these kinds of subtle gambits, which do more damage than good. If professionals don’t practice good boundaries–if their sharing is too profuse–then individuals are provided with backdoor access to the private process between a therapist and a client, which in turn will damage trust sooner or later. As for that popular and sometimes insidious phrase, “Lets see if we can get on the same page”: as often as not, I find that invitation is not quite as collaborative as it may seem. The phrase might be translated as “would you please read the same page as me.”

Got a phone call last Monday morning. A woman saying she was a producer for KFI Talk Radio in Los Angeles asked if I’d be interested in going on the Bill Carroll Show an hour later.

“Uh, I’m on my way to work,” I said dully, half thinking this was a crank call. Days earlier I’d been quoted in an LA Times story about AB1775, the controversial child porn law that I’ve skewered so much on this blog it’s become my own kind of abuse victim. Following this media exposure, invites to talk shows were at least plausible, but if you were a self-published author suffering junk solicitation on a weekly basis, you’d be a little skeptical too. So given the short notice, I was a little indignant and a whole lotta skeptical. Still, I asked my wife to check out the show to which I’d been invited to see if it was legit, and indeed it was. In fact, it was so legit that it featured Melissa Melendez, the assembly woman who sponsored AB1775, in cozy discussion with host Bill Carroll, a Howard Stern-lite type who on the Monday show seemed sympathetic to Melendez’ bill, and fairly skeptical of what therapists do, especially with anyone who looks at child porn.

I sent that producer a snarky e-mail later in the day. Fuming at the one-sidedness of the day’s show, and further annoyed at gratuitous digs at my profession, I asked if Melendez was also given an hour’s notice before appearing—turns out she was. Anyway, the producer called back saying I could appear the next day during the same time slot, and rebut what I’d called the “anti-therapist drivel”. So, I was going to be on the radio. Specifically, I’d be on a station billed as the most popular in Southern California. I’d be on with Bill Carroll, talking about AB1775. It was on, I thought, sitting nervously in my home office, on hold with my cell phone pinned to my cheek. I was introduced as a therapist upset with the new law, and even more upset at being given short notice to appear the day before. Before uttering a word, I was set up as a self important clinician, clueless as to how the rough and tumble world of radio works. Bill Carroll warned me that if I spent time arguing about my precious need for adequate notice, I’d miss my chance to excoriate AB1775. I pictured my colleague Don Mathews, a plaintiff in the case seeking injunction against the bill, upon telling him I’d had a chance to make our case to God knows how many listeners, but squandered it railing against the media’s disregard of a professional’s time.

“I’m over that. Let’s talk about the law,” I said, like I was inviting a fellow gunslinger to draw. Moments later, I was deflecting Bill Carroll’s first ill-considered question, instead complaining that Melissa Melendez and others had misrepresented the issue. You see, they keep saying that because child porn is illegal, the new law is simply ‘clarifying’ matters related to reporting requirements, or updating language because of the internet phenomenon. Therefore, the law simply asks therapists to perform what has always been their duty.

Wrong. Or bollocks, as my nephew likes to say.

I pointed out to Carroll that this explanation doesn’t make sense. If the existing Child Abuse and Neglect Report Act stipulated that therapists and other mandated reporters reveal to authorities those who view child porn, then why was it necessary to ‘clarify’ this for supposedly confused mental health professionals, and thus re-write the law with the excuse that advances in technology had enabled more users? If viewing child porn—in addition to producing and distributing child porn—is and was understood as sexual exploitation, then what difference does it make to that understanding how many more people are able to do it? Are we to believe that some therapists started hearing words like “download”, or “streaming”, and became confused as to whether this constitutes watching child porn? No. What happened was this: some people noticed that the pre-existing law, which is over thirty years old, did not stipulate that viewing child porn is reportable by therapists. Thus, they sought a change, one that would sneak in behind a technological cover, a conflation of child porn use into existing abuse definitions.

The lawyers promoting AB1775 obfuscate on this point, repeatedly complaining that child porn use has always been illegal, and thus reportable. But illegal and reportable are not interchangeable concepts, as some appear to think, and lawyers in particular should know better. If therapists reported everything said to them that is illegal (and the list of things illegal but not reportable might shock you), we’d be little more than glorified informants for a police state. Does it not seem like common sense to point out that the most anti-social elements of our society don’t choose to enter psychotherapy, and even if they did—or were ordered into therapy—would they not simply avoid telling therapists about their child porn use if they knew such information would be passed on to police?* Lawyers. If this law sticks, lawyers may be the only ones left talking to child porn users–that is, advising them not to share their truths with therapists.

So I read out the new law on the air, which, as I promised, took about a minute of the radio show’s precious time. I pointed to the spot in the California penal code—section 11165—wherein the new deed was done: the words, “downloading, streaming, accessing, though any electronic or digital media, material that depicts minors engaged in obscene sexual conduct” (FYI: the latter term is defined rigorously elsewhere in the penal code) were inserted into a subsection of the code defining sexual exploitation, thus altering it from a matter of production and distribution, to include the more commonplace act of viewing. I then pointed out to Bill Carroll that the language of the law also implicated “sexting”, which is often practiced by teens (minors), over electronic or digital media (computers and cell phones), displaying their so-called junk (examples of obscene sexual conduct). Carroll was at first evasive, saying he didn’t think teens would bring this matter to therapy.

“I disagree,” I said. “Teens go to therapy. They talk about sexting, and because of how this law is written, therapists will have to report them to police.” The argument scored a hit with the host, and Carroll finished the show calling for a ‘tweaking’ of AB1775, thus, in effect, rebuking Ms. Melendez, who had earlier stated she was not interested in making changes. The show continued, with Carroll challenging my thoughts as to whether sex offenders could be treated at all; about whether they could be treated by circumventing the facts of their child porn use, by talking about feelings relating to porn use instead (surely not the intent of the prosecutorial AB1775 supporters). To his credit, Carroll seemed like he was trying to see things from a therapist’s point of view, which was refreshing given the previous day’s rhetoric. For the last five minutes, Don Mathews joined the show, demonstrating the flexibility of which Carroll had boasted, and spoke more pointedly about AB1775 harming instead of protecting children. Time ran out. Regrettably, I missed rebuking Ms. Melendez’ semi-informed assertion that priests and other clergy are also mandated reporters—this was partly in response to Carroll’s stated wish to punish those who fail to report if thereafter a child abuse instance or pattern occurs. Actually, neither he nor Melendez were aware that penal code 11166 allows for an important exception for the clergy: if they hear of child abuse in the context of ‘penitential communication’ (i.e.: confession) they actually don’t have to report child abuse.

Would assembly woman Melendez sponsor a bill that rewrites—excuse me, ‘clarifies’—that subsection?

* one more thing to clarify: as a point of law, a therapist must tell a patient of potential benefits, risks, and alternatives involved in any treatment procedure (this includes legal exceptions to the basic confidentiality rule).

Time for another review and a tie-in to…something. Recently saw Testament and Youth, a film apparently released worldwide last fall, but only recently making it to Bay Area theaters. The film is based upon a First World War memoir of the same name by Vera Brittain. Swedish actress Alicia Vikander plays the historical figure, a suffragette and then later, a pacifist. That pacifism comes later is one of the story’s tragic themes. Vera is born into a well-to-do family in rural Britain, headed by a stern, if decent paternalist (played by Dominic West), and mothered by a prim yet henish character played by Emily Watson. Opening scenes feature Vera as a petulant but gifted daughter, angry at her father for buying her a piano for her birthday, with money that should have been allocated for an Oxford education. He exasperates over her ingratitude. She despairs that chauvinistic men, however benevolent, will never listen. Vera wants the world to listen. She is poetic, ambitious of becoming a writer, envious of her brother and his two friends, a triumvirate of carefree maleness.

Vera spends her spare time in their company as often as possible, partly because they are charming and fun, but more importantly, because theirs are privileged and coveted lives. Her brother, in particular, is a cheerful saint: advocating for his sister, he insists that their father allow Vera to “sit” for entrance exams at her dream college, Oxford. The father reluctantly agrees, and Vera passes the requisite exam, despite flightily overlooking instructions to write her essays in Latin and not German, which she has prophetically learned as a child. She returns home, initially discouraged, thinking she has failed in her dream. However, the head mistress who oversees admissions appears to like Vera, saying she has an “original mind”. Indeed she does, though following events reveal her to be as naive–and in some ways traditionalist–as anyone.

It is 1914 and war is breaking out. The young men of the towns and villages are signing up for military duty, gleeful at the chance to serve, plus believing the villainous Kaiser will be vanquished in no time. Vera’s father, however patriotic he may be, is nonetheless anxious about allowing his only son to fight, but Edward (Vera’s brother) is determined to serve, and Vera, reciprocating Edward’s earlier support of her, exhorts her father to “let him be a man”. It’s an interesting passage in the film, and surely also in the original memoir, for it betrays a likely truism: that while many women challenged the status quo with respect to their social roles, fewer sought to challenge the mores that led men to slaughter. BTW: it’s known that most notable suffragettes, like Emmeline Pankhurst for example, supported the war and recruitment efforts, and even suspended their violent campaign for voting rights. Vera Brittain was on the periphery of this movement, it seems, but in the story is more concerned with her education. She is concerned about the war because it would separate her from her brother, and in particular, because it steals away the emerging love of her life, Edward’s friend Roland.

The middle portion of the film introduces everyone to the horrors of war, firstly by revealing the shellshocked detachment of Edward and Roland when they return home on leave. Roland in particular seems distant and angry, often snapping at Vera, impatient with her innocence. He recovers his loving nature sufficiently in order to propose marriage, but of course the wedding never happens. Roland is killed in France soon after, a year into hostilities. Grieving but galvanized, Vera abandons college, signs up to be a nurse, first on home soil, treating returning soldiers, then later on the front lines, in France. Initially, her challenge is to overcome the severity of her nursing supervisors, the grudging attitudes of her peers, who smell Oxford elitism upon her. But Vera is resilient, tough, and above all truth-seeking, which eventually wins her admirers. Most powerful is a scene in which she has sought out the commander of Roland’s former unit. Bravely, she penetrates the commander’s consoling platitudes and learns the full truth of her fiance’s dying ordeal.

It’s another turning point in the story, which plunges further into the horror of war, sparing no one the grisly details. On the front lines, Vera treats the maimed and the dying with increasing maturity but diminishing hope, all the while maintaining a grim hold on reality. One after another, characters perish. Finally, and inevitably, Vera learns that her brother Edward has also fallen victim. At this point it is 1917, just before the end of the war. On Armistice day, she wades through a crowd of revelers, unable to join in celebrations, for everyone she has loved is either dead or has been broken irrevocably. At her home in the countryside, her mother dithers, a shadow of her once vital self. She is unable to get out of bed. Her father is quiet, at times sobbing–a lonely, depressed man. The film’s climax is a town hall meeting: Vera takes the stage and shouts down a raucous crowd which is protesting the notion that Germany might receive any leniency in post war negotiations. She displays her credentials, her irrefutable losses, but recounts the moment in which her knowledge of German was put to good use. It was a death scene: one in which she hovers over a dying “Hun”, apparently taking in a confession that fights against the man’s final breaths. In the meeting, unlike the earlier scene, Vera discloses the content of the man’s thoughts: a plea for forgiveness from a former sweetheart; a moment of redemption that equalizes friends and enemies.

Vera’s memoirs, written in sequence in the post-war years, were a testament to the realities of war, highlighting the ways in which women are changed by war.