Fewer words from me this week, more quiet satisfaction. And so, a guest blogger of sorts. I’ll read along
https://www.forewordreviews.com/reviews/the-situation/
Affirmation at last
Why I don’t do free consultations
Recently I had a call from a prospective client looking for a therapist. He and I had one or two phone exchanges, discussing my approach, plus logistics like schedule, insurance matters and fee. At the end of the second call, which, like the first, lasted minutes, we agreed upon an appointment time and I indicated my fee for a first session. The caller balked, saying he’d hoped for a free consultation, and adding that he’d seen numerous therapists over the years, all of whom had offered an initial free session: a “screening” he called it; a “feeling out process”, seeing if we’d “connect” he added. I was dubious about his claims.
I replied that, contrary to his personal experience, free consultations are not a norm in psychotherapy, though some, perhaps many, do offer a free session at the outset. I added, pleasantly I hope, that the assumption of a free consultation was inappropriate for various reasons, not least of all because a therapist’s time, which is actually our only reimbursable commodity, is not free. The caller gently deferred on this point, but asked to call me back as to whether he’d make an in-person appointment. I sensed that his shopping had yielded other willing participants in the free service department, and that I’d not hear from him again.
Indeed, we did not meet. So, for those who have received free consultations from therapists, or who might think them appropriate, if not a standard of the profession, I will now explain why they are not.
Firstly, returning to the earlier point, a therapist’s time is his or her only reimbursable service. Meaning, there is no commission placed upon an individual’s mental health. That said, if anything, therapists might reasonably raise fees if a person’s circumstances improve, as they may be an indicator of a person’s growth and the therapist’s good work. To put it another way: why shouldn’t therapists, like everyone else, merit a raise from time to time?
Secondly, if a therapist doesn’t receive a fee, then he or she is simply giving away their time. If a private practitioner, there is no agency, hospital or other institution that will absorb the cost of the therapist’s time; not PTO that will pay for an un-reimbursed hour, and the opportunity cost of the “free” time cannot be written off taxes.
Well, what of the ideas tabled by that caller? You might ask. What’s wrong with the idea of “feeling out a therapist” as he put it; checking to see if a “connection”, a rapport, seems apparent before making a commitment to actually engage in therapy. My answer is as follows: an opening session may be a breezy, shopping encounter for a would-be client or mental health patient, but it is not and cannot be such for any mental health professional. From the outset of an episode, even during an initial telephone exchange, therapists incur responsibilities, legal and ethical–what’s called fiduciary terms–which are rivaled by few other professions. Take confidentiality, for example. That responsibility, to keep client material private, kicks in before therapists even meet their clients, when they are speaking by phone. Why? Because if I receive a later phone call from that caller’s girlfriend, for example, who wants to give background for a prospective therapy, contribute to the intake process, it’s not as though I can exchange information with that person. In a first session, in which a client may be deciding if there is a connection, a therapist must make certain assessments: is the person in danger? Is psychotherapy even appropriate for them? Are they suicidal, a danger to others, and what are the recommendations for other treatments that will best serve them? This is not a feeling out process. It is work; it requires years of education and training, and it’s not free.
Free consultations, a kind of coupon therapy, does occur in our business, and a therapist may ethically choose to work for a significantly low fee with someone of especially low means, or pro bono with someone who cannot pay at the outset of an episode. But, of course, we can’t do this with many people, and with most the practice is inappropriate, especially if done for business reasons: a teaser of free service, designed to entice customers; ideas borrowed from retail culture. Such gestures can contaminate therapy, creating tacit dependencies that likely undermine therapeutic goals, enabling false understandings as to the nature of therapist-client relationships.
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New Changes to Child Abuse Reporting Law
In August of 2014, the California legislature passed bill AB1775, which stipulates important changes to the Child Abuse Reporting Act, and was apparently sanctioned by CAMFT(and conveyed to CAMFT membership the same month), despite objections by the National Association of Social Workers, which reasonably argues that AB1775 will stymie therapeutic disclosures and hamper child abuse prevention efforts. This law went into effect on January 1st of 2015. Ostensibly, AB1775 calls for all mandated reporters to report instances of child pornography to authorities, social services or police. Legislative author and state assembly woman Melissa Melendez, who authored the bill (it was actually written by lawyers for CAMFT–The California Association of Marriage and Family Therapists in concert with law enforcement and child advocacy groups), pledges to crack down on child pornography, though the impact of the law is likely more far reaching.
To explain: pre-existing law dating back to 1980 (the once Child Abuse and Neglect Reporting Act, or CANRA law) stipulates that mandated reporters alert authorities to sexual exploitation, material that depicts minors engaging in obscene sexual conduct, through the mediums of film, videotape, negative or slide. The language of AB1775 is updated as followed: “sexual exploitation includes downloading, streaming, or accessing through any electronic or digital media, material in which a child is engaged in an act of obscene sexual conduct.” Meanwhile, Penal code 11165, subsection 311.4 defines obscene sexual conduct as, among other things, “exhibition of the genitals for the purpose of sexual stimulation of the viewer”, as well as lewd and lascivious acts, which are further defined in subsection 288.2 as that which depicts touching intimate parts of the body, including “buttocks of a person and the breasts of a female” (subdivision d). The law further removes the need to observe an “identifiable victim”, as is typically required by social service investigators. Thus, the idea is not to protect victims per se, but rather to capture those who view obscene material, and engage therapists as informants. **But if you work with adolescents in particular, note the word minor (meaning under age 18), the reference to “electronic or digital media” (i.e.: cell phones and computers), and the language of the penal codes, and understand why sexting, for example, is now reportable under the law.
Of course, the issue is bigger than that. A person who discloses to you that he or she looks at teen or preteen pornography, who is perhaps seeking help, afraid they might hurt minors more directly, must be reported to Child and Family Services, who will likely defer to law enforcement investigation due to lack of identifiable victims. As an experienced sex addiction/offender therapist, let me describe the likely fallout: arrest, incarceration, loss of job, estrangement from peers, family, possibly lifelong registry on a public sex offender list. Next, because sex offender treatment is under the exclusive authority of The California Sex Offender Management Board (CASOMB), which certifies providers, YOU WILL LOSE CLIENTS that you report if you’re not certified. Finally, for those who recall the CAMFT Bylaws debacle of 2013, observe that once again CAMFT has co-signed an initiative that will bind its vast membership without actively engaging that membership in the process. Don’t be taken for granted! Discover research by Dr. Karl Hanson, whose work distinguishes child pornography users from child predators (versus conflating them), become educated as to the implications of this short-sighted legislation, and learn through the website, www.stopAB1775.org, how we can block it.
Graeme Daniels, MFT
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Good Enough
It’s a holiday giveaway, these free books (almost, but not quite free if you click on the link). A year after it’s initial publication (actually, closer to a year and a half), I’m looking to stir interest in my non-fiction and memoirish work, Working Through Rehab: An Insider’s Look at Adolescent Drug Treatment. This latest giveaway comes upon the heels of a workshop I recently taught–an overview of the disorder of self model created by James Masterson, that I provided for interns at a community mental health setting. Masterson’s work, referenced minimally in most training programs these days, is referenced centrally in WTR, as a guiding set of principles for what might happen in community or residential treatment settings, especially those straining to incorporate psychodynamic perspectives.
The difficulty is outlined in one of Masterson’s final works, The Personality Disorders: A New Look (published in 2000), in which he reviews the various methods used to treat Borderline Personality Disorder, as well as concomitant conditions such as Bipolar d/o or PTSD, and bemoans the dilution of intrapsychic focus in favor of pragmatic and utilitarian approaches. Like many, Masterson points out that modern neurobiological research has determined that a child’s brain increases 2 and 1/2 times in size during the first year of life, suggesting an “experience-dependent” growth pattern tied to a dynamic between caregiver and child–that the role of a caregiver is that of regulation; regulating the immature psychological systems which influence biochemical growth.
Masterson’s contemporaries, Otto Kernberg and Heinz Kohut, suggested more or less competing models for the treatment of individuals who suffer from development dysfunctions such as BPD. Kernberg drew from ideas put forth by Melanie Klein by indicating a constitutional excess of aggression on the part of such patients, with maternal or caregiver interaction playing a less influential role in his model. Like Masterson, Kernberg recommended an expressive psychoanalytic psychotherapy in treatment, but one that favored a focus upon transference interpretations, with insight into such interactions promoting integration, and thus growth. Masterson disagreed, thinking that confrontation of ego defenses, particularly regressions designed to ward off what he termed “abandonment depression” (as in an abandonment by a primary object) was the central task of psychotherapy. In Masterson’s view, interpretations prior to containment of defenses, or the establishment of therapeutic alliances, were ineffective. Meanwhile, Heinz Kohut, in whose model I was initially trained in the nineties, recommended an approach that drew attention to patients’ so-called unmet needs. Focusing more upon Narcissism than Borderline pathology (once deemed interchangeable conditions, incidentally), Kohut taught a model which focused upon mirroring responses, with less emphasis upon transferential interaction (Kernberg), or defense analysis (Masterson). The differences are crucial, parallel to what are termed “enabling” versus “recovery-oriented” approaches in the lexicon of CD treatment. As Masterson would say, what we call defense they call the patient’s “efforts to repair”.
In WTR, I describe the influence of Masterson in my growth as a therapist in a residential setting, as well as my movement away from the Kohut model I’d originally been taught. My rationale was as follows: the patients whom I saw repeatedly in treatment were mired in patterns of lying, self-destructive behavior, suicidal and violent tendencies, alongside a variety of other defensive habits, yet few of these patients were sociopathic. They were admitted for a treatment episode that was daily, intense, would last over months, if not longer, and engender transferential bonds that were complex. The stage was set for a psychoanalytic treatment, yet over time, the prominence of such models diminished, in favor of derivative approaches, Dialectical Behavior Therapy, so-called Strength-based models, that focus upon symptomology versus intrapsychic, or internal change.
Change. Meaningful, lasting: everyone in the field claims to want it, and even resistant patients give it lip service. Notions of it inform but also confound treatment plans. In dispute with Kohut, WTR mischievously contends that mirroring defenses tends to reinforce defenses. In dispute with Kernberg, I offer that a focus upon constitutional aggression ignores underlying pathology. In dispute with Masterson, I’d say that mandated referrals engender “compliance” defenses, which contaminates therapeutic alliance, enabling defenses. Such bonds, as well as defenses, are nonetheless fluid, predictable and not. But to work through rehab, as either a patient or a professional, you have to make a choice at some point as to what approach is right. Hopefully, your choice is good enough.
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The Conversation, part two
Sophia quickens her step, chasing after Lefty, who did what his name suggests–he left–just as things were heating up with Harmon.
“Hey,” she calls out in a curt, half-friendly voice, like there was just one quick thing to discuss. Lefty slows but doesn’t turn, like he’s been caught by an officious school mistress. Maybe she doesn’t want much. Maybe she just wants to understand the few jibes he’d directed at her; the oblique remarks about her name, that of Harmon–his curious take on things. “I’m the community analyst,” he’d said in parting. Sophia catches up with him, is slightly breathless as she takes a pause, thinks about her name and wants to change it.
“I wanna know what’s up with you,” she asks.
“Oh, right. Acknowledgement”
“What?
“Nothing. Just something that was said.” Sophia blinks, taking in the data. It doesn’t compute. “Look, can’t you just be straight. We’re trying to have a serious conversation.”
“So am I,” Lefty replies with aplomb.
Sophia recoils. “It seems more like it’s a game to you–a game of hide and seek. I mean, do you even have an opinion about what happened. Do you think an injustice occurred, is happening, like all the time?”
“I don’t know,” Lefty shrugs. Sophia’s eyes narrow: a blur of contempt and hurt.
“How can you not know? Do you honesty think that if that kid had looked like you or me, the same thing would have happened? Don’t you see the inequality that’s all around you, or do you just not care because to look at it would mean you’d have to give up your privilege?”
Symbolically, unconsciously, Lefty looks askance, past Sophia’s shoulder, her hot, burning eyes. He sighs.
“Actually, I do think those inequities exist, and I do think them unjust. I just don’t know if the incident yesterday was an example of that.”
“Are you kidding?”
Lefty straightens, gulps. “No I’m not. That incident needs to be looked at on an individual basis, not as something representing a trend. Those people, all of them, deserve a fair hearing, not to be treated as scapegoats.”
Sophia protrudes her face into his. “Really?” she retorts, portending sarcasm. “You think all of them are scapegoats, as in equally?”
“Maybe,” Lefty musters.
“You need to wake up, friend, and by the way, I’m not sure you are a friend. You need to get off the fence, open your eyes. I can’t believe this. It’s so frustrating to know people who just refuse to see things. I could tell you about countless stories of people getting abused, persecuted. I bet that none of that has ever happened to you. I mean, I’m not saying this never happens to us, but…whatever.” She stops, takes a breath just as her volume reaches some predetermined threshold. She looks away, heaves a deep breath.
Disgust.
Lefty searches for her gaze, his own breath trapped. He has nothing left to say, and neither does she, but her job is done. Satisfied, she sees it in him, finally–what she’ll settle for. Lefty is uncomfortable.
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The Conversation
Harmon, a man concerned with togetherness, saw it in Sophia: the fear. He saw it in her name: so much fear. But that was beside the point. The point was to speak openly, to matters that were front and center, not these fanciful tidbits, undercurrents.
“We need to have a conversation about justice,” Sophia brightly declared.
Harmon was hesitant. “Well, yes, of course. Though I think it’s really about social cooperation, plus economics, philanthropy, about having the conversation that brings different sides to the table.”
Sophia scratched her head and furrowed her brow. Consternation–twitchy, nervous consternation.
“Why do you do that with your hands?” This was Lefty, on the periphery of friendship, niggling at Harmon. Lefty was so-named because he came at things sideways, liked to observe that which happens in silence, detached from intellect.
“It enhances my point,” replied Harmon curtly. His hands, aloft and frozen, had been rotating vertically, moving the air.
“I…I don’t really know what you mean. I mean, sure–it’s about cooperation, and economics–but I think certain things need to be acknowledged. I think some things speak for themselves, and it’s not about whether people give things. It’s about how things are divided, about poverty and inequality.”
“Yes, all these contexts are important, but I think you have to be careful on these subjects. You can’t just come at people bluntly–the way you want to. It makes people defensive.” Harmon, on precise cue, delivered a sweet smile. Sophia, diffident yet brave, soldiered on, shaking her head.
“I don’t know…I just think we need to be honest, not have some kind of dance–this ‘cooperation’ as you call it. It’s important. People are getting hurt, being traumatized. People are dying.”
Harmon stretched out his arm and held his palm upwards. “Sure. But see, it’s not a zero sum game, social justice versus cooperation. It can be both if you take an even-handed approach.”
“What does that one mean?” asked Lefty, eyeing hands studiously. Harmon cut him a sideways look; ignored him and continued. “Words like justice are…” he paused “…inflammatory. You have to build slowly, assert an agenda but one that seems inclusive, doesn’t alienate with tendentious language.”
Sophia’s reply was brittle. “I think this is disingenuous. If we bring people to the table, have this conversation, it needs to start with some understandings. We need to say to one side, ‘look, you’re in the one-up position. The onus is upon you to acknowledge that, at least–”
“They’ll know you want more than acknowledgement. That word is disingenuous also.” This wasn’t like Harmon to interrupt. His face and tone hardened. Lefty noticed, smiled.
“Well, sure. That’s right: I–we–would want more than acknowledgement. That’s just where it would start: agreeing that things aren’t equal.”
“They won’t necessarily agree with you.”
“They should.”
Harmon winced, and his hands came together, though only at the fingertips. They barely touched.
“And that one?” Lefty asked.
“Look, shut up,” spat Harmon. Lefty burst into laughter while Harmon turned on him bitterly. “If you don’t have anything meaningful to say, then why are you here?” An awkward silence followed: Harmon sat back, embarrassed. His reasonable front had been broken. Sophia leaned forward and sulked.
“You’re missing it,” said Lefty finally. He’d become serious all of a sudden. “The conversation won’t happen talking about justice, or cooperation in the way you’re talking about it. The problem is with the people–all of them. They don’t really listen to each other. They don’t know how.”
Harmon shook his head. Sophia’s face clouded over. She turned to Harmon: “Whatever. We need to continue this conversation.”
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More on that law
So the dialogue continues on the new law AB1775, the surreptitious addendum (from the POV of therapists and others who will actually have to follow it) to the Child Abuse and Neglect Reporting Act, which decrees that “certain persons” who fail to report to police or a department of social services those who “access, stream, or download through electronic or digital media (material) which depicts a child engaged in obscene sexual conduct” are committing a misdemeanor. Obscene sexual conduct is defined in California Penal Codes 311.2, 311.3, 311.4, and 288.2, among others, and refers to various sexual acts, including the broadly termed “lewd and lascivious acts”, which is in turn defined as that which touches intimate parts of the body (sexual organs, buttocks, breasts of a female) and is “intended to arouse, gratify the lust of another”.
Most of those chiming in on my association list-serve are commenting on the absurdities of this law, pointing out (rightly) that this law will disrupt therapeutic episodes, ruin the lives of people unnecessarily, while doing little to prevent the proliferation of child pornography–the supposed purpose of the bill. The most ardent of critics argue that advocates of the bill lack compassion for those who struggle with porn addiction. Their opponents respond, without apology, that critics are supporting the wrong people (versus victims of child sexual abuse) while delivering motivational harangues about the scope and seriousness of the child porn problem. We are informed of cults, divisions of government–the CIA–who are perpetrating ritual sexual abuse of thousands of children; recruiting children for an army of sex…anyway, something like that. Advocates of AB1775 employ the logic of demagogues: in the 50s they would have justified blacklisting suspected communists by pointing out how many people Joseph Stalin was killing.
I think the issue is not so much one of compassion as common sense. Despite three months of asking, advocates of the bill are yet to give a sensible answer as to how the reporting and subsequent persecution of individuals viewing obscene material will stop those who produce the material. We are told isolated anecdotes of hard drives confiscated, images discovered, and through those images, the locations of victimized children are determined. Really? I wonder how many times this sort of intervention has occurred, and who gave the tip-off(s), which begs the question, why do authorities need therapists to provide the tips. And does it occur to anyone governing sex offender treatment that if someone is referred to said on the back of an episode in which a mental health professional tipped off police about child pornography use, why should such an individual thereafter trust the therapeutic process?
In deference to my esteemed colleague and crusader against ritual abuse, I declare that I’d actually be happy to report the CIA for sexual abuse to my local offices of Child and Family Services, though I don’t suppose the investigation would get very far. Meanwhile, I should get back to my office and prepare for some sessions with adolescents (wrong people) who present with more commonplace habits. You see, I need to explain to them the new law. I need to explain that the law specifies “child” as a minor, and so if they look at pornographic material depicting persons of their age group, I have to report them to authorities. However, if they look at a pornographic image of someone ten years older, then it’s all good. Also, I must warn that if they insist on sending pictures of their junk, breasts, zits on inner thighs and so on, then I might have to report that behavior also. Welcome to the new world order. I hope their generation is smarter. I doubt it.
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The law that will lose us our clients (among other things)
In a recent editorial directed at leaders of the California Association of Marriage and Family Therapists, LCSW Robert Weiss wrote eloquently in protest of AB1775, a new California law (effective in January, 2015) which reduces therapist-client confidentiality, purportedly because it will protect children from the downloading and dissemination of child pornography. It won’t.
Weiss reminds us that the protection of client confidentiality is among the most elemental facets of a productive and meaningful psychotherapy relationship–that without the safety and trust provided by client confidentiality there is no true clinical path to healing. This teaching follows ethical standards dating back to the Roman Hippocratic Oath. The legal exceptions to this principle center on the prevention of imminent direct harm to others.
Perhaps the most significant change in so-called “duty to warn” laws occurred in 1976, with Tarasoff v. Regents of the University of California, a case whose finding determined that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient. A less palatable revision of confidentiality law occurred in 2001, following the 9/11 attacks, in the form of the Patriot Act: section 215 authorizes FBI agents to request a subpoena from a special court, obtain access to psychotherapy records, and further prohibits clinicians from revealing to clients that their clinical records have been subpoenaed. Today, for the moment, the hysteria that induces totalitarian intrusion surrounds pedophilia, hence AB1775. Not surprising, really. If you want to pass a law that is uninformed by research or logic, your best bet is to have it be about sex.
Ostensibly, AB1775 will broaden the scope whereby a clinician such as a therapist can report an individual to authorities if said individual has used child pornography. Under the existing Child Abuse and Neglect Reporting Act, therapists are mandated to report sexual exploitation: “depicting a child in, or knowingly developing, duplicating, printing or exchanging film, videotape, negative or slide in which a child is engaged in obscene sexual conduct”. Failure to report is a misdemeanor, and admittedly, some of the language of this legislation seems anachronistic. Now observe the language of AB1775: sexual exploitation includes “downloading, streaming, or accessing (accessing?), through any electronic or digital media, a film, photograph, videotape, video recording, negative or slide, or slide in which a child is engaged in an act of obscene sexual conduct.” This bill was signed by Governor Brown and filed on 8/22/2014.
Bear in mind that the law defines a child as someone under the age of 18, and given the language of the law (“accessing through any electronic or digital media”), therapists will now have to report to authorities teens who send naked pictures to each other over their cell phones, or someone exhibiting an “obscene” picture of a minor on Facebook. Also, porn use that depicts teenagers (not preteens) constitutes child porn, according to the law.
And if you think this might be a good thing, let me now elucidate other problems, including elements that pertain to this blog’s title: after an individual is reported and later arrested–their computer and other hardware materials confiscated–they would begin an adjudication process that would likely result in a referral to counseling, with a provider who is certified in sex offender-specific treatment, as presided over by a government entity called The California Sex Offender Management Board (or CASOMB). Such a referral is a requirement for those who will likely have to register as sex offenders. Therefore, if a therapist reports an individual for engaging in sexual exploitation, as defined by AB1775, and he or she is not a certified sex offender treatment provider, a court has the authority to remove the client from the therapist’s care, thus disrupting not only therapeutic continuity, but also that therapeutic bond. Now a certified CASOMB provider (BTW: this takes a while), I write from experience on this matter.
Finally, recall the term ‘imminent harm’ from earlier “duty to warn” provisions. This language pertains to the concept of protecting from harm versus reporting past events. So, we now have a social reality wherein someone can report raping or murdering a stranger, and the therapist is not required to report the event because the event is past tense. Indeed, he or she would be compelled to maintain confidentiality. Meanwhile, if someone reports viewing a singular image of a minor, of something that could be construed as obscene, the listening therapist is required to alert police. Absurd.
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Graeme Daniels Psychewriter 