Archive for the ‘avoiding confrontation’ Category

Unethical, Illegal, Unprofessional, (Immoral Or Fattening)

Sunday, June 26th, 2011

At various times I’ve heard some wisenheimer or another say that “everything good is either illegal, immoral or fattening.” I’m not going to contest that (cause I know what good was in those instances and, yeah, those things were those – more or less.) No, what I’m talking about here is the accusations leveled at practitioners by patients (though never at me, of course,) sometimes by practitioners at patients, and other times by patients and/or practitioners at insurers or other third party payers. Confused yet? Don’t worry. It’s like what Bohr said of quantum mechanics. If you’re not getting a headache you don’t understand it. Wait, there’s more. Most of the time people are using those words incorrectly! Often when someone says something is “unethical” he really means “unprofessional” or “illegal” (maybe even “immoral” but rarely, if ever “fattening.”) Often “unprofessional” is used to mean “I don’t agree with or like what you’re doing,” which may be illegal or unethical (by some set of standards somewhere) or may just be that you believe you were treated “unfairly,” which probably has nothing to do with “unethical, unprofessional” or “illegal.” What’s the difference between unethical, illegal, and unprofessional? That’s where I’m going. I’ll leave immoral and fattening up to those better qualified. Ready? Deep breath and here we go.

Unethical: thorny issue to start off with because, some will say, it depends on whose view of ethics you espouse: Aristotle’s or Kant’s. Kant takes a more utilitarian view to arrive at ethical decisions that Aristotle, but let’s leave that aside for now. Maybe for this whole post. For a working definition let’s describe ethics as values put into action. It’s about doing that which is right because it’s right, not because the law says so or some written code of behavior says so. Ethical behavior may be congruent with the law or the code, but it might not.  Let’s leave the definition there.

Unprofessional: this means that a practitioner is not behaving according to his or her profession’s code of conduct, which is often referred to as a “code of ethics.” See where the confusion begins? An example of this is the National Association of Social Workers’ “Code of Ethics.” It’s not. It’s a written codex that describes the minimum expected behavior by a member of the Association. By being a member the practitioner has said that he/she subscribes (underwrites, agrees to be bound by) this code and will conduct him/herself accordingly. Violating this code isn’t necessarily “unethical” but it is “unprofessional.” An example would be showing up for work in an impaired state. The NASW code of ethics says this is a no-no. We can agree that this is bad form. Is it “unethical?” Probably, maybe, I don’t know, I’m not going to make that statement. What I will say is that it is “unprofessional” because it goes against the agreed upon code of conduct. An example of what’s not unprofessional is charging a patient for a missed session, which I spoke about in an earlier post (see how I did that?), or not extending a session because the patient arrived late and still charging the full fee to the patient (that’s also neither illegal nor unethical behavior,) yet these are two of the things that a patient is talking about when he says that the practitioner behaved “unprofessionally.”

“Illegal.” When I’d say that something was “illegal” my father would always respond “that’s a sick bird. You mean unlawful.” He might still say that, for all I know. I haven’t said anything was illegal around him in a while. The New Oxford American Dictionary that came with my Amazon Kindle ™ says that illegal is an “adj. contrary to or forbidden by law, esp. criminal law: illegal drugs,” whereas unlawful is also an adjective but means “not conforming to, permitted by, or recognized by law or rules: the use of unlawful violence; they claimed the ban was unlawful.”  Seems like we’re splitting a blond hair here and it doesn’t matter for our purposes. Illegal or unlawful would be doing something that is not allowed, such as having a phone session with a client who is in another state in which the practitioner has no license and/or using claim code 90806 (45-50 minutes face-to-face psychotherapy) to charge the session to the insurance company. That’s where this gets thorny because:

It’s not necessarily unprofessional or unethical to have the phone session with the patient who is out of state if the patient has moved and is seeking other help, is in transition and still wants psychotherapy. To say that I can’t help her is abandoning her, even though the law says, depending on the state, I have to have a license in the state in which the service is delivered. I can’t ethically abandon a patient who is “in pain.” Some states say it’s OK, most don’t. What do I do? Act ethically or obey the law. My “code of ethics,” the code of professional behavior doesn’t necessarily help because it will tell me to do both or to follow the nobler path (which is exactly what?) No matter which I do I’m being “unprofessional.”

This is getting long & I’m forgetting where we came in. Oh yeah: the things that patients claim we are when they are unhappy with what we’ve done. No matter what we do, someone is liable to be unhappy about it and use some word to say that what we’ve done is a violation of some principle or other. Maybe it was. Most likely it wasn’t. If it was he or she is probably using the wrong word or principle. It’s more important to me to know why the claim is made than to put the claim into the right category. What’s behind it. What does my patient perceive, not is the perception in the right realm. Repair, not correct (at least for now.) As long as my patient is still in the room there’s still the possibility of treatment going on, right? If he leaves he may not come back.

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Hand Movements May Give Clues to ADHD Severity – MedNews

Tuesday, March 8th, 2011 recently posted an article about ADHD that – wait – you don’t get news from How else are you going to find out about new drug approvals by the FDA, breaking information about recalls & lots of other useful stuff? Where else are you going to get articles like the one about which I’m commenting?

OK. So they posted this article about studies involving hand movements and ADHD which had some interesting points. One study found that children with ADHD weren’t able to perform the finger-tapping exercise without extraneous movements that weren’t as apparent in “typical children.” Another demonstrated that magnetic pulses caused movements in ADHD children to a greater degree than “typical children.” They said something about myelination of the left/right brain connective nerve tissue, the brain’s “braking mechanism” on movements, and a demonstration of why ADDers have a problem with keyboards and fine hand movement tasks.  The article also said that there wasn’t a clear “clinical” application for the outcomes of this study or these tests.

Whoa! That’s a lot of stuff there, compadre! First of all, does anyone other than me have a problem with comparing ADDers to “typical” children? Typical? What are they saying? Who are they stigmatizing? How about calling those “typical children” as having “Attention Surplus Disorder” (thank you Thom Hartman.) Typical indeed. Read Harte’s anthropological & historical view of ADD in “Think Fast: The ADD Experience,” T. Hartman & J. Bowman, 1996, Underwood Books,(link to Amazon page for the book,) a book of excerpts from the Compuserve (remember that) ADD forums. Typical! Poppycock!

Next: What do you think of a parent that allows his/her child to be subjected to “magnetic pulses” as a form of testing without knowing the outcome? Even with knowing the short-term outcome.  I realize that it’s hard to test pediatric effects and dosages but, really…. “God said, ‘Abraham, kill me a son.'” (“Highway 61,” B. Dylan, as if you didn’t know) but Abraham was spared from having to do that by the substitution of a ram at the last minute (insert computer and RAM joke here.) How do you feel about parents submitting children to experiments in the name of science? Me, I believe in things between consenting adults being permissible (within limits) but how does a parent consent for his/her child to be subjected to “trans-cranial magnetic pulses” – zapping the kids brain with magnetic charges – to observe if his/her arm jerks in response.

Finally, and this is the big one for me, and the whole point of this post: No clinical application? Are you ferreal? How about the simple “clinical” value of a piece of psychoeducation? Being able to tell a frustrated parent that the fidgeting child doesn’t have anything wrong with him, that it’s just the way his brain works and let’s find things that will help him learn instead of beating him down for not being able to sit still. How about being able to tell the child who doesn’t have the same fine motor skill as some of his buddies that, believe it or not, that will develop with time but, in the mean while, what can you do that they can’t because that’s what makes you special. How about using the information to educate teachers so they can learn that the kid who gets up from his seat to watch the squirrels running in the ivy on the side of the school building is also learning something, probably already finished the assignment, and is preventing himself from being bored (and getting in trouble for fidgeting.)

How about forgetting this ADHD vs “Typical.” Treat a child like he’s defective and you get a problem child. Treat a child like he’s a member of the family and you get a member of the family who can use his gifts.  ADDers aren’t defective. Just different. If  you think they frustrate you, you have no idea how frustrated the ADDer is – but that’s for another post.

Are Psychoanalysts Ever “Off-Duty?”

Tuesday, February 8th, 2011

First, a disclaimer. I don’t go around listening in to conversations at nearby tables, on the street, the bus, or anywhere else. Maybe I should say I don’t try to listen. I can’t help it if you’re going to speak loudly enough for everyone in the general area to hear you. This isn’t about why people think others need to hear what they’re saying, so enough of that. It’s just a disclaimer. Period. Done.

OK – so why the disclaimer? The other night I was walking home after getting off of the bus and there was a group of three people on the street ahead of me, two men and a woman. As I was approaching I heard a part of the conversation. One of the men said to the woman,”You’ll like him. He’s a psychoanalyst.” She responded by asking something about are psychoanalysts always analyzing everybody or do they ever turn it off. She also said something about it being tiring to always being “on.”

Do we ever turn it off? You betcha!  Tiring to always be”on?” Jeez. Probably even more tiring for everyone around than it is for us. Can you imagine that? Why would I, using myself as the example I know best, want to constantly be confronting people with their “hidden motives” for doing things? Where would my respect for my friends and neighbors be if I did that?

The people who come to me for psychotherapy are asking me to use my skills to help them.  They expect me to “listen with the third ear,” as Langs put it, to attend “with free-floating attention,” to quote Uncle Sigmund. They pay me to do this. My friends, family, neighbors and total strangers aren’t paying me for my time or my skills. They aren’t asking me to listen to their free associations and make an interpretation. I’m expected to be just another person in the room and not invade the privacy of why they do what they do.

Yeah, I’m a curious guy. Uh, maybe I should rephrase that. I’m curious about a lot of things in this world. I’m curious about what makes people tick, including me (especially me,) and seriously hope, as the old, sad joke says, that it’s not a time-bomb. That doesn’t give me the right to pry into what’s going on in someone’s psyche and, contrary to what some believe (and/or have done) it’s not a parlor game where I can (or will) look at people in the room, talk with them for a couple of minutes and then give a psychoanalytic profile.

I like my friends, family, neighbors (trust me on this.) Why would I want to piss them off by telling them why they’re doing what they’re doing or trying to manipulate them by analyzing them without their knowledge or consent. Ah, there it is – perhaps the real point of the question (OK – this is analyzing but it’s me thinking about what I might be trying to accomplish by that seat-of-the-pants analysis) is whether I would be “using my powers” for my  own nefarious purposes. To manipulate things & people.

What do you think? Do you think we ever “turn it off” other than when we sleep? Do we manipulate people? Let me know – leave a comment. I won’t analyze what you’re saying or how you say it – promise.

Therapists Behaving Badly

Wednesday, November 24th, 2010

This one’s gonna be touchy. I’m not all that clear about putting this post up there. It could be nothin’ but net, could be a brick. I’m sure this is going to make some people unhappy on both sides of the couch but, I gotta say something & so, as Wellington said to his mistress when she threatened to make his letters to her public, “Publish and be damned,” though I probably already am. It’s a professional liability.

This is written in part for patients, in part for therapists, and in part to get it off my chest ’cause its been there for a while & it’s startin’ to feel like a 10-ton safe. Here goes and if it bends you out of shape, so be it.

I was in the elevator going up to my office a few weeks, maybe a month and-a-half ago with 3 other people. Two were therapists, one was, I think, a patient. One therapist asked the other about his next patient & the comment came back something along the line of “He’s a real borderline.” The other said something like “yikes,” and then followed with a comment about being told by some mentor that you shouldn’t have more than one on your caseload. The one who made the comment in the first place said something about that being right.  If you’re reading this and you recognize yourselves, I’m not picking on you. I’ve picked you as an example. If you’re offended you can take it up with me. Leave me a comment. Please. If you have an opinion about what I’m saying here, please, leave me a comment.

The whole time this exchange was proceding I was uncomfortable because I wanted to say something to this pair. The other guy in the elevator (remember him, the patient looking guy?) was looking decidedly uncomfortable and unhappy.  I wanted to tell this pair to pipe down, that there’s other people on the elevator. Mind you, they didn’t say anything that might identify the patient (other than that he’s a he.) The behavior broke no privacy or confidentiality rules, HIPAA was certainly not violated. So, what’s my beef?

That’s easy. It makes patients uneasy when they hear this. They already think we talk about them when they’re not present. They have wonderful imaginations and are very sure we talk about them. There’s no need to prove them right. It doesn’t make them happy and gives them a not great opinion of us because, they think, it tells them what we think of them.

We’re not even going to talk about the categorizing of a patient with an unflattering label. We all know what borderline means, and that includes patients. It means difficult, explosive, unmanageable, right? Too bad it didn’t mean that when it was first proposed, but that’s what it’s come to mean. But I digress….

My point here is this: I was fortunate. My first internship was, in part, at the James A. Peters Veterans Medical Center in the Bronx where there were signs on the two side walls of each elevator reminding the staff to not discuss patients in the elevators because staff, patients and patients’ families all share the same elevators. Good signs to post because people forget.

What I’m saying to therapists – pipe down! If you must talk about patients, and I’ll be generous and say that you’re “consulting” with a colleague, do it in your office or your colleagues office and do it with the door closed. Not in the hall. Not in the elevator. Not in the toilet. Let’s show them the respect they deserve.They come to us in pain and we’re not here to add to it by hearing us talk about patients (in the pejorative) in public. We’re not carnies and our patients aren’t Rubes. If you can’t pipe down, and you’re in a public place with me, expect that I’ll ask you to hold it for when you’re alone. I invite any other clinician to do the same when they hear another of us doing this.

By the same token I’m saying to patients that it’s OK to tell the therapists who are having this conversation in front of you that they should zip it. Tell them not to have this discussion in front of the kids. Tell them that you feel disrespected. Tell them that they’re treating you like you’re not there. They may get huffy. Let ’em.