What's Wrong With "In Treatment"

I just watched the first week's episodes of the HBO series, In Treatment. As a clinical psychologist, I feel compelled to educate people about the ways in which the therapist, Paul, violates legal mandates of health care providers and how his work with at least some of his patients flies in the face of good clinical practice. There were enough legal and ethical transgressions that I am concerned about what viewers will come to believe about therapy in the "real world." Of course it's only a television show, but the show can shape viewers' beliefs and expectations about therapy (and whether to begin therapy), which in turn will influence their behavior. I'm not going to address Paul's theoretical approach to his clients or his specific interventions—or lack of interventions. I just want to set the record straight about what should happen during a first session with a mental health professional.

Health Insurance Portability and Accountability Act: Procedures, Policies and Confidentiality
If you've been to a health provider in the last couple of years, then at your first visit, you've received a copy of his or her "Notice" as mandated by the Health Insurance Portability and Accountability Act (HIPAA); this Notice outlines the policies and practices of the health professional, including matters regarding confidentiality and the limits of confidentiality.

During Paul's first sessions with his two new patients, Alex and Sophie, Paul makes no mention of HIPAA, of the limits of confidentiality, nor does he ask whether the patients have any questions about confidentiality or other office policies or procedures. It is always good therapeutic practice to discuss with new patients the limits of confidentiality and ask patients whether they have any questions. Yet Paul doesn't do this.

Evaluations as Part of Legal Cases and Treating a Minor
One of Paul's new patients, Sophie, is a 17-year-old girl, coming to him for an evaluation related to her dispute with an insurance company; she was hit by a car but the insurance company is concerned that the accident arose as a suicide attempt. There were three significant pieces of information that Paul did not explain to his minor patient:

1. Sophie is being evaluated by Paul as part of a dispute with an insurance company. Given the possibility of Paul having to testify later, he should address with at the outset the issue of confidentiality and its legal variant, privileged communication—who has the legal right to decide what is disclosed to others? Good clinical practice requires that at the outset of an evaluation that may involve the legal system, mental health clinician explain to the patient about privileged communication and the limits of patient confidentiality. (When the evaluation is court-ordered as part of a criminal case, the patient usually is not the person who decides how the information is used.)

2. Given that Sophie is a minor, she cannot legally consent to having Paul release any information to her lawyer or to the insurance company. Her parents would have to consent, and according to Paul, he had not spoken with her parents. Paul should have made it clear to Sophie and her parents that her parents are the ones who must give consent.

3. For patients or clients over the age of 18, the therapist is not legally allowed to disclose any information without the patient's explicit permission, except to speak with the patient's other caregivers, or in circumstances that that clinician is legally mandated to disclose information, such as imminent suicide risk or in cases of child abuse. With patients who are minors, though, parents and their child's therapist are legally allowed to speak with each other, even without the child's permission. Good clinical practice, however, dictates that the therapist let the minor know about limits of confidentiality and the parents' rights; when the child doesn't want the therapist to tell the parents about certain information, the therapist usually tries to work with the child and the parents to honor the child's wishes, unless there are legitimate concerns about withholding that information from the parents (e.g., suicide risk). Paul said nothing to Sophie about any of this.

When Therapists Want Help
On the final show of the first week, Paul's own troubling responses to his patients lead him to see Dr. Gina Toll in her office. What is the nature of their relationship and what type of help was he seeking from her?

When therapists are having a hard time managing their own feelings about patients, they may seek supervision, a time-limited (e.g., 1-4 session) consultation for advice, or their own therapy. Although the lines among these three forms of assistance may at times be blurry, both the therapist and his or her "helper" (supervisor, consultant, or therapist's therapist) are best served by a clear discussion of the goals of the visits: Supervision/consultation (to help the therapist become more effective with his or her patients) versus therapy (to help the therapist address personal issues that may, coincidentally, be affecting his or her work with patients). Neither Paul nor Dr. Toll clarified the nature of his visit (therapy, supervision, consultation) or his goals in seeking her out.