Thursday, February 28, 2008

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.

Sunday, February 10, 2008

Cultural Learned Helplessness

What do these societies have in common: Gotham City before Batman, the Star Wars universe under Emperor Palpatine, the wizarding world of Harry Potter, and the United States under George W. Bush? The citizens of these societies experienced learned helplessness. What's learned helplessness? It is the type of "giving up" that happens to people when they are repeatedly or chronically in an aversive situation and nothing they do can stop or help them escape from it. The original research on learned helplessness, by psychologists Bruce Overmeier and Martin Seligman, went like this: A dog was placed in a cage, and received shocks from which it could not escape. After an initial response of agitation and making noises, the dog eventually became passive in response to the shocks—as if it gave up. The dog was then put in a new cage—with two halves that had a low barrier between the halves. If the dog jumped over the barrier when shocked, it could escape the shock. But the dog never did go over the barrier. (Dogs who hadn't experienced inescapable shock would jump the barrier when shocks began.) Learned helplessness became a model of depression for people who experience uncontrollable or inescapable aversive situations such as abuse and discrimination. Learned helplessness can be a helpful lens through which to examine the citizenry of Gotham City, the Galactic Empire and the magical world of Harry Potter—as well as contemporary America.

First, Gotham City: Before Batman's arrival in Gotham City, criminals controlled the city, and the police force was riddled with corruption. Citizens feared to go out at night and they—and the good cops on the force—felt helpless against the ever-encroaching tide of crime and graft. Gotham residents seemed to have had learned helplessness in response to the crime in the city—nothing they did made a difference. But Bruce Wayne didn't feel this way. He became an agent of change on behalf of Gotham's citizens. Why didn't he experience learned helplessness—particularly after witnessing the murder of his parents? His wealth and position in society shielded him from the chronic and inescapable crime and corruption experienced by most of Gotham's residents—and hence from the learned helplessness-inducing cage of the city. So Wayne was in a better position to feel hope (or at least to feel that there was something he could do to turn things around). And he was right: When Batman arrived in Gotham City, his image and actions reversed the culture of the city: it was criminals who felt fear, and the upstanding citizens and good cops could mobilize to take back their city. Wayne's being an outsider was instrumental to his belief that he could change things.

Next, the Star Wars universe (episodes IV-VI). Emperor Palpatine was a ruthless tyrant, who ruled the galaxy with an iron fist. He stopped at nothing to instill fear in those who would oppose him and used terror tactics when necessary to hound the populace into submission. He sought to create learned helplessness across his Empire—to create a citizenry ready to do his bidding with no questions asked. In Episode IV ("A New Hope"), it was only a relatively small band of rebels who were sufficiently motivated and able to fight back in any way they could. Two of these rebels were Princess Leia and Luke Skywalker. (In fact, there's a sense in which Leia was the key player: she inspired Luke to join the Rebel Alliance. Han Solo only became part of the rebel cause through circumstances and his relationships with Leia and Luke.) How did Luke and Leia escape the learned helplessness prevalent throughout the Galactic Empire? Like Bruce Wayne, they were raised outside the dark cloud of fear and oppression—in remote regions of the galaxy outside the Emperor's glare. Leia, like Bruce Wayne, was raised in a position of privilege and was brought up to be a leader. Luke grew up on an even more remote planet. Both were untouched by the pervasive hopelessness in the larger society; they were outsiders, rebelling against the dark forces and instilling hope.

Onto the Harry Potter's wizarding world. In Goblet of Fire, Harry's godfather, Sirius Black recounts their world during Voldemort's first ascendance: "You know [Voldermort] can control people so that they do terrible things without being able stop themselves. You’re scared for yourself, and your family, and your friends. Every week, news comes of more deaths, more disappearances, more torturing … The Ministry of Magic’s in disarray, they don’t know what to do…Terror everywhere … panic … confusion … that’s how it used to be." Here again, the heroes are outsiders who rebel against dark forces and inspire others. Harry and Hermione grew up in the Muggle world, outside the terror of Voldemort's reign (Ron, raised within a terrorized society, is less of a leader than a follower. Like Han Solo, it is his relationships with the leaders that impel him to takes the risks that he does.)

I think that for many people in the United States, the years of George W. Bush's administration have been a period of learned helplessness. The administration and its cronies have engaged in fear-mongering, corruption and graft (legal though it may be in some cases), the curtailing of civil liberties, and outright lying about events relating to the Iraq war and other matters. Citizens who see these abuses of power have come to feel helpless to change them during his tenure; they are counting down until he leaves office. People also feel ground down by years of bitter political fighting between the parties.

Barack Obama is popular, in part, because he seems to be outside the system relative to other candidates. Like Batman, Princess Leia, and Harry and Hermione, when he looks at his society, he sees what's possible and wants to make that possibility a reality. But Obama goes one better than the heroes and heroines I've noted. In his work as a community organizer, he's done more than fight the good fight and inspire people, he's encouraged people to act on their own behalf. He didn't do all the work for them; he helped them to help themselves. I think that's part of his appeal. To use a Batman metaphor, he doesn’t offer to swoop in and round up all the bad guys; he'll help people figure out what they need in order to do their own policing, and then try to make sure they get what they need. People talk about Obama being more than a candidate—that he's the center of a movement. I think that analysis is correct: for many people, his candidacy isn't about what he'll do for Americans, but what he'll inspire us to do for ourselves.

Robin S. Rosenberg is a clinical psychologist and author; most recently she contributed to and edited the book Psychology of Superheroes.