Uncommon Sense
by Dr. John Riolo
Well Garry, it looks like we are at it once again. If I understand you correctly, you are taking the position that risk management is actually too risky for patients! So to practice risk management can be a form of malpractice? Hmmm! You mean more risk is better? What an Ingenious idea!
OK, I have read Ofer Zur’s work and we had some communications a while back. He sure makes good points. Actually in theory I agree with him. He offers some very practical common sense approaches to ethics and boundary issues. In some ways he reminds me of my old therapist, Claude Miller. Claude is a psychiatrist and psychoanalyst in NYC, still practicing last I heard into his 80s. One day a number of us were with him in group therapy where we analyzed our dreams, when one member of the group accidentally injured himself. Dr. Miller immediately provided hands on medical attention. Another member of the group quipped that that will probably ruin the transference/counter-transference relationship form here on. Claude said that’s nonsense. He reminded the rest of us that he'd been a physician and a human being before he was a psychoanalyst. Only a fool would hesitate, he said; the transference counter transference can pick up where it left off or not, but common sense must prevail. Good advice, I always thought.
But Garry, that is the problem. Claude Miller and Ofer Zur have a rather uncommon commodity that seems to be even less common among psychotherapists. That’s common sense. We would not have such a need for risk management courses if more practitioners were like them or if most had half their common sense. Unfortunately too many seem to lack basic common sense; else why is it that among the most frequent complaints brought to professional ethics committees, licensing boards and malpractice suits are boundary issues in one form or another? Surely we are not claiming that all these complaints are filed by borderline patients as inferred by Martin Williams See Ethics complaints are coming from unexpected sources from the May, 2004, issue of Psychotherapy Finances If that is the case, we can’t be very good at treating this population if they sue us with such frequency.
Why do we need clear standards of practice and sound risk management principles?Let me give just a few examples.
There is no doubt that human beings thrive on touch from infancy to old age. And yes, some therapists, ironically, have a problem getting close to patients. However, is it an over reliance on risk management or the therapists’ own discomfort that’s the problem? Often therapists hide that discomfort behind their rigid theories/ techniques; i.e. hands off; sit behind the patient who is on the couch. Not only is there no touch but no eye contact and probably no emotional contact as well. Theory never stopped Dr. Miller. Therapists who have common sense would not hesitate to give a child or adult for that matter a hug if they needed it. The problem is that with too many of our colleagues we can never be sure who needs the hug more, the therapist or the client. That’s why we often get sued for being too touchy feely or for having loose boundaries. We think we are doing it only for the client, but it’s our own needs that are getting met.
Can some therapists take risk managements techniques too far? I have no doubt. I know therapists and I am sure you do also who are reluctant to shake hands with their patients. Some are so frightened of a boundary issue that they would decline to go to a social event like theater performance if they knew that one of their patients will be in the audience. When common sense is lacking, one can make a rationalization for any extreme.
Garry, when it comes to touching, therapists often get themselves in trouble and cause problems for their patients and themselves. It’s a question of boundaries. Now of course we like to think that we as trained therapists are experts in boundaries. It’s our patients who may have trouble in this area, we claim, and we have come up with an entire set of diagnoses that address boundary problems in one way or another. The problem is that our track record at boundaries is not all that good. By today’s standards some of the worst boundary violators are the founders of psychotherapy from Freud and Melanie Klein to Winnicott.[1] Now, it’s unfair to judge these pioneers by today’s standards. My point is only that modeling their behavior too closely may not help us today and could cause difficulty just as it could by going to the opposite extreme.
Speaking of boundaries and dual relationships there is that case we both know about of the psychotherapist whose patient accidentally crashed her car into the therapist’s house resulting in minor damage to the house. Now most of us with common sense would have simply turned the matter over to our insurance company and let experts handle the embarrassing situation. But no, our colleague could not do that. You see he was afraid to notify his home liability insurance. That would only make sense if he failed to tell his homeowners insurance company that he was operating a business out of his home or his home was not zoned for business. So he used treatment sessions to convince the patient that she must pay for the damages directly. See Accidents Happen. If that’s not a boundary problem and a malpractice suit waiting to happen, what is?
Risk management as I see it, is simply another way of saying we need to look at things from the client’s point of view. That’s an essential ingredient in relationship, alliance building and all the things we claim we are good at. If we can see things from the client point of view they not only will be less likely to sue us they are more likely to get better. That is in essence what Miller and Duncan say No? See Introduction to Articles by Dr Scott Miller and Talkingcure.com
For other examples of where risk management training can be helpful see my Pandora’s Box selections or examples of therapist doing stupid things. Some are just funny but some can get therapists sued pronto.
[1] Reamer points out that Freud himself was a little loose in the boundary department. He took patients on vacation and analyzed them while on Vacation. He wrote letters to patients (Ferenczi) addressing them as Dear Son. Melanie Klien "improved" upon Freud's techniques. When she analyzed Clifford Scott she also took him on vacation and conducted analytic sessions on the bed in her hotel room. D. W. Winnicott had patients living with him as part of their treatment; was reported to frequently hold hands of patients during whole or most of a treatment session and also confided to at least one patient details about his counter- transference reactions to another patent. See Frederic G. Reamer, Tangled Relationships: Managing Boundary Issues in the Human Services Columbia University Press p.3.
John Riolo is a psychotherapist, Vice-President of Psychjourney and consumer advocate. He is known as the Insider and sometimes known as the therapist other therapists love to hate. His website Your Advocate Online includes many articles and audio interviews addressing the inner trade secrets of psychotherapy. Listen to his new Internet radio show, The Insider. Contact him at johnr@psychjourney.com