Obsessive Ruminations #1

(Dr. Alan Karbelnig, who quietly slipped into his 50s last year and lost all decorum in the process, writes this regular column to provoke reaction from his SGVPA colleagues. Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Alan strives to avoid the pablum that characterizes most professional newsletters, and instead strives to serve up more zesty reading. Regarding his professional career, Alan is a long time member of the SGVPA, having served as president in the early 1990s; he has chaired the SGVPA Ethics Committee for the last decade. He practices clinical psychology, psychoanalysis, and forensic psychology in South Pasadena.)

I recently had lunch with two of my illustrious SGVPA colleagues who, in the course of discussing their clinical work, used words such as “attachment,” “affective attunement,” “activation,” and “dysregulation” repeatedly. I understood what they meant. They were describing the phenomena of being close to other persons, of resonating with them, of becoming excited, and of feeling overwhelmed. After lunch I returned to the office perturbed. My fellow practitioners know these words trouble me. Maybe they use them with more vigor when I’m around to demonstrate their attachment or attunement to me. Maybe they want to get me activated. But this time I just felt like shouting. I offer this rant for the SGVPA newsletter instead.

In the middle part of the last century, the psychoanalytic lexicon was rife with earlier versions of these words. Had you dined with psychoanalysts in, say, 1955, you would have heard about patients’ cathexis to their analysts, or about their ego weaknesses, or about the corruption of their superegos. If the patients were particularly emotional, perhaps you would have heard them described as overwhelmed by Id impulses that had perforated their repression barriers, over-riding proper ego functioning.

I suppose such language may suffice for communication between professionals, and therefore I should not be so dysregulated by it. But as Thomas Szasz used to say, we psychotherapists need to be careful not to literalize our metaphors. These interesting words – then and now – are chock-full of mechanistic, post-Enlightenment ideology. Used without caution – and this is the danger Szasz alludes to—these terms can violate sanctity of the human subjects who engage us in our consulting rooms. No disrespect to the Age of Reason, but our patients are not motorized contrivances we can deconstruct with a Newtonian calculus. They exist as real, fleshy, sentient human beings experiencing a near-infinite range of sensations, thoughts, feelings, and images, all of which swirl around in inter-relationship with one another, never to be reduced to finite categories. These persons demand to be received in all of their complexity and fullness

Attachment, a horrible word, sounds like a button, or a snap, or a piece of Velcro. What if, instead of affective attunement, we think about being present, as completely as possible, to the being of the person meeting with us? Attunement sounds like a melody produced by a mouth harp, or an mp3 file. Perhaps we could just strive to “be” ourselves instead of being attuned. Perhaps we could flow with others’ words, thoughts, fantasies, images, and feelings. The same holds true for “activation” or “dysregulation,” terms suggesting that a hose attached to your cooling system has come loose. These “technical” phrases are too constrictive as well as too robotic to describe the complexities of the human experience

Samuel Johnson once said that all professions are conspiracies against the public, and I suppose these automaton-like words represent part of the conspiracy of professional psychology. We take the intense richness of human experience and reduce it to a few scientific-sounding categories. That way we can design studies, pretending that we work in a branch of the natural sciences. We can imagine a human person reduced to a set of internal regulatory mechanisms that we can then “treat” according to certain algorithms that emerge from our studies. We can simply ignore the impossible richness of the living subject who will forever lie beyond our categories.

I am of course just as guilty as many of my colleagues. Since I also do some psychological assessment, perhaps I don’t notice my own use of terms such as “behavioral control,” “affect modulation,” or one of my favorites from the Rorschach, “a tendency to abuse fantasy.” I obviously like the phrase “obsessive ruminations,” which of course is also the title of this column, but maybe “ranting” would be more precise, especially if followed by an exclamation point!

So we should persist in our conspiracy, as we must, but since the real human experience is the focus of our profession, I think it would behoove all of us to remember that metaphor is metaphor, and that people live in a real experiential world of language and imagery and feeling. I enjoyed lunch with my distinguished SGVPA peers. I certainly came away feeling peeved, but neither activated nor dysregulated.

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Assaults on Privacy:

February 27, 2008

Reflections on The Erosion of Confidentiality in Psychotherapy

Until the mid-1950’s psychologists and their patients enjoyed a highly private, confidential relationship. No reporting requirements existed. The Evidence Code was rarely utilized to intrude upon psychotherapist-patient privacy. Their relationship was about as private as that between priest and penitent, or journalist and source. Individual privacy rights reigned supreme.

In contrast, psychologists practicing today must contend with societal controls unknown and perhaps unthinkable a generation ago. Now the rights of society have been elevated. The contemporary psychologist practicing psychotherapy must contend with at least 15 distinct potential incursions into the privacy of their consulting room. These include, but are not limited to, reporting on child abuse, elder abuse, threats of violence to others or to themselves (that most recent exception being related to the Menendez brothers’ trial), access by insurance companies, managed care companies, other providers with releases of information or family and friends of the patient with signed releases of information, various permitted disclosures allowed by the Evidence Code (section 1024), requirements of whatever agency or institution the psychologist may be employed by and the whole range of legal incursions related to subpoenas or court orders be they concerning civil, criminal. administrative, workers’ compensation, internal revenue service, EEOC or other matters. The sad fact is that the psychologists’ consulting room has become a rather crowded place, replete with a number of welcome and many unwelcome intruders. The rights of society to have access to information it deems important, even in that private space. now reign supreme (Alderman & Kennedy, 1995).

In the ensuing paragraphs, the identities of these intruders will be briefly delineated with some commentary made upon the appropriateness of their presence. The unwanted intruders are particularly problematic in that they interfere with clinical processes, especially the process of free association and the analysis of projective identification; the very foundations of most psychoanalytic approaches.

Beginning with the welcome and even necessary intruders, these consulting room guests have been present ever since psychotherapy started more than a hundred years ago. They consist of three sets of people. First, patients are accompanied by the ghosts of their past, be they parents, siblings or other influential figures during their developmental years. As practicing psychotherapists know, these ghosts constitute an integral part of the psychotherapy process. By understanding them, how they are projected into various interpersonal relationships and how they affect self-concept, psychotherapy unfolds. The unconscious family of the psychotherapist comprises the second group of hidden intruders. The concept of counter-transference rests on how these ghosts of the psychotherapist either interfere with or facilitate the process of growth in the patient. The third set of intruders consist of the theorists who guide the psychotherapist’s work.

Perhaps the most benign intruders who were introduced more artificially than these first three, consist of the authors of the ethical principles of psychologists established by the American Psychological Association (APA). Section five of the Ethics Code devotes itself entirely to issues of privacy and confidentiality. Section 5.01, for example, requires psychologists to discuss the limitations of confidentiality at the onset of the psychotherapeutic relationship. Section 5.02 requires that psychologists familiarize themselves with the state and federal laws and institutional rules governing privacy. This section establishes that maintaining confidentiality is a primary professional obligation. Section 5.03 requires that psychologists minimize intrusions into that privacy. Section 5.09, which concerns itself with preserving records and data, mandates that psychologists maintain their records in a fashion that maximizes patient confidentiality. The most recent version of the Ethics Code also requires that psychologists make plans for the disposition of their records in the event of their death or disability.

When legal mandates, such as subpoenas, call for violation of confidentiality in a manner that conflicts with the above-noted ethical requirement, the ethics code requires that psychologist adhere to their ethical principles. General standards section 1.02 requires that psychologists follow the ethics code even when it conflicts with the law. In such instances, they make known their commitment to the ethics code and try to resolve the conflict in as efficacious a fashion as possible, always working toward the maintenance of the privacy of the psychotherapy patient.

As if this group of extra-therapeutic observers were not enough, psychotherapists, whether aware of it or not, have assembly people and senators from the California State Legislature and justices of the California Appeals Court, the California Supreme Court and the United States Supreme Court in the room with them as well. Section 1024 of the evidence code, which was the creation primarily of legislators who in turn were repeatedly influenced by court precedent, allows for a number of incursions into psychotherapeutic privacy. Delineation of all of these potential incursions lies beyond the scope of this paper but include that psychologists may violate the confidentiality of their patient if the patient tenders their mental status as an issue in a legal proceeding, the patient uses the psychotherapeutic relationship to plan the commission of a crime, or if the patient threatens a reasonably identifiable individual.

Because of these possible intruders, psychologists increasingly find themselves caught between the Scylla and Charybdis of the interests of the individual versus the interests of society. These legislature/court mandated possible incursions, which include child abuse and elder abuse reporting, are based, simply put, on the idea that it is in the greater interest of society to be aware of the potential threat of these individuals than it is the right of these individuals to obtain treatment in absolute privacy. There once was a time when these individuals could obtain that treatment in such a private fashion; that time, at least for now, is over. Psychologists have become, as Christopher Bollas (1995) has written, the “new informants.”

Interestingly, California law also holds psychologists responsible for maintaining confidentiality as much as possible. In the psychology licensing law, which was similarly pieced together by state legislators, psychologists are required to maintain confidentiality – and that is according to law, in addition to ethics. Section 2918 of the licensing law reads, “The confidential relations and communications between psychologists and client shall be privileged ….” In section 2960, which delineates the various reasons that can cause a psychologist to have their license suspended or revoked, reason (h) reads, “willful, unauthorized communication of information received in professional confidence.”

So we have a consulting room already crowded by the patient and their unconscious family, the psychotherapist and their unconscious family, the psychotherapist’s theorists, the authors of the Ethical Codes of the APA and various state legislatures and justices. The room will become further crowded by the lawyers and municipal or superior court judges, in the event that a psychologist’s patient becomes embroiled in any type of legal proceeding, whether criminal or civil. Indeed, the very rationale behind the Evidence Code is to allow attorneys access to certain private communication revealed in a psychotherapist’s office in order to prosecute, or defend, an individual involved in a legal proceeding. Many of the subpoenas that arouse such anxiety in practicing psychologists arc related to just these type of matters.

There are two additional sets of intruders. If the patient is using insurance to pay for all or part of the treatment. then the executives of that insurance company, whether they provide indemnity or managed care coverage, are additional and perhaps the most unwelcome intruders into the consultation room. The insurance contracts signed by psychotherapy patients may require the psychotherapist to limit the degree of treatment, to report on extremely private details of the patient’s life, or to provide copies of actual clinical notes. Failure to adhere by these regulations can cause benefits to be disallowed or, in the case of managed care contracts, for the psychotherapist to be dropped from the managed care panel or even potentially sued for breach of contract.

The last type of unwanted intruder only applies to psychologists working for an agency or institution. For those psychologists, the administrators of whatever agency or institution they work for are also present in ghost form. These psychotherapists may be required to make certain other mandated reports, such as of spousal abuse or HIV infection, if the particular institution for whom they are employed requires such disclosure.

The incursions into psychotherapeutic privacy by these overzealous intruders can be limited, or perhaps even ejected from the consulting room, by the psychology profession as a whole. Organized psychology has failed to sufficiently establish the importance of the tenet of confidentiality and privacy, is the very foundation of any psychotherapeutic approach. Perhaps by educating the public, members of our own profession and state legislators regarding how and why maintenance of privacy and confidentiality is absolutely crucial to provision of effective, competent and ethical psychotherapy will the tide be turned back toward maintaining the privacy the consumer of psychotherapeutic services deserves.

Our profession has unfortunately been emphasizing societal rather than individual needs, sacrificing some degree of privacy and confidentiality in the process. Bollas noted that, in a policy statement during 1989, the APA declared “the social policy of protecting children from child abuse outweighs the social policy supporting the protection of confidentiality in the therapy relationship.” Although psychologists were initially left out as mandated reporters of child abuse, the then president of the California Psychological Association, Lewis Carpenter, Jr, PhD, wrote a letter to State Assemblyman Lockyer, on June 3, 1977, insisting that psychologists be placed on this list of mandatory reporters of child abuse. As discussion regarding adding mandatory disclosure of spousal abuse or HIV infection grows in intensity. psychologists who practice psychotherapy must increasingly wonder when their role as patient advocate will be entirely replaced by one of patient informant.

In the meantime, individual psychologists can best serve the needs of their patients by understanding all of these potential incursions. They then need to work, in full compliance with the law and the Ethics Codes, to limit these invasions of psychotherapeutic privacy. These strategies include, but are not limited to, fully understanding the Ethical Codes, the various laws that allow for intrusions into the consulting room including reporting requirements and the Evidence Code, and familiarizing themselves with the policies of whichever institution for which they work, or of whichever insurance company is contributing to payment for the treatment process. When their patients become involved in legal situation that can allow for violation of their psychotherapeutic privacy, then treatment providers need to familiarize themselves with the nature of that specific legal situation and be willing to contact their local experts in ethics, or their own legal counsel, so as to best protect their patient’s privacy.

Through the combination of working as a community to change laws affecting legal or insurance company incursions into the psychotherapeutic process, bolstering our ethical codes in the favor of protecting patient privacy, and educating psychologists regarding these various potential incursions and how to control them, the profession as a whole will hopefully be successful in working toward protecting, if not increasing, the foundational privacy and confidentiality that lies at the heart of any successful psychotherapeutic approach.

References
Alderman, E. & Kennedy,C. (1995). The Right to Privacy. New York: Knopf.

Bollas, C. & Sundelson, D. (1995). The New Informants. Northvale, New Jersey: Aronson.

Published as:

Karbelnig, A. (1999). Assaults on privacy: Reflections on the erosion of confidentiality psycho therapy. The California Psychologist, 32(6), 34-37.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

Psychology’s Perverse Vision

February 27, 2008

Instead of directing their sexuality towards a more conventional object, individuals with perversions deflect their desire elsewhere, be it towards special clothing, shoes, or more dangerously, even children. Professional . psychology, on a state and national level, displays a similarly perverse deflection in its objectives. Its proper aim of providing the highest possible quality services has been *misdirected by financial concerns. The profession emphasizes educating psychologists to “survive” by working with managed care companies (Murray, 1998) rather than aggressively finding alternatives; it passively allows the unregulated proliferation of new doctoral programs rather than improving existing ones; worse yet. it enthusiastically pursues the gravest perverse aim of professional psychology – the quest for prescription privileges (Sullivan, 1997)when so many psychologists lack proper training now.

So why has psychology’s vision become so distorted? Because over the course of its short history, economics has replaced ethics as the motivating force of the profession. Beginning during World War II. with the need for mental health practitioners to treat psychologically traumatized soldiers, clinical psychology emerged as the bastard child of medicine, relegated to a second-class position, but tolerated due to need. During the ensuing three decades, with much sweat and toil on the part of its leaders, psychology emerged as a distinct discipline. By the 1970s, it had gained considerable respectability. Psychologists’ expertise in provision of psychotherapy, and psychological and neuropsychological assessments, was well-established. Many psychologists practiced independently. Graduate schools excelled in training psychologists in these basic tasks.

Then, with the malignant spread of health maintenance organizations and preferred provider organizations, commonly referred to as the “industrialization of medicine,” the face of psychology rapidly changed. Issues of privacy and provision of sufficient treatment took the back seat to concerns about cost-cutting. The insidious descent into motivation by money over quality gained momentum. As psychologists panicked at loss of insurance reimbursement, their concern turned to self-preservation. By the late 1980s, some psychologists began seeking prescription privileges as a way of competing with medicine and working within the new time-limited, cost-controlled system. No matter how they packaged it, the prescription privilege movement reeked of hoped-for financial gain, not quality of care. Unaccredited schools began sprouting up. feeding like so many sharks on naive graduate students of psychology heading toward professional slaughter. Administrators and instructors in these schools were easily found in the ranks of underemployed psychologists.

Meanwhile, managed care spread like wildfire, further limiting length of treatment, restricting provider participation, requiring utilization review by less qualified professionals, and increasingly invading the privacy of treatment, thereby ruining it. It was then only a short trip to the dark collection of various recently published, particularly nauseating articles in the professional newsletters, screaming of rationalization, such as one recent gem in the APA Monitor (Galante, 1997) which described a psychologist’s discovery of how working for a managed care company, which she had previously viewed as “the enemy,” was rewarding. She writes, “I disagree with the view… that MCOs (Managed Care Organizations) denigrate, limit or dictate the profession of psychology. I believe providers have irrational attitudes and behaviors toward MCOs.”

Because it has been responding to market pressures rather than improving its services, professional psychology now hemorrhages credibility. The continued capitulation to managed care forces will lead to further limits on outpatient psychotherapy and greater erosion of confidentiality. Patients who would best be served by psychological interventions will increasingly be herded into cheaper but often less effective psychopharmacological interventions; those in need of psychological assessments will rarely receive them. Insufficient energy gets directed towards finding alternatives which are cost effective yet retain confidentiality and access to treatment.

The managed care problem at least receives active discussion in professional newsletters, and some degree of action, but one reads much less about the expanSion of, existing and new training programs. More doctoral level psychologists are graduating than ever before, despite an absence of internships or actual professional jobs. One recent doctoral level psychology graduate appeared in Playboy magazine (October 1997 issue). How many more will be driving taxicabs, working as waiters or functioning in other businesses? These trends tarnish the reputation of the field. For those who find work in psychology, their fees or salary will be reduced, as will respectability, as quality of services falls. The supply of psychologists already exceeds demand. The public will become increasingly aware of how many of the swollen training programs – many of which are motivated by profit rather than excellence – inadequately screen or train their graduates.

Finally, the inevitable failure of the prescription privileges effort will drain limited financial resources for political lobbying and weaken the profession in the eyes of other professional colleagues, not to mention the public.

As I argued in more detail in an earlier California Psychologist article (Karbelnig, 1995), psychologists already have a more than sufficient number of skills. The addition of applied psychopharmacology will only aggravate the fields’ identity crisis. Obtaining mastery in even one of the varied schools of psychotherapy, in performing psychological research, or in conducting psychological or neuropsychological evaluations already requires a lifetime of devotion. So why add another complex competency, which so greatly overlaps with medicine, when psychologists’ plates are already overflowing? The suggestion that prescription privileges are needed because rural America lacks sufficient psychiatrists lacks logic; it makes more sense to train rural primary care providers or nurse practitioners in provision of psychotropics. Better to leave the psychopharmacology to physicians who should be devoting their full-time energy to adjusting chemicals rather than providing psychological services. The time and energy wasted on seeking prescription privileges should be spent instead on dealing with managed care and improving training.

Perversions typically prove difficult to treat because of the gratification individuals find in the distorted object of desire. A compulsive, self-reinforcing pattern usually develops which ensures the continuation of the behavior. This is just the sort of dynamic that has possessed professional psychology. It has become entrenched in certain paths: Lobbying for prescription privileges when many psychologists are inadequately trained in their basic skills; training psychologists to work within a managed care system, which destroys the provision of meaningful psychotherapy, rather than aggressively promoting quality alternatives; and allowing graduate training programs in psychology to proliferate, many of them without APA accreditation, when higher standards for screening and training should be developed instead.

In cases of severe perversions, behavioral changes typically only follow major consequences, i.e. arrest or public exposure. If hope exists for the future of psychology, it sadly lies on a similar path. As the profession’s credibility plummets, the prescription privileges effort fails, and the number of unemployed psychologists reaches into the hundreds or thousands, perhaps only then will we be able to focus our attention on these three focal tasks: relinquishing the absurd push for prescription privileges, eliminating, replacing or severely controlling managed care in professional psychology, and greatly increasing the standards for professional education through better screening, training, and the elimination of unaccredited schooling.

References
Galante,V. (1997). Managed care is not the enemy. APA Monitor, 28(9).

Karbelnig,A. (1995). Prescription privileges:An iatrogenic disease for psychology. California Psychologist, 28(8).

Mad about Christina. (1997). Playboy, 44( I0).

Murray, B. (1998). Psychology trainers urged to update their programs. APA Monitor, 29( I).

Sullivan, M. (1997). Prescription privileges. The California Psychologist, 30(6). Califorma

Published as:
Karbelnig, A. (1998). Psychology’s Perverse Vision. The California Psychologist, 31(7), 24-25.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

Most psychologists have had negative managed care experiences, but a recent particularly malignant one elicited more horror than most. It also begged for the development of fresh solutions to managed care as it currently exists. Consider this case situation: A 24-year-old female financial services employee sought treatment for severe post-traumatic symptoms of five years duration. In 1987, she was brutally date-raped by a man she had known for more than a year. Coming from a conservative family in which talk of pain or of feelings in general was discouraged, she had resisted seeking assistance for years and discussed the incident with no one. Eighteen months prior to entering outpatient psychotherapy, she attempted suicide with tranquilizers and alcohol. Her physician prescribed psychotropic medications, which were ineffective and were quickly discontinued. When the suicidal thoughts recurred, and nightmares and social withdrawal were approaching extreme levels, she finally sought a referral through her company’s EAP.

In completing the outpatient treatment report of the well-known, national preferred provider organization through which she had benefits, 30 sessions were requested initially, and a request was made for treatment to be provided on a two time- per-week basis. Such frequent treatment was required to monitor for suicidality and to quickly build a therapeutic alliance. Hospitalization was neither indicated nor requested. Moreover, she was terrified of psychiatric hospitalization, was not holdable, and would have experienced such iatrogenic shame from the experience that the issue would have only been pushed if suicidal intent was imminent.

Rather than approve what seemed a reasonable, if conservative, treatment plan, the case manager, who was himself a licensed psychologist, offered to authorize either weekly psychotherapy or psychiatric hospitalization. The cost differential between these interventions was apparently irrelevant. When the request was pressed, the case had to be reviewed by another psychologist. When the reviewer was helped to see the absurdity of the situation, he reluctantly authorized one month of twice-weekly psychotherapy. The patient had been symptomatic for five years! As one would anticipate, this experience stimulated some thoughts about managed care and a few ideas about solutions.

Managed care appears to have evolved out the belief that psychological services were not being equally provided and that practitioners were exploiting patients. While there could certainly be some truth to both these assertions, the managed care solution, as it generally exists today, appears no better. Now, instead of the patient dollar being potentially misused by providers and unwitting consumers/ patients, a crop of managed care companies, which are rather large and profitable, have emerged. Now, less money goes to the practitioners and more to these large institutions. A recent article by APA Practice Directorate Executive Director Bryant Welch, J.D., Ph.D., reported that the CEO of one managed care company earns over 5)1 million per year. The managed care firms stand to profit by underutilization of all services. As the above example dramatically illustrates, patients remain just as much the losers, if not more so, than they did under the standard indemnity system.

A few immediate, and admittedly incomplete, solutions come to mind. First, and perhaps foremost, efforts need to be made to educate patients about what has happened to their benefit-dollar. Rather than being exploited by potentially greedy and uncaring practitioners, they are now at risk of being exploited by potentially greedy and uncaring managed care companies. The citizens of this country at one time feared a communist takeover; ,in the realm of mental health, managed care offers a similar kind of central control and loss of individual autonomy that it was feared communist regimes would produce more globally. The managed care system is decidedly unAmerican in that the power lies not with the individual/consumer, but with some larger entity that is supposed to judge the legitimacy of the consumer’s illness, needs or desires. Perhaps educating the general public about the abuses of managed care could be placed on CPA’s agenda, if it is not already.

The second potential solution would involve using APA ethical guidelines as a means of taking action against unethical case reviewers. Again, in the above example, it was grossly unethical to refer a suicidal individual for inpatient hospitalization when two or three-times-per-week psychotherapy is in fact indicated. The case manager violated several APA ethical guidelines, including the general principles of “professional and scientific responsibility” (principle A) and “concern for others’ welfare” (principle E). More broadly, given the complexity of most mental disorders, can any psychologist ethically evaluate mental health services based on a review of a form or a telephone call? When treatment restrictions are unethical, seeking redress through informal and formal filing of ethical complaints via CPA or APA may be useful in insuring proper treatment.

The final idea concerns the need for psychologists to band together to deal with case management practices. If there were enough cohesion among psychologists, then providers would be in a better position to have input, if not outright control over, case management and utilization review procedures. The situation is not unlike that of unorganized labor and “big business,” with psychologists being in the role of unorganized labor. There have been instances of providers being “black-listed” for not providing brief enough forms of treatment, failing to file forms in a timely enough fashion, or other mild infractions; isn’t this reminiscent of non-unionized workers being unjustly laid off or terminated because other workers were eager to take their jobs?

It behooves us to remember that these companies make a profit on the services we provide, and therefore they need us to provide them. Until the whole system is dismantled or altered, and (in accordance with the dictates of our democracy) individuals are empowered to make decisions about their care without having a central agency in which they have no representation control those decisions, then every effort should be made to insure that the interests of our patients are respected. So, rather than advocating for psychologists or against the interests of the insurance companies and managed care organizations, perhaps psychologists could join together as advocates of those who need our services by educating them, insuring that the ethics of our profession are upheld by all its members, including those who work for managed care companies, and finally by coming together as a cohesive unit to work toward positive changes in case management and other managed care procedures.

Published as:

Karbelnig, A. (1995). Patients Remain the Losers Under Managed Care. The California Psychologist, 25 (6), 10.
(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

It can now be safely assumed, or at least hopefully assumed. that psychologists know by now that sexual encounters with patients are unethical, illegal. and severely damaging to patients. But in the more subtle area of other types of physical touch, ethical. legal. and clinical guidelines become less clear. Is that hug at the end of the session okay? Is it ethical, and clinically wise, to gently pat your patients on the back as they exit the consulting room?

The APA Ethics Code, and the psychology licensing law, address blunt concerns like sexual relations with current or former patients which, obviously, are completely prohibited. Sexual harassment is expressly forbidden. The appropriateness of less sexual forms of touch, such as hugging or patting backs, is only addressed indirectly. Within Section One, for example, psychologists are cautioned to avoid harm, to avoid misusing their influence, and to monitor their own personal problems and conflicts. Fairly intimate physical contact like a hug could occur as a result of a lapse in one of these ethical guidelines. For example, a psychologist might initiate a hug because of their own excessive loneliness or some such. This could be an ethical violation, since it could be a result of “their own personal problems…”

The psychology licensing law derives some of its rules directly from the Ethics Code and is therefore similarly vague regarding more subtle forms of physical touch. Other areas of the law, for example the Civil Code, allow for causes of action against psychotherapists who engage in sexual relations with patients. The law is silent regarding specific remedies in cases where patients are harmed or injured by other types of gentle physical contact.

Turning to the clinical realm, and using psychoanalytic theory as a guide, the overriding area of concern when considering physical touch is its potentially negative impact on the psychoanalytic frame. This ambiguously defined phenomenon may be viewed, in brief, as the envelope or membrane around the psychotherapist- patient relationship that renders the relationship therapeutic. It may include such pragmatic considerations as the fee and the amount of time spent providing each treatment session. More subtly. it includes such things as limitations in self-disclosure, allowing for the transferential relationship to unfold, and abstaining from acting out feelings which are, instead, to be discussed and understood. Obviously some place exists for physical touch, i.e, restraining a patient who has an epileptic seizure, or hugging a patient who is leaving treatment after many months or years of intensive psychotherapy, but any physical touch that even begins to border toward the sexual. or is inappropriate in some other fashion, risks harming the psychotherapeutic enterprise by destroying this psychotherapeutic frame. Although they all overlap with one another, and share in common a destruction of the psychotherapeutic frame, nine distinct problems can occur whenever physical touch is introduced into the psychotherapeutic relationship.

First, though most psychoanalytic treatments encourage regression, and this is indeed part of the transformational process, it is important that the crucible in which this regression occurs is closely controlled. Physical touch risks eliciting what Michael Balint has termed malignant regression. He wrote of such patients, “as soon as one of their primitive wishes or needs was satisfied, it was replaced by a new wish or a craving, equally demanding and urgent.” (p. 138). While psychotherapists must continually be distinguishing between benign and malignant types of regression, once touch is introduced, it may become impossible to differentiate between them.

Second, physical touch risks rendering the transference concrete. What distinguishes psychoanalytic psychotherapy from any other type of treatment intervention is the emphasis on having the transference relationship to study as a vehicle for psychological change. For example, once psychotherapists interpret patients romantic feelings as real, and act upon them in some way, then the fantasized, projected relationship that can be interpreted and understood vanishes.

Third, and similar to the concretizing transference issue, the countertransference can be concretized. Psychotherapists may interpret their romantic feelings for patients as real rather than a reaction to something symbolic occurring which may guide the psychotherapy in a helpful fashion. Sandor Ferenczi, an early and innovative follower of Freud, learned the hazards of this after experimenting with what he called “active therapy.” He attempted to create a directly loving environment for his patients, believing it would heal by providing love they had never had. Toward the end of his life, he regretted the approach, finding that the patients had developed an intense dependency rather than experiencing much improvement.

Fourth, any type touch by psychotherapists may be construed as incestuous. One of the most harmful aspects of actual incest is the fact that the parental figure, as a idealized symbol of a safe and secure world, is destroyed by the incestuous act. Most patients, even if only on a deeply unconscious level, want their psychotherapists to have a certain authority that will be utilized to help them. Once psychotherapists begin acting like lovers, or even too affectionate parents, their appropriate authority disappears.

Fifth, physical touch may severely harm sexually abused patients who already have a great deal of confusion regarding physical touch, love, and appropriate boundaries. Even such overtly benign activities as occasional hugs by psychotherapists may be highly traumatic to patients with a history of sexual abuse.

Sixth, physical affection may offer gratification that appropriate psychotherapy should not provide. Effective psychotherapy strives to empower patients to manage their own lives more effectively. If lonely patients, yearning for physical touch, can count on haVing regular hugs and other forms of physical contact with their treating psychotherapists, this may actually impede their ability to learn how to obtain much-needed contacts in their own lives.

Seventh, physical touch risks restricting the range of affect available for expression, and exploration, within the psychotherapeutic process. Patients who undergo psychotherapy in an appropriate frame, and with appropriate boundaries, must come to terms with a variety of loss experiences. As Robert Stolorow remarked in a recent lecture, psychotherapists spend their entire day telling patients who have become highly attached to them to leave their offices at the end of 45 or 50 minutes. Patients should feel rejected by that experience! Sessions that end in an affectionate hug may deprive patients of the ability to experience such emotion, express it, and ultimately work through it.

Eighth, physical touch may well lead to what Glen Gabbard has called a “slippery slope” toward other, more severe boundary violations. In actual cases of sexual misconduct by psychotherapists, usually there have been other, more subtle boundary violations such as sessions lasting overtime, or sessions held late at night, that often predict .a sexual violation. Excessive physical touch could certainly be construed as yet another predictor of sexual misconduct by psychotherapists.

Ninth and last, inappropriate physical touching most likely reflects psychotherapists’ impaired ability to tolerate pain — a skill that psychotherapists require to be effective with their patients. It is of course the most natural thing in the world to want to hold or otherwise physically comfort an individual in your physical presence who is experiencing pain in some sense. However, and again in the interest of empowering patients, they should be assisted in developing their own ways of handling pain rather than becoming excessively dependent on their treating psychotherapists.

Most likely, physical contact at the very least risks adversely effecting the psychotherapeutic relationship in any number of ways, but these nine at least provide a fairly comprehensive overview of the primary ways such touching may be harmful. In brief, physical touch risks destroying the frame in which the transformational process unfolds. And once the frame deteriorates, psychotherapy cannot occur.

References
Balint, M. (1968). The Basic Fault. Northwest University Press. Evanston, Illinois.

Published as:
Karbelnig, A. (2000). Physical contact between psychotherapist and patient: Ethical, legal, and psychoanalytical considerations. The California Psychologist, 33(6), 32-34.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

In an arguable effort to weaken – not strengthen – the profession of Psychology, the California Pychological Association (CPA) has propelled the obtaining of prescription privileges to the top of its legislative agenda for 1995. This at a time that the profession falls victim to unprecedented attacks. The insurance companies strive to severely limit patients’ access to mental health services; the medical establishment often views psychological services as “medically unnecessary”; the drug companies sell psychotropic medication as being more cost-effective and efficient. And the American public, possessed by the spirit of fast-food, all too often bows to these forces. All this after psychology finally emerged, in the last few decades, as a strong, distinct, independent discipline.

Rather than protect professional psychology’s strengths, the CPA seems to increasingly capitulate to these political and economic forces. The CPA has repeatedly co-sponsored programs with managed care companies that promote exclusively short-term, crisis intervention psychotherapy. They have provided training in gaining access to provider panels and, more disturbingly, in how to “sell” one’s clinical experience so as to be palatable to managed care companies. Many other CPA programs and articles preach compliance to these dangerous trends that threaten confidentiality and restrict access to treatment. Now, the CPA strives to earn the ability to prescribe psychotropic medication, also in accordance with the prevailing opinion that such interventions are more efficient, cost-effective, and necessary for the survival of the profession.

Not only are such conclusions an unnecessary surrender, but the timing of their promulgation could not be worse. The current competencies of psychologist have to be supported and strengthened, especially in the public view. Instead, organized psychology appears to be accommodating to the view of the insurance companies. Both the rallying point and the metaphor for this struggle has become the push for prescription privileges.

Those in favor of such privileges suggest that psychologists could use another competency with which to compete with other healing professions. They believe that prescription privileges would make psychologists more competitive in the mental health marketplace. They argue it would allow psychologists with certain specialized training, such as those in medical psychology or in the neurosciences, to more directly apply their clinical skills. Finally, they propose that it would allow psychologists to help more people in more diverse locations. With the possible exception of this last point, these conclusions are easily dismantled.

First, psychologists hardly need another competency. Their capacity for conducting psychotherapy and related treatments, performing psychological assessments and doing research has not nearly been developed to its fullest. Doctoral training programs and internships already lack sufficient time for training in these areas. One could devote one’s entire career to the study of psychotherapy and not master the technique. The same goes for psychological assessment or research.

Second, regarding the idea that prescription priVileges would make psychologists more competitive, this, if valid at all, would be countered by the increased diffusion that would occur in the field of psychology. The American Psychological Association is already so split by factionalism that the addition of another major clinical area may well destroy it, most definitely resulting in a loss of professional power. The public is already confused about what psychologists do. What competitive edge would be gained by adding another clinical skill when many psychologists lack mastery of the skills they are already licensed to provide?

Furthermore, prescription privileges could make psychologists less competitive. At its best, the privileges would be limited in scope. At its worst, they would be granted only under the direct supervision of a physician. In either event, rather than strengthening the independent practice scope of psychology, the move would only serve to further the perception of psychology as somehow being “beneath” the medical profession. Whatever prescription training psychologists obtain would be second rate compared with complete medical training. Prescription-pad wielding psychologists would still be ill-prepared to deal with complicated medical/psychological issues, such as providing an anti-depressant medication to a diabetic or to a person with heart disease.

Third, regarding the ability for psychologists trained in the neurosciences or related areas to apply their skills, those psychologists who wish to expand their scope of practice should do so fully. Among the first set of individuals chosen to go through the Department of Defense . training in prescription privileges for psychologists, a number of them ended up applying for and being accepted to medical school. Obviously, many who are interested in obtaining prescription privileges desire to practice medicine. If the neuropsychologist or health psychologist desires prescription privileges to more directly help patients, they would be better served by formal medical training.

Fourth and last, it is a compelling argument that a need exists for provision of psychotropic medication to members of the population lacking sufficient access to physicians. But this issue would be better addressed by providing incentives, and training in psychotropic medications, for family practitioners or internists.

To add prescription privileges to the psychologist’s tool box to fill this one need is inefficient and unnecessary. These under-served people would be consulting psychologists with second class prescribing power rather than physicians. And the question of easier access to psychologists has yet to be addressed. Providing incentives for psychologists to serve these people would be no easier than doing so for physicians.

Instead of bowing to competitive and economic forces by seeking prescription privileges, professional psychology would be better served by endorsing its strengths and acknowledging its limitations. If one is trained as a lawyer, should one be attempting to psychologically counsel distraught clients? Or should a surgeon attempt medical management of a chronic diabetic? Both professions could perform these services, but should they? Legislative efforts would be much more effectively directed towards promoting psychology’s provision of excellent psychotherapy, assessment, and research, thereby filling the vacuum left by psychiatry and by masters level psychologists.

With economic changes affecting the income that physicians make, and other social changes, admission to medical school is easier than it was in past decades. For many young psychologists, it would not be too late to enter a medical training program. Rather than weaken the profession of psychology, and provide a service that is second-class to our medical colleagues, it would be wiser for psychologists interested in prescription privileges to seek formal medical training. Psychology needs to stand strong as a peer among other fields in the healing arts, not capitulate by mimicry or by attempted merger with medicine.

Published as:

Karbelnig, A. (1995). Prescription privileges: An iatrogenic disease for psychology. The California Psychologist, 28(8), 22-23.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

SACRAMENTO, JUNE 15, 2015: While searching the abandoned headquarters of the California Psychological Association (CPA), noted UC Berkeley Sociologist W.R.D. Klein discovered documents indicating that a disinformation campaign by major insurance companies during the late 20th century led to the destruction of Psychology as an independent discipline. According to these documents, which were buried in a wall while the building was being remodeled during 1996, officials of Hatena and Get Life insurance companies either influenced CPA officials or, more dramatically, may have actually have placed “moles” within its leadership. The profession of Psychology, which had emerged as a distinct discipline during the 1940’s and flourished through the late 1980’s, was formally incorporated into the medical profession during 2005, thereby terminating its status as an independent field.

Dr. Klein, who specializes in the study of professions in American society, is publishing a book on the demise of Psychology. He believes that the disinformation campaign sought to undermine the integrity of psychologists in the eyes of the American public. Two major themes were stressed in the campaign, he said in an interview yesterday.

First, the CPA placed prescription privileges as its top priority for legislative action during the mid-1990’s. This move, which was crushingly defeated by the California State legislature during 1997, drained resources from the professional organization and was an embarrassing, pUblic humiliation for the profession. In seeking these privileges, Psychology placed itself squarely as an inferior child to Medicine. Klein predicted that, if prescription privileges had passed, it would have had such a divisive effect on the field, would have drained much-needed resources for training in the areas that Psychology already served, would have confused the public, and would have also cemented Psychology as a secondary, inferior specialty to Medicine. The profession would have been destroyed anyway, he believes. He said, “Medicine had relinquished psychotherapy beginning in the 1970′ s, and Psychology lost its golden opportunity to seize that opening to focus on providing those specialized services to the public. Psychologists were already respected for their research, assessment, and teaching services. These skills should have been developed further rather than diluted by merging with Medicine.”

Second, and related to the issue of prescription privileges, the CPA failed to aggressively rally its members around a concerted fight against managed mental health care. In Klein’s view, the problem with managed care was a simple one, namely that it destroyed the psychologist’s ability to provide mental health care services in a confidential and private fashion — an absolute requirement for provision of psychotherapy and psychological assessment. Psychologists were viewed as joining the forces that placed profit before human services, thereby compromising their credibility.

Klein’s book, which he hopes will assist in the re-emergence of Psychology as a profession, includes a section outlining the steps he believes could have saved the profession and, indeed, allowed it to flourish into the 21st Century.

First and foremost, Klein writes, the profession needed a strong call for unity, not instigation of a professional civil war through making prescription privileges a priority. While he tends to be rather gentle and calm in tone, Dr. Klein was forceful on this point. In the course of the interview, he stated, “What were they thinking? With attacks on the profession coming from insurance companies, the medical profession, and some patient groups, to make prescription privileges a priority, thereby squandering resources and causing disunity, is unbelievable.” He believes the profession would have been better served by joining with the other mental health professions, from social workers to marriage counselors to psychiatrists, to combat threats to performing competent psychotherapeutic work, mostly threats that came through managed care companies. other weaknesses he points to include the failure to coordinate, in conjunction with the American Psychological Association, uniform standards for training psychologists. The plethora of unaccredited institutions, as well as some institutions which irresponsibly flooded the state of California with psychologists during the late 20th century, also served to weaken the profession. He also emphasizes that educating the public about the value of psychological services would have been most helpful. Such an educational campaign began during 1996, but was “too little too late.”

The steps that Dr. Klein recommended were not adopted. As a result, CPA membership dwindled. The profession increasingly lost credibility. After the overwhelming defeat of the prescription privileges bill during 1997, the profession essentially collapsed and psychologists were relegated to a clearly subservient role to that of physicians. Dr. Klein added, “We can only hope that had members of the professional organization known of the disinformation campaign during the early 1990’s and taken the necessary steps to counteract it, the profession of Psychology could have survived. Consumers of mental health services in this country would have been much better off with their active participation in, if not dominance of, the mental health field but, alas, such was not the case.”

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)