Jul 17

Impaired Therapists: How to Intervene

Unbreakable Kimmy Schmidt and Gypsy are a couple of the latest TV series, both streaming on Netflix, to feature impaired therapists. Kimmy Schmidt‘s Tina Fey has a minor role as Andrea, an alcoholic therapist who somehow still manages to offer the lead character (Ellie Kemper) tidbits of useful advice. Her impairment, however, has ultimately led to losing her license, one possible outcome in the real world as well.

Gypsy‘s Naomi Watts portrays a therapist who’s been described as unethical and a sociopath.

In real life a relatively small percentage of clinicians in any of the mental health disciplines—which include such areas as social work, psychology, and psychiatry—are likely to be impaired therapists. However, in order to protect the clients who may potentially be affected, rules have to be in place.

Therefore, the various professional organizations whose members are providers of mental health services have pertinent codes of ethics. According to a leading ethical expert in my own field, Fredric Reamer, impairment can not only involve failure to comply with those ethical standards but also incompetence (Social Work Today).

The social work code of ethics specifically states the following regarding steps to take when a colleague is deemed impaired:

(a) Social workers who have direct knowledge of a social work colleague’s impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.

(b) Social workers who believe that a social work colleague’s impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.

All of the above takes into account the unfortunate fact that sometimes the nature of certain personal issues—such as addictions, burnout, health issues, and mental illness—can mean they will go undetected by the practitioners themselves.

Pertinent to this is a quote from the NASW Impaired Social Worker Program Resource Book that Reamer cites:

The problem of impairment is compounded by the fact that the professionals who suffer from the effect of mental illness, stress, or substance abuse are like anyone else; they are often the worst judges of their behavior, the last to recognize their problems and the least motivated to seek help. Not only are they able to hide or avoid confronting their behavior, they are often abetted by colleagues who find it difficult to accept that a professional could let his or her problem get out of hand (p. 6).

It’s not only colleagues who have recourse; clients do as well and need to trust their own instincts in this regard. If you notice something is wrong and talking it out with the therapist either doesn’t seem like an option or fails, you can report the impaired therapist to his/her employer and/or professional association and/or licensing board, and/or, if involved in payment for services you’re receiving, your health insurance company.

Jun 30

“Gypsy”: Role Model for Unethical Therapists Everywhere

Coming to Netflix today is Lisa Rubin‘s Gypsy, a widely panned series starring Naomi Watts as a therapist—a vastly unethical therapist.

Let’s just get the trailer out of the way:

 

Rubin offers this official film description:

Gypsy is a ten-part psychological thriller that follows Jean Halloway (Naomi Watts), a Manhattan therapist with a seemingly picturesque life who begins to develop intimate and illicit relationships with the people in her patients’ lives. As the borders of Jean’s professional life and personal fantasies become blurred, she descends into a world where the forces of desire and reality are disastrously at odds.

Psychological thriller? Most critics seriously question how well Gypsy fills that particular bill.

Further plot details from Jen Chaney, Vulture:

Happily married (Billy Crudup plays Michael, her handsome lawyer-husband) with a daughter, a nice home, and a New York City office yanked straight out of a Z Gallerie catalogue, Jean ticks most of the boxes on the ‘she has it all’ checklist. She does have some issues, though, including a strained relationship with her mother (Blythe Danner), difficulty coming to terms with her non-gender-conforming daughter, and a low-simmering jealousy of the relationship between Michael and his assistant. To cope, Jean does what Gypsy the series does: spend minimal time genuinely exploring these matters in order to channel energy into unethically infiltrating the social and family circles of her patients.

Selected Reviews: Comparisons and Conclusions

Dan Fienberg, Hollywood Reporter:

Watts doesn’t play Jean as victim or villain and Gypsy doesn’t judge Jean, though many viewers are probably going to think it should. Professionally, the things she’s doing are wrong and the show’s only real tension comes from playing the same, ‘Is she about to get caught in her latest lie?’ beats over and over without offering an alternative perspective, allowing us to root for the cruelly manipulated patients.

Jen Chaney, Vulture: “It’s like In Treatment with more weird, stalker-y behavior, except when it’s delving into Jean’s conflicts with fellow moms in her chichi Connecticut suburb. Then it’s like a far inferior version of Big Little Lies.”

Maureen Ryan, Variety:

It’s hard not to compare this show to ‘In Treatment,’ the HBO series about a therapist which had the good sense to keep its episodes to under 30 minutes. Not only did that series do a better job of turning most clients into three-dimensional people, it distilled the intensity of sessions into efficient, effective installments.
What transpires in Jean’s office, however, usually lacks insight and spontaneity, and her patients — who nurture obsessions with people who don’t return their interest — are a pallid, moderately annoying bunch. Jean’s eyes often glaze over with boredom, and it’s easy to see why.

Inkoo Kang, Village Voice:

The show is a confluence of interesting ideas: female midlife crises, competitive mothering, the parenting of a very young trans child, the invisibility of female sociopathy, mental-health professionals’ frustration at their own helplessness, and, especially, the vicarious thrills therapists (might) experience when they hear about the life-derailing pleasures that got their patients into trouble. But each scene wastes every opportunity to reach for something fresh or original.

Brian Tallerico, rogerebert.com:

…a depressingly bad show for the talent it wastes on horrendous dialogue, unbelievable characters, and the kind of soapy plotting you’re more likely to see on a Lifetime TV movie than prestige drama…
Worst of all, none of it rings true…If I was the show’s therapist, I’d suggest it stop taking itself so damn seriously. Pick up the pace and give us something to care about. Get to the point and stop dancing around your issues. Because no one wants to dance this slowly.

Jun 26

“My Mourning Year”: Therapist’s Own Grief Process

Andrew Marshall is best known for his self-help books, but his memoir demonstrates that mental health, even for experts in the field of psychology, is a universal struggle. Failed counseling sessions, spontaneous vacations, and romantic dates are all attempts Marshall makes in order to move past “the black holes of Thom.” Zane DeZeeuw, Lambda Literary, reviewing My Mourning Year

Although known in the United Kingdom as a top-notch couples therapist and author of 18 self-help books, Andrew Marshall‘s My Mourning Year: A Memoir of Bereavement, Discovery and Hope, about the death 20 years ago of his partner, may be his best writing, according to Zane DeZeeuw, Lambda Literary.

My Mourning Year is an almost unedited version of the diary he kept following Thom’s death. “He does not offer steps or guidance for how to navigate the mourning process; instead, Marshall uses his experience as anecdotal evidence that a person can survive and learn to live again after being affected by a tragedy.”

As Marshall explains in a Telegraph article, “When my partner Thom died 20 years ago, he was just 43 and I was only 37. I did not have the first idea how to cope with the grief that enveloped me.”

By publishing such a personal book, going against the usual privacy he’s maintained throughout his career, Marshall states, “I want to show that there is no right or wrong way to grieve and everybody – even therapists – make mistakes.”

One significant point Marshall makes in My Mourning Year (and I will continue to quote from Telegraph) is that “Bereavement has the knack of finding the fault lines in your life and blowing them apart. It exposed that my parents were not entirely comfortable with me being gay and I was not comfortable with their polite but distant way of showing they cared.” He needed to take some space from them.

And, adds Marshall, “the most important message of all: grief does not work to a conventional clock. Sometimes it feels like 20 months since Thom died and I still find new things to mourn. (Just recently, I wept about never getting to know him as an old man.) At other times, Thom’s death seems so long ago that it happened to someone else – perhaps because I’m not the same man I was 20 years ago.”

In the aftermath of Thom’s death there were certain things that failed to make Marshall feel better: a rebound relationship, for example—also counseling, it turns out. He actually tried it twice. This “was particularly upsetting because up to then, I’d thought of therapy as the holy grail. The problem was partly me. Just as doctors are terrible patients, therapists make terrible clients.”

(My own take on that latter statement is that it’s overly generalized and certainly not always true. I’ll accept, of course, that he is a therapist and that he feels he made a terrible client.)

Some of the things that did help Marshall’s grief process included the catharsis involved in attending theater, learning to be assertive about specific needs, taking a course in something new to him, and a one-year death anniversary dinner shared with close friends.

Eventually, moreover, he mended the rift with his parents that Thom’s death had provoked. Too, he was able to love again:

Bereavement is a wake-up call that none of us immortal. So I worked hard on improving my relationship with my parents and they have not only learnt to accept me but came to my wedding, two years ago, with joy in their hearts.
Perhaps this is the reality of mourning: you never get over the loss, but if you allow it to open you up to new experiences, you can transform your life into something that might be different, but still rewarding and meaningful.

Apr 14

Lying in Therapy Is a Researched Thing

The topic of secrets and lying in therapy is just one aspect of research at The Psychotherapy, Technology, & Disclosure Laboratory at Teachers College, Columbia University. Dr. Barry A. Farber is the lab’s leader, while doctoral students Matt Blanchard and Melanie Love run the Lying in Psychotherapy element.

From the latter’s online description:

Client dishonesty is a broader category of non-disclosure that includes distorting and fabricating as well as omission, avoidance, secret-keeping, etc. Our initial survey of 547 psychotherapy clients showed large percentages of clients concealing therapy-relevant information, such as suicidal thoughts. We are now preparing a follow-up survey to replicate our initial findings, conducting interviews with clients, and developing a related survey for therapists.

According to the abstract of an article by Blanchard and Farber, the vast majority of clients (93%) admitted to lying in therapy.

Common therapy-related lies included clients’ pretending to like their therapist’s comments, dissembling about why they were late or missed sessions, and pretending to find therapy effective. Most extreme in their extent of dishonesty were lies regarding romantic or sexual feelings about one’s therapist, and not admitting to wanting to end therapy. Typical motives for therapy-related lies included, ‘I wanted to be polite,’ ‘I wanted to avoid upsetting my therapist,’ and ‘this topic was uncomfortable for me.’

Ryan Howes, Psychology Today, interviewed Blanchard about the research, and some of the more interesting excerpts from their exchange are presented below verbatim:

  • Omission is about 3.5 times more likely than fabrication. Similarly, clients report minimizing the truth about 6 times more commonly than they report exaggerating.
  • …(M)ost demographic factors—gender, ethnicity, education, income—had no relationship to dishonesty in therapy.
  • …(Y)ounger clients reported more lying. Those who lied about one or more topics were on average 4-to-7 years younger than those who reported total honesty. This finding matches findings about lying in everyday life outside of therapy, too.
  • Most commonly, clients lie to avoid the shame and embarrassment they feel even in the confidential, protected space of the therapy room.
  • One of the last questions we ask clients is: “How could your therapist help you be more honest?” We imagined that clients would want more warmth or skill from their therapist, or to know their therapist shared their problems, or understood their culture or class. On the contrary, the dominant response was, “If my therapist asked me directly.” So one simple takeaway from our work is: Just ask.

A “spinoff” of the Lying Lab is called Therapists’ Lies & Detection of Lies, run by doctoral student Devlin Hughes. “Specifically, the lab is exploring how therapists respond when they believe a client is being dishonest with them…”

Tori DeAngelis, not a representative of the above resources but a journalist, has compiled her own suggestions for therapists (APA) to minimize lying in therapy. Some examples paraphrased from her article:

  • Establish a safe space for clients; convey a nonjudgmental attitude.
  • Model the practice of honesty.
  • When possible use humor and acceptance regarding omissions and lies.
  • Tread more lightly regarding possible secret-keeping of a more sensitive nature, but do consider how to reach that material, as clients usually benefit.
  • Keep in mind that you as a therapist may have also had difficulty admitting the truth in therapy. One study “found that about a fifth of 800 therapists surveyed admitted there was something important they had kept secret in therapy. In most cases it involved sexual issues.”
Mar 31

“Big Little Lies”: Domestic Violence Therapy

The current and highly rated HBO comedy/drama mini-series Big Little Lies, a suburban murder mystery starring such notables as Nicole Kidman, Reese Witherspoon, Shailene Woodley, Laura Dern, Alexander Skarsgård, and Adam Scott, is based on Liane Moriarty‘s 2014 bestselling novel.

The Washington Post said of the book, “Big Little Lies tolls a warning bell about the big little lies we tell in order to survive. It takes a powerful stand against domestic violence…”

One way the TV series differs from the book is that creator David E. Kelley has placed more emphasis on a certain delicate and challenging situation being addressed in therapy. According to Carolyn L. Todd, Refinery29, the series in this way helps “make a very unlikable character more sympathetic.”

That character is Celeste (Kidman), an abused spouse. Although she first enters therapy with husband Perry (Skarsgård), this changes when he has to go out of town.

But in the book, Celeste sees the therapist alone from the get-go. Having Perry participate in therapy makes him seem like a better guy: he’s a domestic abuser, yes, but he knows he has a problem and is willing to work on it. It indicates he knows his behavior is unacceptable and wants to change. Celeste and Perry seem like more of a team. Plus, the tense dynamic of the therapy sessions is riveting, as is watching the pair negotiate in the moment how much truth about their marriage they want to share with the counselor.

Although therapists on TV are often portrayed sketchily or negatively or unfairly, there’s a general consensus that this isn’t so in Big Little Lies:

Caitlin Flynn, Bustle: “Therapy isn’t often depicted on TV and, when it is, the scenes tend to be brief and lack depth. The therapy sessions on Big Little Lies don’t just break that mold — they shatter it.”

Maria Elena Fernandez, Vulture: “Dr. Amanda Reisman (Robin Weigert) and Celeste and Perry Wright (Nicole Kidman and Alexander Skarsgård) are so realistic they’re draining.”

Melissa Dahl, New York Magazine: “And you know who else loves the therapist on Big Little Lies? Actual therapists.” Some of the highlighted factors: the realism, Dr. Reisman’s apparently advanced knowledge regarding domestic abuse, and her astute ability to pick up on subtle cues from the client.

Regarding the advisability of seeing Celeste alone considering that it was supposed to be marital therapy, it’s the existence of domestic violence that allows for this. For the optimal care of the victim, an experienced therapist is aware of the need to further assess the circumstances without the direct participation of the abuser.

Flynn expands on how the therapy in Big Little Lies proceeds:

It was only when Celeste began seeing Dr. Reisman on her own that she very, very slowly began to shed her facade. These scenes hit the nail on the head because Dr. Reisman successfully strikes a balance between needling the truth of Celeste without pushing her too hard, which could cause her to shut down and never come to another appointment. The scenes are lengthy, which allows Big Little Lies to flesh out what therapy really looks like — especially for abuse victims. Celeste can’t bear to speak the truth out loud, and her strongest moments in these scenes are conveyed through facial expressions, body language, and eye contact.

By the way, the seventh and final episode airs on Sunday. Time sums up the arc: “…The dreamy miniseries opened on a mysterious murder at the most glamorous trivia night ever. But six episodes in, we still don’t know who died and who the killer is.”