Clinical Update, May 2008 OCD: Obsessive-Compulsive Disorder Our latest online course (6 CE Credits): Obsessive-Compulsive Disorder (OCD). Obsessive-Compulsive Disorder (OCD) occurs when an individual experiences obsessions and compulsions for more than an hour each day and, most importantly, that these experiences interfere with his or her life. Obsessions are intrusive, irrational thoughts, unwanted ideas or impulses that repeatedly well up in a person's mind.  Compulsions are repetitive rituals such as handwashing, counting, checking, hoarding, or arranging. About 18% of American adults have anxiety disorders. The National Institute of Mental Health estimates that more than 2% of the US population, or nearly one out of every 40 people, will suffer from OCD at some point in their lives. The disorder is two to three times more common than schizophrenia and bipolar disorder. OCD affects 1% to 3% of children and adolescents. Heredity appears to be a strong factor in the development of OCD.  If you have OCD, there is a 25% chance that one of your immediate family members will have it. Sufferers experience "pathological doubt" because they are unable to distinguish between what is possible, what is probable, and what is unlikely to happen. Generally, OCD symptoms are not relieved by psychoanalysis or other forms of "talk therapy".  However, there is strong evidence that behavior and cognitive-behavioral therapies can be effective alone or in combination with medication. Compared to other conditions, OCD is generally treatable. About two in every 100 adolescents experience OCD. An estimated 700,000 to 1.4 million people in the United States are believed to have compulsive hoarding syndrome. A reasonable estimate is that 20% to 30% of individuals diagnosed with OCD have hoarding symptoms. People who hoard also have higher rates of personality disorders, social phobias, and pathological grooming behaviors such as skin picking. Psychoanalysts classify hoarding as reflective of anal eroticism. According to the Academy of Cognitive Therapy, diminished symptoms of OCD are reported by 75% of those who complete exposure and response prevention treatment. Clinical Update, June 2008 Menopause in the New Millenium As Baby Boomers enter midlife, millions of women (more than ever in human evolution) are facing menopause.  An unprecedented number of women are making the transition through "the change", creating a massive impact on the healthcare and integrative medical systems, as well as increasing the use of numerous alternative treatments.  With so many women entering this phase of their lives, it is imperative that clinical personnel be aware of the parameters, symptoms and solutions of this physical, psychological and emotional passage.  Our latest online course (6 CE Credits): Menopause in the New Millennium. Recent studies show: In 1900, the average life expectancy for an American woman was 48 years.  Today, most women experience menopause between ages 45-55. Some symptoms that are commonly considered menopausal may actually be related to aging in general. Contrary to the myth that postmenopausal women are sexless, studies show that about 50% experience no change in sexual appetite and pleasure, over 30% experience an increase, and less than 20% experience a decline. In the US, almost half of all postmenopausal women studied report having used hormone replacement therapy (HRT). Most often, HRT is taken in pill form. Although most women started using HRT around the time of menopause, 25% started taking it five or more years after menopause. Among women who were at least 10 years postmenopause, 14% had taken HRT pills for at least 10 years. Compared to women with natural menopause, those with surgically-induced menopause were much more likely to have used HRT and also more likely to be currently using it. There was no difference in HRT use among age groups for women with natural menopause. Non-Hispanic white women were more likely to use HRT than either non-Hispanic black or Mexican American women. Women with more than a high school education, or whose household income was above the poverty level, were more likely to use HRT than women with less education or lower family income. There are no substantial differences between HRT users and nonusers in terms of risky health behaviors and self-reported health issues. Diabetes was twice as prevalent among nonusers and past HRT users than among current users. Approximately 45% of women 40-60 years of age reported receiving counseling from a physician about the pros and cons associated with using HRT after menopause. Women with higher levels of education were more likely to receive counseling than women with less education, regardless of race or ethnicity. Women who had received recent preventive health services, such as mammograms, pap smears and general examinations, were much more likely to have received HRT counseling than those who had not. Of all ambulatory medical care visits by women 40 years of age and over, 7.5% used an HRT prescription. Obstetric/gynecology visits were 1.9 times more likely to result in an HRT prescription than visits to primary care physicians. On average, women develop heart disease approximately 10 years later than men, but the largest increase in coronary mortality coincides with menopause. Osteoporosis affects an estimated one in six women and one in sixteen men over the age of 50. Women can lose up to 20 percent of their bone mass in the five to seven years following menopause. Aerobic, weight-bearing and resistance exercise improves bone mineral density (BMD) in postmenopausal women, whether or not they use hormone therapy. Perimenopausal and postmenopausal women differ hormonally and experientially. Therapies tested on one population should not necessarily be extrapolated to the other. New online course (6 CE Credits): Menopause in the New Millennium.  The new Menopause course will: Educate clinicians about Perimenopause, Menopause and Postmenopause Describe the symptoms associated with each of these phases Identify conventional and integrative medical interventions Review the debate about Hormone Replacement Therapy Clinical Update, May 2008 DSM: Diagnosing for Status and Money A Critical Look at the DSM and the economic forces that shape it. In principal, mental health diagnoses can be helpful to clinicians and researchers in their formulation of treatment, research and communication with other professionals.  Unfortunately, the DSM has been shaped by economic and political influences rather than by scientific and medical ones. The DSM assigns diagnoses in a biased manner, resulting in more harm than good to our patients, their families and society at large while delivering huge profits to pharmaceutical companies.  Women, children, minorities, lower income and older people are the groups most likely to be negatively affected by the biases presented in the DSM. A newly published article: DSM: Diagnosing for Status and Money Online Course for 4 CE Credits: DSM: Diagnosing for Money and Power DSM Recap: The DSM has been called the billing bible of psychiatry and has become one of the most influential texts in the field of mental health. The DSM is a powerful tool of social control: its criteria are used to judge who is normal or abnormal, sane or insane or who should remain free or be hospitalized against their will. Most texts and graduate and postgraduate courses present the DSM as an objective, scientific document.  It is neither. The DSM is primarily driven by the psychopharmacological industry, which reaps huge profits from each new diagnosis that can be treated with medication. The frame of the DSM is distorted by a primarily intra-psychic-individual focus and tends to ignore contextual factors. It does not address what cannot be solved with a pill.  It does not appropriately address patients who, in fact,  are wrestling with social problems, such as sexism, racism, or homophobia, or existential anxieties regarding loneliness or death.  Unfortunately, using the DSM, the dis-ease of such patients will be redefined as medically treatable maladies. The DSM perpetuates the myth that the medical-mechanistic model can simply be applied to psychology. Some clinicians have used the DSM categories as a form of "name calling".  Accordingly, the DSM gives some therapists an illusory feeling of power and superiority driven by the "power to name". DSM-based research has repeatedly been shown to be of questionable validity and is, in fact, very unreliable. Since its inception in 1952, the DSM has consistently viewed pathology as residing within the individual.  Subsequent revisions in 1980 and 1987 have evolved toward a more firmly biological perspective. In response to insurance companies' need for increasing specificity in diagnoses and the psychopharmacology industry's need for new markets, the number of available diagnostic labels rose from 297 in 1994 to 374 in 2000.  The upcoming DSM V is likely to include hundreds more "new" (and profitable) mental disorders. DSM is big business, not only for its publisher, the American Psychiatric Association, but even more so for the psychopharmacological industry, which profits from prescriptions written for the ever-increasing numbers of DSM disorders. DSM pathologizes many normal and healthy behaviors: Shyness: You are mentally ill if you are very introverted or extremely shy. Grief: God forbid if you intensely grieve the loss of a beloved one for more than six months. Depression: You must be mentally ill if you respond to real life issues or injustices with deep sadness and intense despair.  (For more, see our online course: Depression.) Anxiety: You must be mentally ill if your reaction to the existential reality of mortality or loneliness involves profound or debilitating anxiety.  (For more, see our online course: Anxiety.) Lack of Sexual Interest:   Lack of sexual interest is often not a mental disorder.  Many women may have good reasons to avoid sex that may stem from domestic abuse, overwork or other reasons.  Kaschak and Tiefer (2001) discussed Female Sexual Dysfunction (FSD) as "a textbook case of disease mongering by the pharmaceutical industry..." or what they call the "medicalization industry."  (For more, see our online course: Feminist Sex Therapy.) Spirited Children: DSM casts a very broad net around the ADHD diagnosis, and often includes millions of spirited, strong-willed, and highly gifted and creative children.  It results in huge profits for medicating psychiatrists and pharmaceutical companies.  (For more, see our online course:  ADHD: Myths or Facts.) Online Course for 4 CE Credits: DSM: Diagnosing for Money and Power Clinical Update, May 2008 Borderline Personality Disorder: How Therapists Can Successfully Treat One of the Most Difficult, Fascinating, Volatile, Dreaded and Potentially Rewarding Populations Our new online course on Borderline Personality Disorder is offered for 5 CE Credits. No other mental disorder has stirred and evoked more fascination, volatility, trepidation and dread in therapists as borderline personality disorder (BPD).  We have all heard statements like the following: "Never have more than one or two Borderlines in your practice at a time." "You are one Borderline away from losing your license." "I have one Borderline too many in my practice." "If you take on a BPD client, you will be swamped with late night phone calls and an all-consuming, volatile therapeutic relationship." The Risks: Litigation Risk: BPD clients are more likely than other clients to file complaints and initiate legal actions against their therapists. Emotional Toll:   Working with BPD can be emotionally taxing and exhausting.  Learn about the nature of the disorder and carefully manage your counter-transference.  Do not act impulsively.  Do seek support and consultation as necessary. The Hope: Contrary to the prevailing myths that BPD is incurable, new perspectives and new (and old) therapies have proven surprisingly effective.  With the aid of this online course, it is our hope that BPD will no longer be the disorder that therapists dread.  The course will discuss how BPD is eminently treatable and show how working with BPD clients can be highly rewarding. Strategies for Risk Management: Developing a deep understanding of the nature of BPD and treatment options. Comprehend the actions and reactions that are often evoked. Implement clearly articulated treatment plans. Set clear, appropriate and compassionate (not punitive) boundaries. Carefully manage your counter-transference, do not act impulsively. Terminate thoughtfully. Document, document, and . . . document. Consult, consult, and . . . consult. RECAP: Borderline Personality Disorder The DSM captures only part of the symptoms of BPD. Research shows that most therapists use other tell-tail signs as diagnostic tools. Instead of diagnosing and understanding BPD from DSM symptom checklists, it may be more accurate, and provide a richer clinical picture, to think in terms of four symptom clusters: affect, cognition, impulsivity, and interpersonal relationships. BPD has diverse etiologies, including biological and psychosocial. Understanding your client's specific etiology will help you make effective treatment choices. The belief that BPD is an intractable part of personality may not be true. Many BPD clients mysteriously shed their BPD symptoms. They sometimes do so without treatment. There are several different highly effective treatments for BPD. Many treatments are new, but some are traditional. There is a tangled web between Axis I mood disorders and Axis II personality disorders. Understanding your client's specific web will help you make better treatment decisions. Although no medications specifically address BPD, some medications may occasionally play a valuable role in treatment. Neuro-imaging studies suggest how and why BPD develops. Observational studies of mothers and babies may provide insight as to how BPD is transmitted from mother to baby. Dialectical behavior therapy, interpersonal psychotherapy, transference-focused (psychodynamic) therapy, emotionally supportive therapy, and mentalization-focused therapies have all proven effective with BPD. However, they each address different dimensions of the disorder. Therapists are particularly prone to strong counter-transference with BPD clients, which presents a legal peril. Understanding the dynamics and taking precautions may help insulate you from legal problems. Many treatment failures with BPD clients may be due more to therapists' hesitations and defenses than to the "intractability" of BPD. This Course Will Help Therapists to: Identify the symptoms and accurately diagnose BPD. Understand the diverse etiologies of BPD. Identify effective therapies. Learn the principles of several effective therapies. Understand the limitations of DSM taxonomy in regard to BPD. Learn the appropriate use of medications for BPD. Learn the common ethical and legal pitfalls in treating BPD. Practice ethical risk-management with BPD. Access resources for therapists, clients and families. Borderline Personality Disorder Online Course-5 CE Credits Clinical Update, April 2008 Innovations in Infertility: Nuts & Bolts of Fertility Medicine for the Curious Clinician After two years, and more than a hundred thousand dollars spent, I sat in the fertility specialist's office and stared blankly at him as he informed me, "Regretfully, it's not possible for you to have a baby!" "What?" I thought again to myself. "But women are designed to have babies." Twenty years later, I can only smile at how wrong he was as I listen to my five (!) children play gleefully in the other room. Dr. Debeixidon, Author of Infertility Course Unlike the Baby Boomers before them, much of the following generation has placed greater focus on developing careers than creating a family. Many decided to delay families while getting their careers in order, only to discover that when it was finally the right time to have children, it was no longer biologically easy or feasible. Infertility is now rampant amongst 30-45 year olds, affecting about 25% of reproductive-aged couples, leaving many with heartache and guilt.  In a desperate effort to turn back their biological clocks, couples are spending hundreds of thousands of dollars for technical procedures and costly medications.  While there is certainly merit to all that is available through modern medicine, a growing number of couples are looking to a more comprehensive approach to infertility treatment, one that actively combines tools from Western and Eastern Medicine. Our latest Online Course on Infertility Innovations is offered for 5 CE Credits. Our CE Accreditations include APA, BBS-CA, NBCC, NAADAC and CA-BRN. View our Online Course Offerings by Course Title. Infertility - 101: It is estimated that more than 6.1 million people were diagnosed with some form of infertility in the US. Research suggests that 9% of those of reproductive age suffer from infertility. Nearly three quarters of a million women lose their pregnancies each year to ectopic and molar pregnancies, miscarriage, and stillbirth. The decrease in female fecundity beginning after the age of 30 and exaggerated after 40, is a well-documented finding.  The incidence of miscarriage increases with maternal age. Women who conceive late in life generally have a late menopause as well. As most clinicians have experienced, while we can address and explore the loss of a pregnancy with a couple, nothing seems to deter them from the desire to succeed with a live birth. Having techniques that are designed to provide more than just loss management or bereavement counseling provides more of what these couples are seeking. Approximately 1% of the live births in the US are due to Assisted Reproductive Technologies (ART) procedures. Success rates for pregnancy by ART range between 20% and 30%. The first "test tube baby" was born less than 30 years ago. The research suggests that implantation and "take-home baby" rates are significantly higher with electro-acupuncture than without. Acupuncture can increase blood flow to the reproductive organs, which dramatically improves a woman's response to the hormonal therapy. Infertility can result from building up emotional baggage- when you stuff the contents of your emotional life into virtual suitcases inside, and fail to empty them out at an appropriate time. Use of individual and couples psychotherapy to increase awareness of process and to explore emotional and psychological issues has been proven to increase chances of conception. Research conducted through Harvard Medical Center indicates that use of mindfulness techniques can significantly, positively, impact fertility. The Infertility Online Course will: Deepen clinicians' understanding of infertility Summarize the current and latest advances in infertility treatments Broaden clinicians' knowledge of fertility medicine Clinical Update, March 2008 From King David to Katharine Hepburn to Bill Clinton to Eliot Spitzer: Infidelity, Affairs, Monogamy and Their Clinical Implications  From King David in Jerusalem to Kathryn Hepburn in LA, Prince Charles in England, Bill Clinton in DC and Eliot Spitzer in NY, infidelity has been a consistent part of "his-story."  Infidelity is much more common than we like to believe.  It is also no longer primarily the province of men, as women, statistically, are catching up fast.  Equal opportunity, indeed.  The world has long been titillated by the extramarital transgressions of the high and mighty, from emperors, queens and presidents, to evangelists and movie stars, as well as our co-workers, friends and families.  The theme has threaded itself throughout history, art, literature and, certainly, through politics and Hollywood.  Moving this trend into high gear is none other than the Internet, where couples meet and mingle frequently, anonymously and sometimes perfidiously. The online course Infidelity and Affairs: Myth, Realities and Effective Therapies for 5 CE credits, examines the issues and complexities of infidelity. Myths and Facts about Infidelity Myth: Infidelity is rare in the animal kingdom. Fact: Only 3% of the 4,000 species of mammals are genetically pre-programmed for monogamy.  Humans, doves and swans are not among the faithful 3%: however, the flatworm is. Myth: An affair inevitably destroys the marriage. Fact: Many marriages survive affairs and even emerge stronger. Myth: Infidelity is not normal. Fact: Men's infidelity has been recorded in almost all societies, and in quite a few cultures it is the prevailing norm. Myth:   Western culture supports fidelity. Fact: Western culture gives lip service to fidelity, but actually supports infidelity through its obsession with sexuality in the media and role modeling by celebrities. Myth:   People's attitudes toward infidelity are consistent with their behavior. Fact: A striking paradox is that while 90% disapprove of extramarital relationships, about a third to a half of couples and partners are, in fact, engaged in such relationships. Myth: Men initiate almost all affairs. Fact: Unlike in the past when women could lose everything, including their lives, infidelity has become an equal opportunity venture in the West.  Women are catching up rapidly as they are less dependent on men for physical and financial support. Myth: An affair always means there are serious problems in the marriage. Fact: Some who engage in affairs report high marital satisfaction.  Others report that the affair has actually spiced up their marriage. Myth: Disclosure of the affair to the betrayed spouse is essential to healing the marriage. Fact: Therapists must conduct a careful risk-benefit analysis before encouraging or insisting that clients disclose their affairs.  Some affairs are best kept secret.  Some disclosures, especially by women, can increase the likelihood of domestic violence and homicide. Myth: Full disclosure of all the details of the affair to the betrayed spouse is essential to regaining trust. Fact: This moralistic-puritanical view of affairs can be very destructive. Giving the partner X-rated details of the affair can be haunting, traumatizing and can fuel obsessions.  When appropriate, sharing very general information is often sufficient.  Myth: Extramarital affairs are never consensual. Fact: Open marriages used to be popular in the 1970s and are still around today. Many couples have an implicit or explicit consensus regarding extramarital relationships. Myth: Couples therapy is the best approach to dealing with an infidelity crisis. Fact: No one approach is best.  Therapists must take into consideration the type of affair, personalities, culture, etc. when constructing a treatment plan. Learn how to assess, counsel and intervene in  cases of infidelity with the Infidelity Online Course. This course includes a printable informational brochure to provide to clients as an adjunct to therapy. Clinical Update, March 2008 Feminists' New View of Women's Reproductive Health Exposing How Pharmaceutical Companies Boost Drug Sales by Inventing "Medical Conditions" and "Disorders"  Pharmaceutical companies have recently appointed themselves experts in the area of women's reproductive health. Not feeling amorous?  No problem.   Just pop this pill.  Just use this cream.   Pharma ads urge women to reach for the drugs, and end with an image of a happily embracing couple.  Moreover, to really  boost sales, these companies employ both the carrot and the stick: that is, the promise of bliss and the fear of failure.  In addition to guaranteeing instant romance, the companies must persuade consumers that any variation in desire indicates a medical condition. In other words, if you're not always ready for romance, you're suffering from a disease.   Feminist researchers and clinicians have worked diligently to develop innovative ideas about these issues, and offer not only new definitions and descriptions, but have also designed alternative methods for optimizing women's reproductive health.   Our latest online course is authored by Leonore Teifer, Ph.D. and presents research and writing by notable feminist scholars.  Contributors include Leonore Tiefer, Ph.D., Marny Hall, Ph.D., Kathryn Hall, Ph.D., Lisa Aronson Fontes, Ph.D., Marilyn P. Safir, Ph.D., Anna Arroba, Ph.D., and Sadhana Vohra, Ph.D. To access the complete Clinical Update and read more about this topic, click here.  To access our new online course for 6 CE Credits, click here.  Related online courses that critique psychiatry and the pharmaceutical industry: DSM: Diagnosing for Money and Power PsychPharmacology Szasz and the Myth of Mental Illness Clinical Update, January 2008 Cinema Therapy with Children and Adolescents A young grieving child who is struggling with loss may beneifit from watching The Lion King, as it may help him or her gain hope and understand the importance of relying on supportive friends and adults. Suggest films like Bend It Like Beckham, Whale Rider or Free Willy, to a child struggling with anxiety or low self-esteem as such films may help the child develop self-compassion and hope. Invite bored and lost adolescents to watch any of the Star Wars movies to help them gain hope and to help them see that even the most difficult situations can be salvageable. Let a child whose parents have recently separated or divorced watch Mrs. Doubtfire, Stepmom, or The Parent Trap and learn that families can transform in positive ways as they move through crisis. Movies are much more than entertainment.  Given their attraction for young people, and the profound impact they often have, movies can help build a bridge to self-understanding.  Many young people identify so strongly with the storylines and characters of such movies as Star Wars and Harry Potter, that they purchase products related to the movies, dress as their favorite characters, set up camps and stand in line for hours in front of theaters.  They spend countless hours talking to friends in school, on cell phones or over the internet, discussing their strong identifications in depth.   Therefore, these young clients often come to therapy primed by this process: they tend to be more attentive and naturally cooperative during the therapeutic hour when clinicians make use of their interest in films by using Cinema Therapy.   Acknowledging cinema as a powerful resource for therapy with our young clients, or the children of our clients, we have added a new online course (5 CE Credits), Cinema Therapy with Children and Adolescents. This is the fifth in a series of online courses, written by Dr. Birgit Wolz, using movies for clinical purposes. All five online courses (25 CE Credits) can be purchased with the Movie Lover Package. Cinema Therapy can be an effective therapeutic tool in work with young clients:  Cinema Therapy can be incorporated into therapy with young individuals, their families, and into group therapy. Movies can be employed in conjunction with depth psychotherapy, cognitive behavioral, and systems-oriented therapies, among others. Assessment In children's and adolescents' choice of movies, therapists may find clues to their working role models, ideal self-images, internal resources, potential goals and perceived obstacles. In addition to the standard assessment, clients may be asked to name films they like and explain what they like about these movies. Observing young clients' responses to movies may help therapists understand their personalities, concerns, interests or their current problems.  Facilitating Communication Whereas adults more easily find the words to talk about problems, thoughts, or emotions in psychotherapy, most children and adolescents find it difficult to adequately express themselves. By referencing movie characters and familiar dramatic vignettes, children and adolescents may reflect on their own internal process while maintaining a necessary emotional distance from stressful or frightening topics. Films often provide a common ground for discussions about problems related to family, friends, school, anxiety, love and more. Rapport can develop faster with Cinema Therapy, as movies speak a familiar language which is less intimidating than psychological jargon. Client resistance can dissolve when young clients become curious when the therapist suggests that they watch a movie. Learning by Example Movies present young viewers with best and worst case scenarios as characters get in and out of various predicaments. Antagonists, enemies and villains usually offer cautionary examples of how not to behave. They may help young clients and/or their families learn by proxy why not to behave a certain way. Finding Hope and Possibility Resistance to therapy often results from a feeling of helplessness. Many movies may enable children and adolescents to envision how their own problems might be solved. Watching movie characters and situations may give young clients ideas of how to deal with problems in their own lives. CINEMA THERAPY FOR YOUNG PEOPLE The Lion King may help a child cope with the loss of a family member and learn about responsibility. Bridge to Terabithia may complement the treatment of depression resulting from grief. Bend It Like Beckham may be recommended when a child struggles with anxiety and self-esteem issues. Ever After or The Never-Ending Story may help children learn how to cope with bullies. Whale Rider and Free Willy may help teens develop self-esteem. Mrs. Doubtfire, Stepmom or The Parent Trap may be used for treatment of children struggling with divorce and stepfamily issues. EXAMPLES OF THERAPEUTIC THEMES & MOVIES FOR 7 TO 12 YEAR OLDS Abuse and Molestation: Do You Know the Muffin Man?, Matilda, Radio Flyer Adoption: Harry Potter Series, Losing Isaiah Conflict with Parents: Drop Dead Fred, Pieces of April Coping with Fear: Antz, August Rush, Bambi, The Golden Compass, Miracle on 34th Street, Yentl Ethical Decisions: Beauty and the Beast, Charlie and the Chocolate Factory Peer and Sibling Relationships: ET: The Extra-Terrestrial, Harriet the Spy, The Little Rascals, My Girl, Stand By Me, Mr. Mom Grief and Death: Finding Nemo, The Boy with the Green Hair, Charlotte's Web, Fly Away Home, Heidi, Ponette, The Secret Garden Illness and Disability: The Cure, David and Lisa, The Horse Whisperer, Lorenzo's Oil, Simon Birch Romance and Sexuality: Antz, Big, The Little Rascals, Milk Money Lying: An American Tail, Hook Moving: Alaska, A Home of Our Own, The Sandlot Prejudice: Babe, The Diary of Anne Frank, Dumbo, Pocahontas, Sounder School: Dead Poets' Society, A Little Princess, School of Rock Self-Esteem: A Bug's Life, The Bad News Bears, Chicken Run, The Incredibles, Pollyanna, Rudy, Searching for Bobby Fischer, October Sky Single Parents and Divorce: Author! Author!, Corrina Corrina, Finding Nemo Clinical Update, December 2007 Rethinking "Inherent Power of Therapists" and "Power Imbalance" in Psychotherapy How powerful are therapists, really? Do we actually have all this power over our clients? Are all our clients vulnerable and dependent? Do clients ever have superior power over their therapists? Do clients sometimes harm their therapists?   Dear Colleague, I invite you to start the New Year with a reflection on issues of power in psychotherapy and counseling.  Thoughts and examples from your own practice where clients were or are more powerful than you, as a therapist, are welcome. Please email your comments to drzur@zurinstitute.com. Let us begin with an example: I once worked with an extremely successful, wealthy and highly educated client (J.D., Ph.D., MBA) woman attorney who used to tease me by saying:  "You think you, with your license, degree and professional aura, have all that power over me.  Like so many of your colleagues, you probably believe that with a snap of your fingers you can get me into bed with you.  Let me tell you about power.  I am wealthier than you are and more educated than you are, which gives me more power than you have. Also, I am professionally more successful than you are and, most importantly, with one call to your licensing board I can destroy your reputation and your entire career." Harsh words, but not without truth.  We have all come across the terms power differential or imbalance of power in our professional literature. Ethics and risk management workshops regularly warn us never to abuse the power position that is inherent in our role as therapist.  Mailings from our licensing boards and professional organizations tell us we must always protect our vulnerable clients and never exploit their dependency.  In fact, it is true that our expertise and license give us some power over our clients, and we therapists should never use this power to exploit or harm our clients.  It is also important to acknowledge that many clients seek therapy in a time of crisis and vulnerability. Most seasoned therapists have worked with high-functional, successful, established and powerful clients.  Many of us can also easily recall working with threatening psychopathic or anti-social clients.  The professional literature reports situations in which clinicians have been bullied, threatened and stalked. In recent years, numerous therapists have been reported to licensing boards by disgruntled parents who disagreed with the custody recommendations provided by their therapists.  And then, as experienced attorneys remind us, "You are always one borderline away from losing your license."  Generally, power is the capacity to direct or influence the behavior of others, or the course of events. Unlike the simplistic view of powerful therapists treating powerless clients, in reality power relationships are very complex and multidimensional.   Accordingly, there are many types and forms of power.  Following is an incomplete list of different types of power. Legitimate Power: Kings, judges, policemen, and licensed     psychotherapists have this kind of power. Coercive Power: Capacity to force someone to do something     against his or her will. Expert Power: Related to knowledge and skills that one     acquires via education, degrees, experience, etc. Reference Power: Derives from people admiring or desiring     to be like another person. Reward Power: The ability to give or withhold what another     person wants. Personal Power: Derives from a person's charm,     attractiveness, charisma, force of personality, or one's capacity     to manipulate, elicit guilt or threaten others. So, how powerful are we therapists, really?    In my latest book, Boundaries in Psychotherapy (APA Books, 2007), I wrote on the subject of power: "In the power differential argument against boundary crossing, clients are often portrayed as passive and malleable, even defenseless, perceiving their therapists as strong and superior.  In reality, many therapists work with clients who are much more powerful than they. Some clients are CEOs of large corporations, judges, powerhouse attorneys, master mediators, or successful entrepreneurs. Often, these clients do not regard their therapists as particularly powerful or persuasive, but as professional listeners or facilitators and, indeed, they may, simply by virtue of their roles in life, exert a power and influence of their own over the therapist." Many authors have written on ways that some psychotherapists perpetuate the power imbalance between themselves and their clients.  Good resources include Arnold Lazarus' The Illusion of the Therapist's Power and the Patient's Fragility (Ethics & Behavior, 1994), Thomas Szasz' The Myth of Mental Illness, Robyn Dawes' House of Cards, Paula Kaplan's They Say You're Crazy, and Richard Schwartz' recent piece in Harvard Review of Psychiatry (V 13/5).  See also Manufacturing Victims: What the Psychology Industry is Doing to People by Tana Dineen and my article, DSM and Power. Of course, there is much more to discuss, reflect, argue and debate.  You are invited to e-mail me your brief thoughts and short clinical vignettes at drzur@zurinstitute.com. Please, be very succinct.  I promise to keep your responses anonymous and confidential. Feel free to forward this e-mail to friends and colleagues. Happy New Year! OZ Clinical Update, December 2007 Harm Reduction: A Growing Alternative Paradigm in Substance Abuse Treatment Most therapists have been led to believe the notion that complete abstinence is the best and only treatment for alcohol and other substance abuse.  However, this paradigm has been losing ground for years.   An alternative treatment called harm reduction, or controlled drinking, has been gaining empirical support and wider practice.  This clinical update does not view harm reduction as a better or worse approach than abstinence.  Instead, it aims to educate psychotherapists and other health care providers about another available option for the treatment of substance abuse. Therapists work with a great variety of people with substance abuse problems.  While 12-Step programs and abstinence may be highly appropriate treatments for many clients, they may not be realistic or effective with others.  Proponents of harm reduction point out that therapists who insist upon complete abstinence as the first and only option with all clients are likely to scare people away from seeking any help at all.  Harm reduction focuses on the presenting problems attendant to substance abuse, as well as the substance abuse problem itself.  It addresses substance abuse as one piece of a much larger puzzle.   Almost all clinicians should have a good grasp of harm reduction principles and techniques in order to treat the kinds of people with substance abuse problems who are most likely to walk into our offices. Our latest course Harm Reduction: The Growing Paradigm in Substance Abuse Treatment (2 CE Credits) will help you understand more about harm reduction-what it is and for which clients it is likely to be appropriate. Harm Reduction Recap  Harm reduction is a therapeutic approach aimed at reducing the    negative consequences of drug and alcohol use. It incorporates    a spectrum of strategies from safer use, to managed use to    an intermediate step towards abstinence. Harm reduction strategies meet drug and alcohol users "where    they're at," addressing the circumstances of the substance use and    not simply the use itself. Harm reduction accepts that both licit and illicit drug use are part    of our world and strives to minimize their harmful effects rather    than simply to ignore or condemn them altogether. Harm reduction calls for the non-judgmental, non-coercive    provision of services and treatments to people who use drugs and    alcohol. Harm reduction is not better or worse than abstinence: it's just    different. Some clients may respond best to, and even require,    abstinence.  Some may benefit most with harm reduction.  For yet    other clients, medication and other approaches may be most    appropriate. Harm reduction is another tool for therapy.  A therapist's toolbox    should be equipped with a variety of tools, techniques, and    approaches.  We must remember the saying, "If all you have is a    hammer, then everything you see looks like a nail." A surprising survey reveals that many substance abuse clinicians    and administrators endorse harm reduction techniques, but cannot    practice them because of agency rules and protocols. A harm reduction approach conforms with the most fundamental    precepts of good therapy: respecting the whole person,    establishing an empathic therapeutic alliance, and helping clients    recognize their intrinsic strengths and their motivation to change. Harm reduction even works for many pregnant women, and it may    be the most effective and realistic approach for high school    and college students. Harm reduction has been around for decades but enduring myths    about substance abuse have impeded its research and use. Many    researchers now understand that the disease model of addiction    and substance abuse has limited our thinking about treatment. Several harm reduction techniques have acquired strong empirical    support. Motivational Interviewing, which had its roots in harm reduction    substance abuse treatment, has proven so effective that it is    increasingly used to treat other disorders as well. Some medications used to treat substance abuse work better with    harm reduction, while others work better with abstinence. Researchers have identified several types of alcohol abusers.  They    range from binge-drinking younger people who don't drink often, to    high functioning people with alcohol disorders, to chronic, older    heavy drinkers with co-morbid mood and personality disorders and    severe legal, social and/or financial problems. It seems likely that    the abstention model, which has grown out of the disease    paradigm, is more often appropriate for the most severe type,    whose recurrent relapse drinking over a long period of time results    in an increasingly severe tailspin.  On the other hand, harm    reduction may be a more viable first option with the other, less    severe, types. Clinical Update, November 2007 Fees in Therapy: Dispelling Myths About Fees Most therapists are more comfortable discussing their client's sex life than their investment portfolio, mortgage or credit card debt.  Money and fees present some of the more complex issues facing therapists and clients, especially at the beginning of treatment.  Nevertheless, they tend to be ignored by many therapists who have neither the training nor inclination to explore these issues. In spite of our reluctance to address financial issues, money, like sex and time, often define people in this culture.  Fees issues are one of the parameters that differentiate psychotherapy from friendship and other intimate or loving relationships.   We have just revised, updated and added new articles to the supporting materials of our online course Fees In Therapy (4 CE Credits).  If you have taken the course before, you may take it again in a different licensing renewal cycle.   In my many years of consulting with therapists on private practice and ethics issues, I have discovered large numbers of erroneous beliefs or myths regarding fees in therapy. Following are some myths, faulty beliefs and misstatements about fees in therapy: Fees in therapy do not have clinical meaning but are purely financial. Discussing money issues with clients is tacky and unprofessional. Forgiving clients' debt is unethical. Employing collection agencies to collect debts from clients can take the burden off the therapist and provides a sure way to recuperate the money. "You get what you pay for," and therefore low fees often result in low therapeutic efficacy. Once an insurance company has paid a claim, they cannot require the therapist to return the fees. It is permissible to bill an insurance company for direct reimbursement without requiring the client to pay the co-pay. It is permissible to bill an insurance company for more than your    customary fee. HIPAA mandates that all therapists use electronic billing. Not billing clients is illegal and unethical. Therapists have the right refuse requests from clients to release their records if these clients refuse to pay their outstanding balance. Verbal agreement regarding fees is generally sufficient to comply with ethics guidelines and states' laws. There is no need for a written document regarding fees. Billing records are not part of the clinical records. Sliding scale is below the standard of care. Regardless of a clients' consent, it is unethical and constitutes a breach of privacy if we send the bill to a clients' relative for payments. It is ethical to pay referral fees if the client stays in therapy. No-fee clients do not appreciate therapy as do full fee clients. No-fee agreement is always preferable to bartering. Bartering is always unethical. Bartering for goods (i.e., painting, vegetables) is as risky as bartering for services (i.e., house cleaning, carpentry). All bartering arrangements involve conflict of interest. Bartering is permitted only with poor clients. Allowing a client to accumulate a large debt is always unethical and illegal. Free Resources on Fees in Therapy Guidelines of Fees In Therapy Codes of Ethics on Fees in Therapy ^^Top of Page Clinical Update, September 2007 Turning Love for Movies into Fun, Learning and CE Credits "If one person came home from the movie theater, just one, and saw somebody screaming at empty air on the street corner and related to them differently with understanding, then we would have done our job."    --Akiva Goldsman (screenwriter of A Beautiful Mind) Movies have been widely used for therapeutic and educational purposes. Lately the popular literature, academic articles and dissertations have increasingly focused on the use of movies in psychotherapy. We now have four online courses that use the movies to address the topics of ethics, boundaries, DSM and, of course, cinema therapy.  These courses are offered as a 20 CE credit Movie Lover's Package at http://www.zurinstitute.com/moviesce.html. Films are particularly well-suited as an adjunct tool in therapy and at depicting  psychological phenomena and ethical dilemmas because: The combination of images, music, dialogue, lighting, camera angles, and sound effects in a film mimic thoughts and feelings that occur in our consciousness. The viewer experiences what a character sees and feels. Movies have become the great storehouse for the images that populate the collective unconscious. Many consider movies to be the most influential form of mass communication, because the spectator enters a form of trance, a state of absorption, concentration, and attention, engrossed in the story and the plight of the characters. The camera carries viewers into each scene. Because they perceive events from the inside as if surrounded by the characters in the film, the characters do not have to describe their feelings. Absorbing information through film descriptions brings an entertaining element into the therapeutic or learning process. When we enjoy ourselves, we become emotionally engaged. We heal, grow, and learn more easily and effectively. The diagnosis of mental disorders and the discussion of ethical and legal themes is usually taught using written or oral techniques and material, although using this material can be dry and tedious. Our attention is more engaged when movies are used as a teaching tool, because of our affective response to the vicarious identification with movie characters.  Because popular movies sometimes distort or exaggerate diagnostic symptoms or behaviors in therapeutic settings, they provide material for fruitful discussions and, at times, produce extra learning material. Without concerns about confidentiality, we become privy to a character’s inner thoughts, feelings, and motivations for illustrative “case discussions”. The following four courses are available as a package at http://www.zurinstitute.com/moviesce.html 1.   Cinema Therapy teaches how to use movies effectively in clinical work. 2.   DSM: Diagnoses Seen in Movies deepens your understanding for the DSM by discussing pathologies of film characters. 3.   Therapeutic Boundaries in Films discusses issues, i.e. dual relationships, self-disclosure, gifts, etc. 4.   Therapeutic Ethics in Movies explores ethical questions in general by contemplating ethical dilemmas that are portrayed in popular movies.  Clinical Update, August 2007 End of Life Issues: Facing and Managing Death, Dying and Beyond Our online course on End of Life Issues is available at http://www.zurinstitute.com/endoflifecourse.html. As I was preparing to send out today's Clinical Update, synchronistically, it came to my attention that Costco is selling all kinds of coffins. "The Lady of Guadalupe Casket " goes for $924.99, "The Mother Casket" for $1,299.99, and "In God's Care Casket" sells for only $924.94.  (Rushed orders are available for an extra fee, sorry, no returns.) Obviously, as the Baby Boomers inevitably face their parents' and their own deaths attitudes and commerce are drastically changing in regard to death and dying. In the United States, it is said that there are two great fears rarely spoken of in polite company: Death and insanity. Insanity can be avoided and treated. Death makes no room for either avoidance or treatment. We all die and there is no cure. Most of us stay away from the dying and the specter of death until a family member, dear friend or neighbor gets terminally ill or suffers from a fatal accident. Then there we are, usually totally unprepared the first time. Since Elisabeth Kubler-Ross' groundbreaking work in 1969 on death and dying, there has been much more research done on end-of-life physical, psychological and social processes. Dr. Kevorkian and the tragic case of Terry Schiavo have also brought the question of "How do we die?" into the forefront of our awareness. Some of the issues, which demand attention include the following:   Medical Science can prolong life almost indefinitely leaving us faced with ethical and moral dilemmas that, heretofore, were not before us. People just died without the heroic, extreme, extraordinary measures taken to keep them alive. People are paying much more attention to how we die and want to have some control over how they end their life. Death is certain. Dying is not a beautiful or romantic process and may even be repulsive. The dying and their wishes are frequently ignored rather than recognized. We want to know what death is, but cannot truly understand it beyond the fleeting "near-death" experiences reported by a few. By the year 2050, people over 85 are expected to make up 24% of older persons and 5%, numbering over 19 million, of the entire population in the United States. Currently, three-quarters of those people who die yearly are older adults. Older adults want information about advance directives, palliative and hospice care and how to die comfortably at home. Most older adults fear pain, being alone when they die and that their wishes will be ignored by health practitioners. There are many ways to die: Natural death of old age, accidents, suicide, homicide, incurable disease, deaths surrounding birth and war, terrorism and execution. Family members are increasingly becoming the frontline caregivers for their older parents or other relatives. Consequently, they are also the primary caregivers during the dying process. What do caregivers (professional, paraprofessional and family) need to know? Curative care is disease-specific and restorative in principle. Palliative care is symptom-oriented and supportive in nature. Hospice care is an extension of palliative care and focuses on preparing, at all levels (physical, social, emotional, spiritual and economic), for death. There many questions associated with death and dying, most of which cannot be answered. These include: "How long will the patient live?" "Can the patient die at home?" "When will professional assistance be used, if at all?" "How can one recognize that death is near?" "What are the signs that death is imminent?" "How does one know for certain that the person has died?" Some of the issues considered by caregivers as death approaches include whether or not to engage or stop extraordinary lifesaving measures, whether to make plans for assisted or non-assisted suicide, whether or not to stop feeding or hydration, and whether or not to make substantial changes in a will or the disposition of the estate. No two people suffer bereavement in the same way. Grief begins before the person dies and even the dying person grieves. The circumstances of death, the age of the dying person and our relationship with that person all influence bereavement. Grief is an intense, bewildering and convoluted experience, filled with a plethora of emotions that can last a long time. Culture and ethnicity greatly impact the decisions and rituals associated with death and dying. When caregivers or providers are culturally different from a dying person or the family, there may be barriers to communication and understanding. Terminal illness, the prolongation of life in the very old, the administration of curative, palliative and, finally, hospice care, and how death occurs are fraught with profound and serious moral and ethical considerations, among them assisted suicide and euthanasia. Caregivers and providers must have an understanding of all of these issues and terms in order to be effective and helpful in the process. The Karen Ann Quinlan case many years ago and the more recent Terry Schiavo case demonstrate that these ethical and moral considerations and consequent decisions are filled with personal pain, questioning, doubt, outrage, indignation and social disagreement and divisiveness. Euthanasia is a medical treatment in the Netherlands and Belgium and assisted suicide is a medical treatment in the Netherlands, Belgium and Oregon. In the United Kingdom, the British Medical Association’s ethics committee in May 2006 recommended that doctors end the lives of some patients “swiftly, humanely and without guilt”. Advance planning for the dying can be a complex process. Having working knowledge of “advance directives”, “living wills”, “durable power of attorney for health care”, and the “protective medical decisions document” is imperative for a clinician who spends time with dying clients. Beyond the legal matters, clinicians have to have clarity regarding their own ethical, moral, and spiritual biases. Most of the world’s spiritual traditions, Jewish, Hindu, Islam, Christian, Jain, Sikh, Buddhist, Taoist, Native American and Indigenous religions, Maya, Animist, Humanist, Agnostic, Atheist and other more obscure beliefs concern themselves with what happens before death, at death and after death. Some say that there is no soul or afterlife. Nevertheless, we are time-space creatures; that is to say, since we are here now, we were always going to be here and when we die, we will always have been in our particular space-time. Catholic faith strives to grow a civilization of love in the middle of a culture of death and says that there are two extremes to be avoided: Deliberate ending of life actively or passively; that is, lethal injection or withholding care with the intention of causing death or to prolong life at all costs not realizing that death is not always a defeat, but the end of the natural process of life. Central to Buddhist teachings about life and death is the concept of impermanence. Form is emptiness and emptiness is form. Death is everywhere all the time and all things pass away. The Tibetan Book of the Dead, or The Great Liberation by Hearing in the Intermediate States, reveals the secrets of enlightened living and life after death. The first complete English translation was recently published in 2006. ^^Top of Page Clinical Update, August 2007 Google Factor: Therapists' Self-Disclosure on the Web Our online course on Self-Disclosure is available at http://www.zurinstitute.com/selfdisclosurecourse.html Traditionally, the professional literature has discussed three types of self-disclosure: 1. Deliberate self-disclosure includes therapists intentionally disclosing, to clients, personal information about their marital status, spiritual orientation, music preferences, political affiliation, etc.  Deliberate self-disclosure also includes information posted by the therapist on their own, and other, Web sites. 2.    Unavoidable self-disclosure includes a wide range of possibilities, such as the therapist's gender, age, physical attributes, disabilities, visible tattoos, obesity, manner of dress, wedding rings, etc. Therapists, who practice in small or rural communities or on college campuses, encounter additional significant unavoidable self-disclosure. 3.    Accidental self-disclosure occurs when there are incidental-unplanned encounters outside the office, or spontaneous verbal or non-verbal reactions. 4. Deliberate but unintentional disclosure occurs when therapists post certain information online. One example is when therapists post information online about their clients while neither getting releases nor adequately concealing their clients’ identities. Other deliberate but unintentional types of disclosures are when therapists condone fraud and illegal activities on the Internet. (For more information on this issue, go to Dr. Riolo’s web page at http://www.youradvocateonline.com.) What And How Clients May Find Information About Their Therapists: In the past, intrusive clients were known to have searched and found their therapist’s home address, marital status or who deliberately, or criminally, stalked their therapists.  The meaning of stalking has radically expanded with the introduction of Internet Search Engines such as Google, and thousands of for-fee services that would find almost anything a client might desire to know about their therapist. What clients can find using a simple Google search to locate online information not deliberately posted by the therapist:  Home address, home or unlisted phone numbers, a personal e-mail address. Licensing Board’s sanctions or complaints. Family members, family trees, or sexual orientation. Volunteer activities and community involvement. Professional activities and membership in professional organizations. Political affiliation and political petitions signed. With a click of a (Google) mouse clients can find their therapists' writings on a variety of Web sites and personal blogs and therapists' own blogs. Other clients’ and peoples’ writings’ about the therapist on a variety of Web sites and personal blogs. These include ex-clients’ complaints, grievances, grouses, cavils, quibbles, grumbles; charging accusations, criticism; IF YOU ARE NOT SURE WHAT ELSE CLIENTS CAN FIND ABOUT YOU, GO TO GOOGLE AND ENTER YOUR NAME.   Ways in which clients can join social networks and find very personal info about their therapists: With a click of a mouse clients can join online social networks, such as Tribe.net, MySpace.com and Facebook.com. Ways in which clients can join social networks, such as Facebook or MySpace, and find personal information about their therapists: a) Clients can "friend" their therapists online, and gain access to all sorts of information, including relationship status, religious views, hobbies and even favorite songs. b) Clients can also read their therapists' blogs, if their therapists use their real names.  Other clients are able to find the identity behind the screenname; those savvy in research may have little trouble at all.  IF YOU WANT TO FIND OUT HOW EASY IT IS TO JOIN SUCH SOCIAL NETWORKS AND FIND INFORMATION ABOUT PEOPLE, JOIN ONE OR TWO AND SEE FOR YOURSELF. What information clients can obtain about their therapists by paying for specialized online background checks: Financial information, including credit reports, debts, liens, Bankruptcies, etc. Criminal records. Small claims civil judgments. Past and present law suites. Marriages and divorces; including divorce records and allegations of domestic violence or molestation. Ownership of property and businesses. Tax information, such as taxes paid and tax liens. Cell phone records, including a 10-year history with available listed phone numbers! IF YOU DO NOT BELIEVE THIS, SIMPLY GO TO GOOGLE AND TYPE “BACKGROUND CHECK” AND SEE WHAT COMES UP. Ways that clients can locate information online about their therapists’ professional lives and what their therapist are posting on listservs and in chatrooms: Clients can often join professional listservs and chatrooms with rather simple pseudo-names.  Often no one checks. On many listservs anyone can join.  This information is then given, from these open sites, to “invitation only” listservs.  Although there may be a registration form required, often all that is requested is: name, business name, address, phone number, E-mail address, and area of practice.  The information is rarely checked for honesty or accuracy.    It is rare that more than 10% of list members post with any regularity and some never do. So therapists, at best, have no information regarding the remaining 90% of people on the list. To make it even easier to learn about someone who posts on lists, some list owners/ moderators insist that one also post one’s name, credentials and location, i.e., city and state, as a signature.  That, of course, would make it easier to Google someone. Some listserv moderators invite participants to present cases online. As a result, clients who deceptively join such listservs, may be privy to information about the therapists’ other clients, and perhaps the details of their own treatment.  Even when the listserv’s moderator appropriately disguises the identity of the client, the clients may recognize themselves in the details, as they also might if someone they know is in treatment with the same therapist. Clients, who join such listservs, may detect information regarding their therapist, illegally or unethically, committing insurance fraud, charging high co-pays, etc. In short clients can learn lot about a particular therapist, as well as the private information of his or her clients, from their comments on listservs. This information, accurate, or inaccurate, may be available indefinitely. Reflections on clients’ search for information regarding their therapists and differences between: Curiosity: Clients’ curiosity about their therapists when they Google them or check their therapists’ professional web site. This search may yield professional orientation of therapists, training, etc. Due diligence or thorough search: Clients who are more seriously looking for information about their therapists. This “due diligence” or thorough approach may include searching the licensing board’s web site to see if their potential therapist had any complaints filed against him or her. It is important to honor clients’ wishes to learn about the people whom they wish to trust and learn from and not to confuse due diligence search with intrusive search. Intrusive search: Clients may ‘push the envelope’ and intrusively search for information about their therapists. They may search for home address or to identify martial status or family members, etc. This may also include disguising one’s identity and joining social networks, listservs, etc., in order to find information about therapists; paying for an online service which legally gathers information about the therapist that is not readily available online. This may include divorce or other court records that are considered public records. Illegal search: Hiring online services, which illegally gather information about the therapist. Such information may include cell phone records and tax records. Note about therapists searching for information about their clients: The above four categories are equally applied to therapists’ ways of finding out information about their clients. Therapists may be generally curious about their clients and try a simple quick Google search to see if anything significant is revealed. If therapists are concerned about their clients, they may search more carefully on issues of criminality, litigious situations, such as past board complaints or lawsuits. Of course, the intrusive and illegal searches are applied to therapists as they do to clients. An example is when a therapist, who is willing to run a bill and carry a debt, may choose to run a credit check on the client with the client’s permission. What therapists should pay attention to when it comes to Internet disclosure: Assume that EVERYTHING that you post online, whether it is on your own web site, private or public blogs, listserves, online bulletin boards, chats, social networks, etc may be read by your clients. Be very careful in discussing case studies online and make sure that you either get permission from the client to discuss it, or make sure that identifying information is removed or changed.  In HIPAA terminology make sure you 'de-identify' your clients' identity. Be aware that your clients may read what you have posted as advice to other therapists in consultation regarding their own cases. Your clients may then draw conclusions based upon what you proposed, or even take the information personally. If you find out that a client or potential client has acted in an intrusive manner in regard to online searching, think about the clinical, ethical and legal ramifications, document your concern, respond appropriately, and, if necessary, seek consultation. Google yourself periodically so you are aware of what your clients may be privy to.  Google yourself using different combinations of name and degree, such as "Mark Smith, Ph.D.," "M. Smith, Ph.D.," "Dr. Smith," etc. If , in your search, you find private information about yourself that you do not want to be public, or misinformation that you want to correct,  find out whether you can have it removed. If the information was obtained or posted illegally or is defamatory, it is more likely that the therapist can remove this information by contacting the web site master and the server who either take the information off line or shut off the web site all together. However, if the therapists put the information online themselves, it may be harder to remove. Clinical Update, August 2007 DSM: Diagnoses Seen in Movies Learning about the DSM with fun and the movies or What can movies teach us about diagnosis? Movies are particularly well suited to depict psychological phenomena. The combination of images, music, dialogue, lighting, camera angles, and sound effects in a film mimic thoughts and feelings that occur in our consciousness. Since characters in many popular films portray persons who live with mental disorders, these depictions offer a unique learning opportunity. A new online course on the DSM: Diagnoses Seen in Movies at: http://www.zurinstitute.com/dsmandmoviescourse.html Following are a few examples of how movies illuminate the multifaceted nature of mental disorders and can help us use the DSM for effective treatment planning, and communicating with colleagues as well as with insurance companies. A Beautiful Mind offers a powerful opportunity to understand Schizophrenia. As Good As it Gets demonstrates almost every possible symptom of Obsessive Compulsive Disorder. Analyze This introduces Panic Disorder and in a humorous fashion. Annie Hall illuminates Anxiety Disorder. Mr. Jones offers the opportunity to learn about many aspects of Bipolar Disorder as well as about the differences between this disorder and Schizophrenia. Mad Love depicts a character with symptoms of Cyclothymic Disorder. Girl Interrupted invites us to discus Major Depression and the complexities of differential diagnosis. The Hospital offers an opportunity to learn about Dysthymic Disorder. In Country depicts a Vietnam War veteran with severe Posttraumatic Stress Disorder. Affliction demonstrates Alcohol Abuse and Dependence. Blow portrays Cocaine Abuse and Dependence. Play Misty for Me helps us understand Borderline Personality Disorder. Wall Street depicts Narcissistic Personality Disorder. Dying to Dance illumines Anorexia. Freeway II: Confessions of a Trickbaby demonstrates Bulimia. Brassed Off illustrates Adjustment Disorder. Clinical Update, July 2007 Cybersex Addiction & Internet Infidelity Our online course on Cybersex Addiction & Internet Infidelity is available at http://www.zurinstitute.com/cybersexcourse.html Cybersex addiction and Internet infidelity are the two most common forms of Internet addiction. Clinicians are seeing a growing number of clients addicted to Internet pornography or couples experiencing trouble because of online affairs. This course shows you specialized techniques in treating these new clinical problems. This course reviews the signs of Internet infidelity, how they develop, and how they differ from offline affairs. You will also learn specialized counseling techniques to help couples improve communication and repair broken trust after an online affair. As Internet sexuality is evolving as quickly as the technology itself, this course shows therapists how to diagnose cybersex addiction, the risk factors involved, the stages of development, and advanced techniques in treatment. Here are some of the most common facts about cybersex addiction and Internet infidelity. With the multitude and abundance of sexually explicit material online, addiction to online pornography has become the crack cocaine of the Internet. Internet Porn Statistics showed there are about 4.2 million pornographic websites constituting 12 % of the total websites. The pornographic pages constitute 372 million hits and daily pornographic search engine requests range to 68 million or 25 % of total search engine requests. Beyond online pornography, users can engage in sexually explicit adult chat rooms. Fantasy role-play rooms exist online with names like, “Hot Sex” “Bondage” or “Black Men for White Women”. With this type of access, cyberspace allows people to dabble, experiment, and explore sexual feelings and indulge in private fantasies unique to the online environment. Online sex is unique and qualitatively different than other forms of sexual behavior. The addict’s preoccupation with sexual arousal stems from his or her own imagination and fantasy history that once unlocked can be difficult to put back inside the bottle. Cybersex addiction can be hidden by overt signs of depression and anxiety, masking how much a client spends online. Therapists often overlook the symptoms of Internet addiction such that the disorder goes undetected, making related problems worsen. Over 60% of cybersex addicts have not previously suffered from a history of sexually addictive behavior until they discovered the Internet. Among many online addicts, cybersex is perceived as the ultimate safe sex method to fulfill sexual urges without fear of disease such as AIDS or herpes. Cybersex addiction can lead to divorce, marital separation, and job loss. Among couples, cybersex addiction and Internet infidelity are leading causes of divorce. Internet infidelity can impact older adults as well as new couples and cause the same kind of pain and devastation as if the affair occurred in the physical world. Treatment for cybersex addiction utilizes cognitive-behavioral techniques specialized to meet the needs of moderating appropriate computer use with a focus on abstinence from problematic online applications. This new 4 credit CE course will teach you How to diagnose and screen for cybersex addiction. How cybersex addiction impacts individuals and couples. How to identify the warning signs of Internet infidelity. How to work with couples after an online affair. How online sex differs from other forms of sexually addictive behavior. How cybersex can be a healthy way for individuals to explore new forms of their sexuality. How online sex can unlock new or hidden sexual fantasies. How to apply behavioral therapy for symptom management with cybersex- addicted clients. How to apply cognitive-therapy to treat cybersex-addicted clients. How to moderate a client’s computer use and manage relapse. How to access self-help resources for clients addicted to the Internet. Clinical Update, May 2007 Depression: The Therapist's Toolkit Our new 9 CE credit online course on Depression is available at http://zurinstitute.com/depressioncourse.html Depression: The Therapist's Toolkit Depression, the most common mood disorder, probably affects a majority of people who seek psychotherapy--whether they come in for depression or not. Therapists who have only one or two treatments in their toolkit will successfully treat only about 2/3 of their depressed clients. Depression in children: how it looks different than adult depression. Is combination therapy--meds plus therapy--really the best treatment for depression? A wider variety of therapies and non-pharmacological treatments than ever before have been proven effective for treating depression. Successful therapists match the best treatment to each individual depressed client. Therefore, it follows that the therapists most successful at treating depression will have the widest repertoire of treatments and ideas. Pregnant women and new mothers are often at increased risk for depression. Research has shown that, at times, it is hard to distinguish antidepressant withdrawal from the return of depression. They can seem the same with unfortunate and even disastrous consequences for your clients. Depression is also caused by situational factors, such as external threat and stress, racism, pace of life and many other environmental factors.  Depression can be rooted in people's inability to deal with existential issues, such as grief and lack of meaning, or in people experiencing a spiritual void. To escape depression, expert suggest, get out of the head and into the gym. As a biopsychosocial disorder, depression has many different causes and symptoms. Learn about them from behavioral, psychodynamic, existential and biological perspectives. Research has shown that relationship-based and psychodynamic therapies work as well as CBT. This course will teach you to The different approaches to the etiology and treatment of depression. To distinguish antidepressant withdrawal from the return of depression as they can seem the same, and to read pharmaceutical research without being misled. How effective are antidepressants? How do you weigh the risks and benefits of antidepressants? What's the story on omega-3 (fish oil) and St. John's wort? Should you use cognitive therapy, behavioral therapy or cognitive behavioral therapy? Or none of them. How new mothers' depression affects their infants. How to access and use self-help resources for your depressed clients. Clinical Update, May 2007 Bipolar Disorder: The Disorder, Its Treatments and Alternative Views Bipolar disorder is also known as bipolar affective disorder and manic depression.  Like diabetes or heart disease, Bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.  It is a disorder that brings up the question, "Is it possible to have too much of a good thing?" The experience of mania raises interesting questions about whether positive emotions, such as joy or exuberance, can be pushed to extremes where they lose their adaptive or prosocial qualities.  Intriguingly, Bipolar is linked with exceptional creativity during periods of good functioning. Dr. Jamison, in An Unquiet Mind, called it "an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering..." Our new  7 CE credit online course on Bipolar Disorder, Bipolar Disorder: The Disorder, Its Treatments and Alternative Views, is available at: http://zurinstitute.com/bipolarcourse.html. Bipolar -- Recap: Bipolar disorder, also known as manic-depressive illness, causes unusual shifts in a person's mood, energy and ability to function. People on the "high" side of bipolar disorder may feel on top of things, productive, sociable and self-confident. Many people have described the "high" of hypomania as feeling better than at any other time in their lives, but the feelings are exaggerated. They often cannot understand why anyone would call their experience abnormal or part of a disorder. There is no cure for Bipolar disorder, and the best pharmacological treatments often are not very effective because of problems with adherence and compliance. Different from the normal ups and downs that everyone goes through, the symptoms of Bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. Like other mental illnesses, Bipolar disorder cannot yet be identified physiologically, for example, through a blood test or a brain scan. Therefore, a diagnosis of Bipolar disorder is made on the basis of symptoms, course of illness and history. Bipolar disorder can be treated, and people with this illness can lead full and productive lives.  Medications are considered mood stabilizers if they have two properties: They provide relief from acute episodes of mania or depression or prevent them from occurring; and they do not worsen depression or mania or lead to increased cycling. Lithium and Depakote have been shown to fulfill this definition.  Other meds were originally developed as anticonvulsants for the control of epilepsy. Other available medications that are undergoing research as promising mood stabilizers include several new anticonvulsants and the newer, "atypical" antipsychotics. More than 2 million Americans in any given year have Bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. More than half of adults affected with Bipolar disorder had their mood disorder begin at age 16 or younger. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Bipolar I refers to a condition in which people have experienced one or more episodes of mania. Though an episode of depression is not necessary for a diagnosis of Bipolar I, most people who have bipolar I will have episodes of both mania and depression. Bipolar II refers to a condition in which people have had at least one hypomanic episode. The diagnosis in general and the rate of the disorder for children, as with ADHD, is highly debatable. Signs and symptoms of mania (or a manic episode) include: increased energy, activity and restlessness; excessively high, overly good, euphoric mood; extreme irritability; racing thoughts and talking very fast, jumping from one idea to another; distractibility, can't concentrate; little sleep needed; unrealistic beliefs in one's abilities and powers; poor judgment; spending sprees; increased sexual drive; abuse of drugs, particularly cocaine, alcohol and sleeping medications; provocative, intrusive or aggressive behavior; denial that anything is wrong. A mild to moderate level of mania is called hypomania. This may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus, even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment hypomania can become severe mania in some people or can switch into depression. Episodes of mania and depression typically recur across the life span. Between episodes most people with bipolar disorder are free of symptoms, but as many as one-third have some residual symptoms. "Pills do not come with skills," and psychoeducation and psychotherapy are important ways of building positive skills to improve relationships, promote academic and vocational success, and produce better coping mechanisms and quality of life. Cognitive behavioral therapy helps people with Bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness. Psychoeducation involves teaching people with Bipolar disorder about the illness, its treatment and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation is often helpful for family members. Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms. Clinical Update, April 2007 Boundaries and the Movies: Learning about Therapeutic Boundaries through Movies Our new (second) 6 CE credit online course on Ethics & Movies, Boundaries and the Movies: Learning about therapeutic Boundaries through Movies, is available at: http://www.zurinstitute.com/boundariesandmoviescourse.html Course fulfills the Law and Ethics Requirement. Themes in movies have long shown a fascination with therapeutic boundaries.  While many movies portray therapists as wacky, greedy and sexually predatory, many other movies deal sensitively with the everyday therapeutic and clinical complexities that we face. Following are a few examples of how movies illuminate ethical complexities and can help us navigate through them in our practices. Antwone Fisher illuminates the therapist's need for flexibility regarding treatment decisions, the value of inviting a patient to a family dinner or calling a patient "son." Good Will Hunting stimulates a rather heated discussion on the ethical complexities of the use of language, physical touch, getting in one's face, sessions outside the office and many other therapeutic boundaries.  Gross Point Blank demonstrates how important it is to inform clients about limits of confidentiality as early as is feasible in the therapeutic relationship.  It also reminds us that sometimes clients can easily instill fear in us, therapists.  The myth of the therapist's omnipotence is challenged. Deconstructing Harry hilariously illuminates for us the potential hazards of the home office. Dressed to Kill invites us to explore the complexities of gift giving and how gifts, which are formulated as a planned intervention, can be ethically appropriate and therapeutically valuable. What About Bob? reminds us how important it is to set boundaries with an overbearing and highly intrusive (but funny) client. The movie shows us how to try to deal with our anger, and to being intruded upon, in the best possible ways. Ordinary People invites us to consider how decisions about the therapist's physical proximity to his client can support a treatment goal. Prince of Tides teaches us about the ethics of sexual relationships with a client's brother. Basic Instinct illustrates the fact that some clients, in some situations, can gain significant power over their therapist with whom they have sexual relationships. Prime demonstrates the surprises and messes that are often unavoidable in our practices.  It proves that dual relationships do not occur only in rural communities and how risk-benefit analysis and consultation can help navigate complicated and unexpected clinical situations.  Frances exemplifies how the inappropriate use of language can lead to a boundary violation.  K-Pax illuminates the importance of consultation and collateral information in understanding the client.  It also demonstrates how physically restraining a client may be necessary to protect the client from him/herself or others. Stay brings up the question of sexual relationships with former clients. It shows how long after termination it is appropriate to get involved and the kind of situation one should never, sexually, get involved in with former clients. The first Ethics-Movies I covers: Confidentiality, Self-Disclosure, Touch, Dual Relationships and Out-Of-Office Experiences (i.e., home visits, in-vivo exposures, attending a wedding, incidental encounters, etc.) and is available at http://www.zurinstitute.com/moviesethicscourse.html The new Ethics-Movies II covers: Informed Consent, Gifts, Home Office, Clothing, Language, Humor and Silence, Proximity and Distance between therapist and client, and, finally, Sexual Relations, and is available at http://www.zurinstitute.com/boundariesandmoviescourse.html   Clinical Update, April 2007 Supervision II: Advanced Topics, Ethics & Law A new (second) 6 CE credit online course on Clinical Supervision is available at: http://www.zurinstitute.com/supervisionadvcourse.html Course fulfills BOTH the Supervision and the Law and Ethics Requirements On Supervision and Mentoring: Some form of supervision, mentoring, or apprenticeship exists in most fields.  Historically, it has been the elders who have provided training and guidance to those with less experience. Whether this mentoring is for the skilled craftsperson (Blacksmiths, Musicians, Jewelers, Carpenters) or professional (Financial Advisors, Psychotherapists, Physicians), this form of assistance enhances both the individual and the community at large.  However, attention to the process of clinical supervision as a distinct area of inquiry is relatively new. Many movies depict different types of profound mentoring relationships. They include, Full proof monk, Seabiscuit, Star wars, The Guardian, Billy Elliot, Dead Poet Society, Harry Potter, Officer & Gentleman, Lord of the Rings, Zoro, The Emperor's Club or The Last Samurai.  (Future course on supervision will focus on mentoring relationships in the movies.) Supervision is defined as the collaborative relationship that exists between a clinician of advanced education and experience and a clinician who is less experienced and often unlicensed. Within the supervisory relationship, the senior, or supervising, clinician is responsible for the oversight, management, evaluation and clinical liability of the junior clinician, or trainee. The primary goals for supervision are: 1. To prepare the trainee to practice independently 2. To advance the status of the trainee from Novice to Master 3. To ensure the safety of the general public by performing consistent and comprehensive evaluation of the trainee The Purpose of supervision is to provide the trainee with: - Education - Training in: Nature of the profession; Theoretical understanding; Research and how to evaluate it; Critical Thinking; and Enhancement of clinical skills - Corrections or revisions of any poor clinical habits, misconceptions, or therapeutic techniques - Professional skills: Networking, Marketing - Burnout prevention strategies - Ethical risk management strategies - Clinical "container" that limits risk for the consumers - Professional growth Supervision increases comfort and confidence in the trainee The process of supervision can enable the trainee to identify his/her strengths and weaknesses, as well as ways to perform optimally As gatekeepers to the profession, it is imperative that the supervisory relationship be educational & evaluative Unfortunately, it is very challenging to assess the effectiveness of clinical supervision! This intermediate-advanced course on Clinical Supervision will teach clinicians to: Identify optimal qualities and skills in both supervisor and supervisee Select a personal style for supervision Enhance creativity as a supervisor Manage challenging people and situations in the supervision process Demonstrate ethically-driven decision-making skills The new 6 CE credit course on Supervision II is at http://www.zurinstitute.com/supervisionadvcourse.html. The original, more basic, 6 CE credit Supervision I course is at http://www.zurinstitute.com/clinicalsupervisioncourse.html. Clinical Update, March 2007 Schizophrenia: Analysis of the Disorder, its Treatment and...its Detractors For a 6 CE credit online course on Schizophrenia: click here. Schizophrenia has been one the most puzzling, disturbing and fascinating mental illnesses of all time, which affects nearly one percent of Americans. Historically, individuals with Schizophrenia were thought to have "split personalities."  Eventually, clinicians came to recognize clear differences between Schizophrenia and Dissociative Identity Disorder.  Now, those in the general population have an even clearer understanding of the nature of Schizophrenia as a result of exposure to films such as "A Beautiful Mind," "Clean, Shaven" and "The Fisher King." Even with improved awareness in both clinical and general populations, there is still active debate about the illness and its diagnosis and treatment.  For my view of the "Village" and Community of Care go to http://www.zurinstitute.com/villageformentallyill.html.   Schizophrenia -- Recap: Schizophrenia is a chronic, severe and disabling brain disorder that affects about one percent of Americans. While schizophrenia occurs in 1 percent of the general population, it is seen in 10 percent of people with a first-degree relative who has the disease. Research has shown that schizophrenia affects men and women equally and occurs at similar rates in all ethnic groups around the world. The modern term, "Schizophrenia," comes from the Greek word "shjzofre'neja," meaning "split mind." Despite misunderstanding by much of our population, schizophrenia is neither "split personality" nor "multiple personality." Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect and sense of self. Due to the disabling "voices" that many schizophrenic people hear, it can be very difficult for them to maintain a job or even manage consistent self-care. As such, the burden on their families and society is significant. The National Institutes of Health says the total costs of the illness approach $30 billion to $65 billion annually. Individuals with schizophrenia may experience positive, negative or cognitive symptoms, all of which can inhibit normal function. Psychotic symptoms (such as hallucinations and delusions) usually emerge in men in their late teens and early 20s and in women in their mid 20s to early 30s. They seldom occur after age 45 and only rarely before puberty. While many of the older antipsychotic medications, such as Thorazine, were associated with adverse side effects, such as Tardive Diskinesia (TD), there are many antipsychotics available today that have far fewer side effects. TD is primarily characterized by random movements in the tongue, lips or jaw, as well as facial grimacing, movements of arms, legs, fingers and toes, or even swaying movements of the trunk or hips. TD can be quite embarrassing to the affected patient when in public. The movements disappear during sleep. They can be mild, moderate or severe. Some of the atypical antipsychotics currently in use include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). Each has a unique side effect profile, but in general, these medications are better tolerated than the earlier drugs. The risk of suicide amongst those with schizophrenia is far higher than in the general population.  And, while Clozaril is associated with several serious side effects, it is one of the only anti-psychotics that effectively reduces the risk of suicide in schizophrenic patients. Some of the atypical antipsychotics can be administered by injection, reducing the risk that the patient will "forget" their daily or twice daily medications. A study in the New England Journal of Medicine found that 74% of the patients in the study discontinued antipsychotic medication before the end of their treatment due to inefficacy, intolerable side effects or other reasons. One FDA Public Health Advisory warned that elderly patients with behavioral disturbances who were being treated with atypical antipsychotics ran a significantly higher risk for death than folks not being treated with antipsychotics. Studies out of the United Kingdom suggest that CBT can be an effective tool for diminishing delusions, as well as for reducing the experience of voices in those with schizophrenia. There are numerous studies suggesting that patients treated with neuroleptics receive more hospitalization than those not treated with neuroleptics.  Contemporary researchers and clinicians regard recovery from schizophrenia not only as the cessation of symptoms but also as the development of new meaning and purpose as one grows beyond the catastrophe of mental illness.  While there is no known cure for schizophrenia, the recovery model provides new hope for those with this disease. Facilities that provide psychosocial rehabilitation provide patients with work and social skills training, education about their disease and why medications are important, symptom management and, often, therapy for dealing with the trauma of having schizophrenia.  There are nearly 4,000 such facilities across the country. In the words of R.D. Laing, "Madness need not be all breakdown. It may also be breakthrough. It is potential liberation and renewal as well