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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 25. This is the beginning of the thread.
Posted by gazo on May 28, 2007, at 9:52:06
Now, for anyone and everyone who feels a need to express their incredulation or other intense opinions regarding the individual therapy process can debate it here, without interrupting the care and support of members who are not interested in such debates or issues.
Go ahead... here is the place to have at it, with civility, of course.
gift giving, hugging, schools of thought, home visitation, self disclosure and on and on and on...
have fun and play safe
Posted by pegasus on May 28, 2007, at 10:20:05
In reply to here you go... the ethics thread, posted by gazo on May 28, 2007, at 9:52:06
There's a great article on therapeutic boundary crossings in the latest issue of Psychotherapy Networker. You can find it here:
-peg
Posted by Dinah on May 28, 2007, at 10:56:25
In reply to Re: here you go... the ethics thread, posted by pegasus on May 28, 2007, at 10:20:05
I'm having trouble accessing the link. Which issue was it in? What was the name of the article?
Posted by crushedout on May 28, 2007, at 11:21:29
In reply to Re: here you go... the ethics thread » pegasus, posted by Dinah on May 28, 2007, at 10:56:25
I'm having trouble, too. I get the link open but no text appears.
Posted by twinleaf on May 28, 2007, at 11:29:46
In reply to here you go... the ethics thread, posted by gazo on May 28, 2007, at 9:52:06
I think that the different schools of therapy, such as the interpersonal and interactive versus the more traditional ones, are not as important as the relationship that develops between a particular therapist and a particular client. There are some basic givens- the type of person each really is is probably the most important; we all have to work within that- a rather introverted, cautious therapist is not going to change very much in the process of conducting therapy, although the client may. We are so lucky if we happen on a "good fit".
Things like gift-giving, and even phone calls, e-mails and notes, as well as spontaneous affectionate comments, might be considered "boundary crossings"- not violations- by some therapists, and not at all by others. It's so clear from a number of posts here that all of these things can be very meaningful in therapy- to both therapist and client. All the good things that happen seem to arise out of a relationship which is already strong, trusting and warm (or at times when it may not be, the possibility is there to talk it all out so as to get back on track.)
I have been to two psychoanalysts, and, although I think they as a group are gradually becoming more interactiive and spontaneous, I do think they are the ones most likely to have been trained to not receive gifts, notes, e-mails, etc. I have never had the impulse to give a gift, as I kind of know they won't receive it, and will want me to talk about why I wanted to give it. That's a little sad, as they become so important to you, and you want to find ways to let them know how much you appreciate your relationship with them, and what they are helping you to do. One thing, by way of compensation, is that, with all their training, they are the world's best listeners- whatever on earth you find yourself feeling or saying, you feel that they are listening with their entire minds and hearts- and that is very validating- being so deeply heard. Of course, analysts don't have a monopoly on that; I'm sure all good therapists, whatever their training and point of view, do that.
I think, too, that each therapist has to make careful judgements as to what is best for each cient, and it will probably be slightly different for each. For example, a therapist will have to be very careful about allowing regression to occur with clients who have had very inadequate or neglectful mothering early in life. Each boundary crossing, such as gift-giving, spending extra time, etc., may cause the client to, consciously or not, hope that that terrible early situation will be made right by the therapist. He/she can do this partially, and to an extent, in good therapy, but never entirely. It's not going to help, and may even be damaging, if the client comes to feel that it can be.
Another area which can be quite tricky: clients who have low sexual self-esteem often feel the need to have everyone in their environment consider them sexy, so maybe they'll be able to, also.. A little bit of implicit sexual interest and regard by the therapist can be helpful - he's standing in for the unappreciative father- but if it goes too far, it will lead to inevitable feelings of disappointment, rejection and even lower self-eseem. I won't comment on sexual affairs with therapists here, as those are outright boundary violations, which we all know are very wrong. I think this topic- what constitutes a boundary crossing, and when they are, or are not, helpful- is a great one. I hope lots of people will contribute!
Posted by crushedout on May 28, 2007, at 11:37:33
In reply to Re: here you go... the ethics thread » Dinah, posted by crushedout on May 28, 2007, at 11:21:29
I think I found the abstract by searching the archives here:but you have to pay to read the entire article. I'm not sure how much.
Posted by Phillipa on May 28, 2007, at 11:51:56
In reply to Re: here you go... the ethics thread, posted by twinleaf on May 28, 2007, at 11:29:46
I just one who listens to me and understands my past which is a long time ago but it influences everthing today. I'd love a psychoanalysist. Love Phillipa
Posted by twinleaf on May 28, 2007, at 12:10:10
In reply to Re: here you go... the ethics thread » twinleaf, posted by Phillipa on May 28, 2007, at 11:51:56
I really prefer them, too- despite my recent bad experience, which I do think may have been due to ilness. I have very wonderful memories of how he dealt with me prior to that. Can't you get one? You can get all the names on Google by looking up APssa and seeing who the qualified analysts are in your area. And most of them don't see people five days a week any longer; it's so expensive, and I think they feel they can help people just as much with fewer visits. The cost is high, but no higher than most good psychotherapists. Many, though not all, will take Medicare, if you have it-up to two visits per year for the entire year. That way, it costs you nothing!
Posted by twinleaf on May 28, 2007, at 12:22:58
In reply to Re: here you go... the ethics thread » Phillipa, posted by twinleaf on May 28, 2007, at 12:10:10
I meant two visits a week for each year.
Posted by Dinah on May 28, 2007, at 12:42:37
In reply to Re: here you go... the ethics thread, posted by crushedout on May 28, 2007, at 11:37:33
That was a very specific circumstance, and I think my therapist would respond similarly to it. I'm not altogether sure I'd want him to come, but that would be something we discuss, I suppose.
I think it might also be found by looking at the current issue, and it's the last article.
Posted by Dinah on May 28, 2007, at 13:14:49
In reply to here you go... the ethics thread, posted by gazo on May 28, 2007, at 9:52:06
How about seduction? If you look it up in the spellchecker here, it says:
seduction
One entry found for seduction.
Main Entry: se·duc·tion
Pronunciation: si-'d&k-sh&n
Function: noun
Etymology: Middle French, from Late Latin seduction-, seductio, from Latin, act of leading aside, from seducere
1 : the act of seducing; especially : the enticement of a person to sexual intercourse
2 : something that seduces : TEMPTATION
3 : something that attracts or charmClearly it's not appropriate for a therapist to entice a client to sexual intercourse.
But while my therapist disapproves of seductiveness of therapists towards clients, in a nonsexual sense, I can definitely see times where he himself is seductive, in that same nonsexual sense.
Is that necessarily a bad thing? In version three of the definition, say. To attract or charm. Isn't that part of how they do what they do? Well, I suppose they could prod and needle, but that wouldn't work overly well with me.
Yet how about when the seduction is done to strengthen the attachment? Is that a bad thing? A good thing?
What sort of things do therapists do to seduce?
Clearly this isn't a therapeutic issue only. But does it have extra meaning in therapy?
Certainly I'm guilty of doing it, in the innocent little girl to *good* Daddy (who doesn't abuse it) sort of way. But it seems sort of natural in the developmental stages way for a client to do it. What if the therapist allows himself (or herself) to be seduced? Surely that's a good thing in some ways, if it doesn't go too far? Or is it?
It's a kind of hard thing to tease out sometimes. If I feel seduced, is he being seductive? To be clear, I don't feel seduced all that often or in that many situations in my life. But sometimes I feel a tug towards him that doesn't seem to be generated by me. And sometimes if I look at his actions in that moment, I can see what he's done that could provoke it. Of course, that doesn't mean that his intent was to provoke it.
Posted by twinleaf on May 28, 2007, at 14:26:29
In reply to Re: here you go... the ethics thread, posted by Dinah on May 28, 2007, at 13:14:49
Assuming we are just talking about mild forms of seductiveness, aren't they just a nice part of life? One could use other words- respect, caring, interest, an awareness of the ways the other person may be appealling or attractive. I think the key is that they have to arise naturally, and be genuine- on both the therapist's and the client's sides. If seductiveness is used more as a technique, without real feeling behind it, I think both people eventually know it. Then it could be harmful, as it will remind the client, and perhaps the therapist, too, of times in childhood when they felt unappreciated or demeaned. I think the main thing we all hope for in therapy is to feel valued, respected and cared about despite revealing the things we feel the worst about ourselves. Little warm, unexpected moments- hearing good things we didn't expect-can feel wonderful- a "safe seductiveness."
Posted by DAisym on May 28, 2007, at 16:14:06
In reply to Re: here you go... the ethics thread » Dinah, posted by twinleaf on May 28, 2007, at 14:26:29
I think one of the areas that therapists lack training about is around attachment. I believe this is changing, as we have more and more research about it, but many of those in private practice today see adult attachment as pathological and something to be avoided. They structure their boundaries based on this view, and this gets reinforced when the client pushes their boundaries. Instead of examining their decisions in the context of this client and this therapy, the "one size fits all" mentality kicks in and/or the "give an inch, take a mile..." worry flares up.
Therapy can cause an attachment crisis for adults. It is a painful splitting apart of defenses and at its worse, you feel completely fragmented and exposed. It is in these really raw times that a good therapist will think about how his/her boundaries are hurting or helping a particular client. Otherwise the client now feels bad about yet another thing - breaking the rules of therapy by wanting some flexibility in the boundaries. Again, holding tight to a boundary might be the most beneficial thing - but it might not be. For example: if the separation anxiety is huge, talking about it and working on ways to manage it seems a lot more beneficial than "just" clamping down and tightening up the boundaries. Do therapist really think that the feelings will just go away if they don't respond to them? I often wonder why so much psychological literature gives thought to how not to be taken advantage of by the client. This hardly feels strength-based to me and I think it sets up a dynamic between client and therapist in which everything is suspect - do all words, actions, noises and sneezes have double (and negative) meanings? (Freud would say yes...)
It must be scary for the therapist on some level to really feel the client's pull to merge; I can understand why so many therapists work hard to not allow these "regressed" feelings into the room. It truly can be dangerous for some people, because letting go of those defenses at the wrong time, or under the wrong circumstances, could result in a psychic break.
I guess I'm thinking that boundaries change from therapist to therapist, depending on whether it is short or long term therapy and whether it is CBT or psychoanalytically driven -- but that basic ethics don't change. Ethically the therapist understands the power imbalance and keeps this well in mind when making decisions. Sexual liaisons are usually harmful, so an ethical therapist avoids them, even if they know of cases when it was helpful not hurtful. Who can know ahead of time? Ethical therapists do what they say they are going to do and mean what they say. And I believe the bottom line is that ethical therapists strive to be helpful and take their role seriously. They don't have some secret pocket of contempt for the "weakness" of clients whom they judge to all be manipulative in some way or another. Instead they see suffering and the potential for change and they respond with hope and kindness.
Posted by sleepygirl on May 28, 2007, at 16:27:20
In reply to here you go... the ethics thread, posted by gazo on May 28, 2007, at 9:52:06
>gift giving, hugging, schools of thought, home visitation, self disclosure and on and on and on...
well...I don't think I'd be comfortable getting a gift from my T, it would be strange I think-gifts are a tricky thing in general with anyone,
but I do like giving gifts to my T, ones that are reflective of the therapeutic relationship or the therapy in general.self-disclosure....now I don't really want TOO much of that from my T, but at the right times it can be helpful to see a real human being, and not just a person I kind of "create" with transference.
I think certain types of self-disclosure on the part of a T can become a burden to a client.
I start to feel guilty because I don't ask a lot of personal questions of my T, like maybe he thinks I'm not interested, that I don't care. But then the therapy relationship would be more about him, and not so much about me. So, it's kind of better for me that my T really limits what he'll say about himself, so I don't have to worry about it so much. Besides all my guessing in the absence of a lot of info is better grist for the mill.hugging....it depends, and probably only very occasionally if appropriate at all
-sg
Posted by gazo on May 28, 2007, at 17:45:06
In reply to Re: here you go... the ethics thread, posted by DAisym on May 28, 2007, at 16:14:06
i have been pondering this Daisy. My pdoc has some psychotherapy training, as i assume most of them do, but he doesn't practice as a therapist so he is limited that way i feel. His ideas seem rigid and antiquated to me. He knows i had an infatuation with my old T and he seemed to think that was problematic had i continued. But now my new T doesn't think so at all, he was the first to say that he felt it could have been a very productive thing to explore... and i agree. As attached as i was i was keen to understand it's deeper meanings and dissect it... just never had the chance. i feel it could have unraveled quite a lot about myself.
i think that is why therapy has to be individualized based on the abilities and limitations of *both* client and therapist. Some patients couldn't handle such attachment, and neither could some therapists... others are not capable of deeper self awareness needed.
All the current literature espouses the harmful and deep damage done to clients by sexual contact... and it's easy to understand how that is. But, what i find more interesting is the virtual irradication from the archives of writings from a while ago which explored otherwise. John Mcartney and James Martin (i think this is the right name) both thought sexual contact was therapeutic. Martin, if i have that name right, wrote "The Love Treatment" and Mcartney sought authorization from clients and families for sexual treatment. The weird thing is that these writings are just plain gone... at least everywhere i have looked... i did find an old copy of the book online somewhere but not in any library i have tried, even through interlibrary loan... and certainly not in medical libraries. The articles regarding what Mcartney called "overt transference" are not there either. Weird. i mean, right or wrong, should the information still be available?
If anyone is able to find access to that article and could bmail me the text i'd be very happy. i just finished reading Exploitation in Psychotherapy and i am very interested. Mostly because i am exporing that transference i felt myself. i am told it is transference, and that acting on it would have damaged me.. and i want to learn about that as well as my own roots of the thoughts/feelings.
Posted by gazo on May 28, 2007, at 17:57:09
In reply to Re: here you go... the ethics thread, posted by sleepygirl on May 28, 2007, at 16:27:20
this is the thing i think Yalom did do well in his book The Gift of Psychotherapy. i disliked his writing otherwise but i liked his thoughts on disclosure, etc.
My cultural heritage is steeped in gift-giving. It would be akin to asking the Japanese not to bow. You give small gifts to people of certain roles... doctors are pretty high in that line. It isn't the same sentiment as in other gift giving, as with friends. There isn't any illusion of intimacy from what i experience in it. It is completely common for people in my home area (not where i am now)it is common and expected really that one gives these gifts. Generally they are homemade things like pies, cookies, etc. You don't do it all the time, but intermittently and is seen as bad form not to, esp at times like xmas.
hmmm.. the classical PA's have always had trouble with not addressing cultural factors. Afterall, Freud's "sample" were all white, affluent northern europeans. And it is still the case that the majority of therapy clients are more affluent.. in Canada it is not covered through healthcare so you need private insurance which most people don't have, and in the US good insurance typically comes with a good job.
just thoughts
Posted by sleepygirl on May 28, 2007, at 22:40:05
In reply to Re: here you go... the ethics thread, posted by DAisym on May 28, 2007, at 16:14:06
>They don't have some secret pocket of contempt for the "weakness" of clients whom they judge to all be manipulative in some way or another. Instead they see suffering and the potential for change and they respond with hope and kindness.
You make a lot of sense, and I do think that a lot of people in mental health are lacking in their understanding about attachment.
It's a vulnerable place to go to you know? Attachment I suppose is what everything else orbits around. It can be intense and frightening, but so very basic.
Posted by muffled on May 28, 2007, at 22:53:05
In reply to Re: here you go... the ethics thread » DAisym, posted by sleepygirl on May 28, 2007, at 22:40:05
and hard and scarey and all that FOR SURE.
I admire those who allow attach.
I start to but freak and run.
Guess boundaries keep attach more safe for all.
So confusing.
Terribly confusing.
Guess thats where T supposed to make it safe place for clients.
Safe.
Big word.
You guys say good stuff.
M
Posted by pegasus on May 28, 2007, at 22:58:31
In reply to Re: here you go... the ethics thread, posted by pegasus on May 28, 2007, at 10:20:05
Sorry about that. You can get to it if you go to the main Psychotherapy Networker site at www.psychotherapynetworker.org, then look on the left side at the May/June issue. In the Featured Articles list, choose Table of Contents. At the bottom of that page, you'll find the article called Family Matters by Dea Silbertrust. That's the one.
Peg
Posted by Honore on May 29, 2007, at 9:54:18
In reply to Re: here you go... the ethics thread, posted by crushedout on May 28, 2007, at 11:37:33
Here's the fee structure for the Networker articles:
"Purchase Options
Psychotherapy Networker Annual Pass (100 Articles) $59.95
Psychotherapy Networker 3 Month Pass (40 Articles) $29.95
Psychotherapy Networker Month Pass (20 Articles) $19.95
Psychotherapy Networker 24-Hour Pass (5 Articles) $5.95
Psychotherapy Networker Article Purchase $2.50Each article is available to you for 90 days from the date that you first view it.
* Best Value: $59.95 Annual Pass
Buy an Annual Pass to the Psychotherapy Networker online archives for only $59.95. Select up to 100 articles while your annual pass is active.* Even Better Value: $29.95 3 Month Pass
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Buy a Month Pass to the Psychotherapy Networker online archives for only $19.95. Select up to 20 articles while your month pass is active.* Good Value: $5.95 24-Hour Pass
Buy a 24-Hour Pass to the Psychotherapy Networker online archives for only $5.95. Select up to 5 articles while your 24-hour pass is active.* Single Article: $2.50
You can purchase Psychotherapy Networker articles for just $2.50 each.Select any purchase icon on the Search Results or Free Preview page and you'll be taken to the purchase page for that item."Honore
Posted by pegasus on May 29, 2007, at 12:57:24
In reply to Re: here you go... the ethics thread, posted by Honore on May 29, 2007, at 9:54:18
But for their current issue you can view the articles for free on their web site. Don't pay for it! I just ran across the article while surfing the other day. It's there right now in their May/June issue.
I promise I haven't paid a dime to read these. I don't have a subscription.
And there are a number of other interesting articles as well.
peg
Posted by Honore on May 29, 2007, at 17:23:30
In reply to Re: here you go... the ethics thread, posted by pegasus on May 29, 2007, at 12:57:24
There's been a theoretical difference between things Ts do to create a "therapeutic alliance" and things that are considered seductive. I suppose you could see the line as being blurred at some points-- but at the same time, conceptually, I would think attentiveness, kindness, carefulness, reliability and things like that wouldn't be considered seductive.
There's always been this idea in classical analysis-- at least in the modern American version of it-- that if you are too gratifying-- whatever that means-- that it induces or fosters dependence-- which could mean that the patient doesnt' confront and work through certain conflicts, but is able to avoid them through fantasies that the T can magically make things better, or fulfill the patient's needs. Then the patient doesn't have to deal with limitations, non-fulfillment of unrealistic dreams and beliefs, or losses-- etc.
So I think there really is a separation between seductiveness-- which could be sexual, but goes far beyond that-- and ordinary decency and respect. Or other things that create a therapeutic environment.
I guess As who reject the acceptance of gifts, or cultivate a certain kind of neutrality tend to see things as primarily working through of drives or internal conflict, and believe that a so-called real relationship is not the primary vehicle of any cure. Other Ts, who believe that the relationship is more real, or like that outside of therapy, although it is different in certain respects, tend to be more interested in attachment, or the ability of the T to provide some degree of reparation or better experience, rather than to allow the P to work out purely internal struggles. For those Ts, accepting gifts could easily be seen a providing a new experience of acceptance and valuing what a P can contribute-- whereas in more classical analysis, that would be considered a harmful enactment. (But then the word "enactment" also has taken on positive meanings in more recent analytic writing, whereas in classical American analysis, it had a very negative meaning.)
Honore
Posted by DAisym on May 29, 2007, at 19:35:27
In reply to Re: here you go... the ethics thread, posted by Honore on May 29, 2007, at 17:23:30
>>>There's always been this idea in classical analysis-- at least in the modern American version of it-- that if you are too gratifying-- whatever that means-- that it induces or fosters dependence-- which could mean that the patient doesnt' confront and work through certain conflicts, but is able to avoid them through fantasies that the T can magically make things better, or fulfill the patient's needs. Then the patient doesn't have to deal with limitations, non-fulfillment of unrealistic dreams and beliefs, or losses-- etc.
<<<My first thought on reading this was, "does anyone really believe that anymore?" But of course they do. I think I am beginning to understand that many of these ideas grew from those treating truly "mentally ill" people - people who might have no judgement or were psychotic or delusional or had some other major pathology going on.
When I think of people who are depressed, or traumatized, some of these "techniques" feel cruel. But I guess that is why ultimately a good therapist understands what his clients need and what he (or she) is capable of giving. Boundaries that are a moving target are, imo, worse than too rigid or too soft.
Great discussion guys!
Posted by gazo on May 29, 2007, at 19:58:02
In reply to Re: here you go... the ethics thread, posted by Honore on May 29, 2007, at 17:23:30
Hi Honore :o)
the question of seduction... hmmm....
> that if you are too gratifying-- whatever that means-- that it induces or fosters dependence--*** now, this exact point worked the opposite way with me i think... and i am putting a lot into examining it myself, i am sure my T will want to as well. The reason i feel i became attracted and dependent to my last T was his resistence to me, his with-holding.. the more he pulled away the more i was lured. THAT is one central issue, or portion of a schema for me.. i am most strongly attracted to and dependent on those who do not give gratification, meaning emotional. The new T i have is very giving emotionally, very animated and has a lot of give and take... and although i like him a lot, and i feel i do need him, i don't feel dependent. The more he tries to reach me the less i want him to....
This is why ideas like schema were developed, for people like me who seem to be opposite to the accepted conventions. i showed my T a dismaying article which referred to such patients (me) as "treatment failures."
> I guess As who reject the acceptance of gifts, or cultivate a certain kind of neutrality tend to see things as primarily working through of drives or internal conflict, and believe that a so-called real relationship is not the primary vehicle of any cure. Other Ts, who believe that the relationship is more real, or like that outside of therapy, although it is different in certain respects, tend to be more interested in attachment, or the ability of the T to provide some degree of reparation or better experience, rather than to allow the P to work out purely internal struggles. For those Ts, accepting gifts could easily be seen a providing a new experience of acceptance and valuing what a P can contribute-- whereas in more classical analysis, that would be considered a harmful enactment. (But then the word "enactment" also has taken on positive meanings in more recent analytic writing, whereas in classical American analysis, it had a very negative meaning.)**i wonder why Yalom feels the way he does about the relationship... he doesn't mention gift giving from what i remember, but he does very strongly insist that the *relationship* is the vehicle of cure. He is PA.
Posted by OzLand on May 29, 2007, at 22:06:23
In reply to Re: here you go... the ethics thread, posted by twinleaf on May 28, 2007, at 11:29:46
I was trained in a psychoanalytic tradition and also have been in analysis in the past. Accepting gifts is a no no; hugs are a no no; if a patient writes a letter or email, it would be accepted but then why was there the need to do this would be analyzed perhaps depending on the degree of illness the patient presents. Doesn't mean that the therapist/analyst does not care; it only means that such things as gifts just complicate the transference which then is not as "pure" so to speak.
This is the end of the thread.
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