Sunday, October 3, 2010

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OUCH OUCH: “Hanging up on Dr. Laura”

The Los Angeles Times recently published a letter to the editor from Eugene Strull, a physician, commenting on the recent brouhaha about “Dr. Laura” (Laura Schlesinger, radio personality).

Dr. Strull pointed out, "Any doctor of psychology who is qualified to treat patients would never make a diagnosis and offer advice after allowing the patient only a minute or two to present their problems."

True, true, oh so true! The "ouch" is the pain that I share with other psychologists when a radio show host is incorrectly assumed to be a psychologist. The antics of a radio show host “advising” callers who have problems and truly need help is painful to hear for any psychologist. This is doubly true when the callers, listeners, news broadcasters and even physicians such as Dr. Strull think that the radio personality is a psychologist.

“Dr. Laura” does not claim to be a psychologist; she is not licensed to practice psychology, and she is running an entertainment show. Like any other entertainment show, the purpose is to generate a large audience and to make it commercially successful. I presume that she uses the title, "Dr. Laura" because she has a Ph.D. degree in physiology. Since she is giving people personal advice, it is understandable that people assume that “Dr. Laura” means a doctor of psychology. To my knowledge she has never claimed to be a psychologist.

There have been a myriad of radio and television personalities who entertain audiences by delving into the personal problems of people and offering advice. This tradition goes back to the original “Dear Abby” and “Ann Landers” newspaper columns. They entertained their readers with wit and they made astute observations about human nature but they were never mistaken for professional psychologists.

The "Dr. Laura" and "Dr. Phil" formats can be immensely successful as mass media enterprises because we are all naturally fascinated by people and their problems. However, most psychologists would be skeptical of the possibility of successfully entertaining an audience, abandoning the principle of privacy in a counseling or psychotherapeutic relationship and at the same time providing ethical and effective professional services in the field of psychology.

So, when you listen to or watch such shows, remember that it is an entertainment show and by all means, do not use it as a personal guideline to follow in your own life.

Tuesday, September 28, 2010

Counseling Online: Skype, e-mail, Text, Telephone

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Counseling online or psychotherapy online:

Is it safe? Is it effective? Is your privacy protected? Who is the counselor or psychologist? How do I know if the on line counselor is competent, ethical, well trained or a licensed professional?

Counseling online and psychotherapy online are exciting new possibilities as methods of providing psychotherapy, marriage counseling, family counseling and relationship counseling.
The convenience of being able to get help in the comfort of your own home, without the bother of commuting to a therapist’s office, without hassling travel, traffic and parking is certainly appealing. This is especially true for people with busy schedules, or living at a distance from the psychologist’s or counselor’s office, or people with transportation or babysitting problems. Should you consider counseling online instead of in a traditional face to face in office visit? We do have some pretty good guidelines for you to use to answer this question for yourself.

You want to make sure that the elements needed for effective counseling or psychotherapy are being provided to you.
Some elements are so well established that they are part of professional codes of conduct written into state civil codes, federal law, or the ethical codes of professional bodies such as the American Psychological Association.

For example, we know that protecting the privacy of communication in a counseling or psychotherapeutic relationship is, for many reasons, an absolute requirement for success. A few other well established requirements for psychologists or marriage counselors are as follows.

We must start with a thorough psychological assessment of problems, strengths, weaknesses and risk factors. We must not only listen to what is said; we must pay attention to tone of voice and nonverbal cues such as facial expressions, hand gestures, bodily posture, and leg movements. Sometimes a slight redness in the eyes allows the therapist to address important feelings of sadness that a person is struggling to suppress. Jiggling feet, tapping fingers or slumped shoulders are all very important clues to the therapist in understanding correctly what a person is experiencing. All of these forms of nonverbal communication are easily observed in traditional face to face counseling or psychotherapeutic sessions.

We must adhere to a formal professional code of ethics as a proven guideline to ensuring the mandate to “do no harm” and to maximize our ability to provide effective help.
One way of assuring these requirements is licensure by a state board that sets professionally agreed upon standards for training and knowledge. Different states have different requirements and examinations to obtain a professional license to practice in that state. It is both a legal and ethical requirement that a psychologist or marriage counselor practice only within the state of his or her professional licensure.

How do these principles apply to the question of doing psychotherapy or counseling online?
The most promising new technology is the use of video/audio communication. New computers come with build in webcams and people are “Skyping” each other routinely. Using this type of technology, the online counselor or therapist is able both to hear and see the person he or she is treating. Does this mean that we can now effectively, privately, and safely offer our professional services electronically? So far, such a technology has major drawbacks.

The confidentiality and privacy issue is a serious problem. The level of encryption presently available for practical real-time counseling online cannot ensure that these personal sessions are not intercepted by a third party. Accidental or intentional invasion of privacy is a danger.

The effectiveness of the therapist or counselor online is impaired because the facial expression, or the look in a person's eyes cannot be observed with adequate clarity. Furthermore, the posture, gestures and body language are completely excluded from the video field. With present technology, the tone of voice and the video itself is subject to distortion or even interruption at crucial moments due to technology failures.
In addition we do not yet have the research results to validate the effectiveness of such “long distance” counseling online and we do not yet have training programs established to allow counselors or psychotherapists to develop the skills necessary to conduct psychotherapy or counseling online therapy.

Although it is tempting to provide counseling online, or psychotherapy on line, these drawbacks raise serious questions about the ethics of a professional counselor or psychotherapist attempting to provide such services.

Some therapists have decided to “just do it,” and are providing treatment by e-mail or by webcam video programs right now. There are plenty of such internet sites available online in a credit card pay-per-minute format. It is hard to rationalize that such a counseling or treatment method meets current professional standards for all of the reasons discussed above. Some of these sites do not even provide the names, training or licensure of the online counselors and therapists, which prevents the public from verifying their qualifications. Many such online counselors are licensed to practice in one state, but are providing services to people in other states or even across national borders. This is clearly an ethical violation. If a counselor or therapist is breaking an important ethical rule, one cannot have much confidence in the quality of professional services he or she is providing

Another concern is the level of knowledge that the therapist has of the community where the person lives, local social issues, customs, sub cultural issues, idiomatic expressions and community resources that are available. A counselor or therapist practicing within his or her own community is likely to have a good understanding of these issues. On the other hand, a therapist in Manhattan or Beverly Hills would be at a disadvantage in understanding and helping a person or family in rural Texas

The potential for offering professional services such as counseling online or therapy online has been of great interest to professional organizations in the field of psychology, and it has been of great personal interest to me. I have followed developments in this field closely and have attended some professional conferences and workshops on this subject. The information I am providing here is based on presentations by experts in this field at the American Psychological Association annual Meetings held August 12 -15, 2010 in San Diego, California .

At these meetings, it was indicated that the issue of how to develop the capability to provide such services effectively and ethically is being addressed on an ongoing basis, but that we do not yet have acceptable answers and solutions available.

Telephone, E-mail and Text Counseling or Psychotherapy
Of course, there has always been the option of offering consultation by telephone, but restriction to voice only communication has been a big drawback. The obvious disadvantages of communicating verbally only, without the important visual dimension allowing the therapist and patient to see facial expressions, body language, gestures and movements have made this a limited an inferior option. Telephone communication by a land line might meet the criterion of privacy, but a determined eavesdropper can tap a phone line. More problematic is the use of cordless phones or cell phones, which certainly can result in accidental or “hacked” interception of communication.

Some therapists have offered professional advice via e-mail, or by text messaging, but this eliminates the nuances of meaning communicated by the sound of one’s voice, limiting communications even further. In addition, email and texting are unencrypted and can be easily intercepted, thereby eliminating the privacy and confidentiality of communication between patient and counselor or therapist. This obviously could make matters worse for the patient and it is an ethical violation for a psychologist to communicate in a way that does not ensure privacy.

Conclusions, Research, Clinical Trials and Future Developments
In this rapidly evolving electronic age it is indeed tempting to use internet communication for counseling online. However, professional ethical standards require us to make sure that we are doing something that has been proven to be helpful, and above all, something that will not harm our patients.

Research methods testing the effectiveness of new methods of treatment cannot keep up with the technology, and require time to assess the outcome of new methods. Some possible research approaches could be based upon the use of “clinical trials.” This approach is used in medicine to conduct research on new methods of treatment. Such trials can be used only when all proven forms of treatment have been exhausted. It would be reasonable to apply the same standard to counseling online or psychotherapy online.

One clinical trial research possibility would be to provide such services only to people who live in isolated communities that do not have psychologists or counselors available. Another clinical trial might be to provide such services to military personal in combat zones where face to face treatment is not available. In these cases we would not be running the ethical risk of providing sub-standard professional services when proven methods of service are available.

Monday, June 28, 2010


For More Information Visit my Website at WWW.PSYCHOLOGYDOC.COM

Disclaimer: It is possible for a psychologist to analyze someone only by working with him personally as a patient. For this reason, my comments about public or historical figures are intended only as illustrations of general psychological principles that apply to the human condition and an expression of how one psychologist views the world.

In my last Blog, I discussed the concept of the “agitator in the factory being a man in rebellion against his father.” This same concept could be applied to the interaction between President Obama and General Stanley McChrystal, a sequence of events that was exhaustively reported in the news.

Military authority could be described, psychologically as being based upon a powerful and rigid system of paternalistic control by higher ranked individuals over lower ranked individuals. This is the usual structure that is found in military organizations throughout history.

The relationship between the President of the United States, and Generals of the U.S. Military is clearly structured in military terms of authority, command and control.

I was drafted for military service when I was a graduate student in psychology at UCLA. I clearly remember that we were asked, in basic training, to name our Commander-in-Chief. None of us knew the answer, but I assumed that it was some high ranking army general on base at Fort Ord, or some member of the Joint Chiefs of Staff in Washington D.C. I was astonished to discover that the President of the United States was in fact the Commander-in-Chief of all of the U.S. Armed Forces. This explicit specification reflects the determination of the Founding Fathers to establish firm civilian control over the military.

General Stanley McChrystal was called on the carpet by President Obama, and ultimately ousted from his command because of his failure to respect this quintessential American principle of complete military respect for civilian authority.

Article 88 of the Uniform Code of Military Justice is titled: “Contempt Toward Officials” It states: “Any commissioned officer who uses contemptuous words against the President, the Vice President, Congress, the Secretary of Defense, the Secretary of a military department, the Secretary of Transportation, or the Governor or legislature of any State, Territory, Commonwealth, or possession in which he is on duty or present shall be punished as a court-martial may direct.”

Certainly we know that General McChrystal, like any officer of the U.S. military is aware of this rule, which is a specific application of the general rule that requires all enlisted men or officers of lower rank to respect the authority of higher ranking officers.

So why would he make such public verbal blunders as “Bite me” for Biden, etc? I know nothing at all about General McChrystal’s personal background and would not presume to “analyze” his personality based upon news reports. But a psychologist would say that such a foolish lapse of judgment in such a bright, accomplished, successful and knowledgeable military man is unexpected, to say the least.

These events could serve as an example of the kind of mistakes we all make, though they are played out on a smaller stage for most of us. In general, we find that uncharacteristic lapses in judgment are not the result of conscious planning, that they appear to be irrationally determined, and that they are based upon unconscious motivation. (Sigmund Freud discussed this issue long ago in his “Psychopathology of Everyday Life.”)

Without having any specific knowledge about a public figure’s personal history, a psychologist does know that every human being, including General McChrystal and this Blogger, shares one common experience: we have all started as helpless, ignorant children in relationships with parental figures who were, by comparison, wise, knowledgeable and powerful. And we all have struggled in growing up to achieve a level of knowledge and power equal to or greater than our parents.

Mark Twain captured the essence of this struggle against parental authority in the following observation. “When I was a boy of fourteen, my father was so ignorant I could hardly stand to have the old man around. But when I got to be twenty-one, I was astonished by how much he'd learned in seven years.”

Many a foolish word has been spoken, and many a foolish action has been taken, that has been motivated by powerful unconscious thoughts and feelings related to this common human experience of struggling against our parents from the position of ignorance and helplessness of childhood.

In this case, the shockingly unexpected statements that have put General McChrystal’s military career in jeopardy may be related to the historical parent-child dynamic experienced by all of us as described above. Could his unfortunate indiscretion be related to an unconscious need to rebel against the father figure represented by civilian authorities above him? There is no way of knowing whether this dynamic, or some other motive, sources of stress, or other unknown psychological factors account for his mistake.

But we do know that he has put himself in the position of being referred to as the “Runaway General” precisely because he failed to restrain himself in his public utterances as is required by his position under civilian authority.

My Blog on "The Girl With the Dragon Tattoo" will be forthcoming.

Saturday, June 26, 2010


For More Information Visit my Website at WWW.PSYCHOLOGYDOC.COM

Disclaimer: It is possible for a psychologist to analyze someone only by working with him personally as a patient. For this reason, my comments about public or historical figures will be intended only as illustrations of general psychological principles that apply to the human condition and an expression of how a psychologist may view the world.

Sigmund Freud is reputed to have said to a group of industrialists, "Show me the agitator in your factory, and I will show you a man who is in rebellion against his father." I am not at all sure if this is a correct quotation of Dr. Freud, who, incidentally, was right about many things and wrong about many things. However, the quotation provides good material to illustrate how a psychologist views human behavior.

For example it does make sense, psychologically, to speculate that an "agitator" in a factory may be driven, unconsciously, in his behavior by memories of having been unfairly treated by his father. Such experiences could indeed generate feelings of anger and rebelliousness against all paternal authority figures, including his employer. However, this does not mean that the rebellion of the "agitator" in the factory has no justifiable basis for his complaint. It may indeed be true that there are real health or safety issues, or unfairness in how the factory is run.

To speculate about the inner personal psychodynamics of human behavior does not in any way undermine the validity of the external circumstances addressed.

Psychologists talk about "multiple determination" of behavior. The human mind is extremely complex; it is not like a light switch, or the basic component of a computer, both of which have only an "on" and "off" position. Therefore we might say that a person who is psychologically "in rebellion against his father" may indeed be more highly motivated to rebel against some real unfairness in his adult world. In this case, we might say that two of the "multiple determinants" of the agitator's behavior are the actual unfairness in the factory, and the unconscious rebellion against his father.

Be sure to view my next Blog, "President Obama and General McChrystal" from the Blog Archive in column on right.
Next Blog Coming: "The Girl With The Dragon Tattoo"