Sunday, October 05, 2014

You Are Not A Therapist!

י״א לחודש השביעי תשע״ה

This post offers some of my personal experience to English-speaking psychotherapists immigrating to Israel, or already here, and who intend to work with English speaking clients. Let this serve as a warning as to what you will be up against.

To those therapists operating with some of the "odd" and unethical practices I list and describe below, and to those individuals believing themselves to be therapists, when they are actually not, perhaps this piece will inspire you to do teshuvah (repentance), particularly during this week right after Yom Kippur.

For the purposes of this piece "qualified psychotherapist," will be defined by the following standards:

1. The minimum of a Master's degree in a mental health related field.
2. The minimum of a Master's degree from a school's program, recognized by at least one professional organization, in or even outside of Israel (eg. אגודת פסיכולוגים קליניים, האיגוד הישראלי לפסיכותרפיה, איגוד העובדים הסוציאליים, APA, AAMFT, NASW, NASP, etc.).
3. One who is licensed, credentialed, or certified, or eligible to become one of the above, based on coursework and supervised training.

I believe these standards to be minimal, and have stated them to be as lenient as possible.

Coaches are coaches. Laypeople are laypeople.

Counselors are counselors, and not necessarily psychotherapists. Counselors put on bandages, replace bandages, sometimes even provide alternatives to bandages. They only irrigate the wounds if it is within their training and scope of their practice.

Psychotherapists do surgery, minor or major, according to that which is within their training and scope of their practice.  

This is not to say that counselors, coaches, and even laypeople cannot be "therapeutic." They are simply not therapists.

Buy My Book!
I saw an episode of a television show once, in which a therapist, before beginning her session with a couple, suggested that the couple buy her book.

The sad part was that except for the obligatory comedic punchline at the end of the therapy session, the fictional therapist wasn't half bad.

But, the main point here is the potential conflict of interest in encouraging clients to buy your book. Would they feeling intimidated, guilted, manipulated into buying it? Is the book absolutely necessary to their treatment? Sure, I suppose a therapist could give clients "homework," and sure that homework could be based on the therapist's book. But, there is a slippery slope here, one to be navigated with caution.

Well,...I'm a Rabbi...
Regarding the many members of the clergy who serve in counseling roles. Some are particularly good at it, and some are not. Still, those members of the clergy who seem to have a knack for counseling, are good at, because they recognize not only their own personal strengths, but their limitations as well.

During my graduate studies, I had some contact with two fellow students, one, a Catholic nun, a year ahead of me in her studies, and another, a Christian minister in a parallel program. Both seemed to be very sharp, and had strong theoretical backing to support their approach to treatment, something which I strongly believe to be problematic when absent.

This is most certainly not meant to be an attack, nor even a criticism on members of the clergy, as long as they are working within their role/assigned position, and have been properly trained for role/assigned position.

Once I entered a crowded cafe. I had to ask to share a total stranger's table, not uncommon in Israel. We introduced ourselves to one another, and chatted briefly. When he said that he was a therapist, I immediately asked him where he studied. His response, though, was, "Well, I'm a rabbi...."

I was taken aback. I pursued the issue with, "Well, what's your training?"

His response to this query was, "Both of my parents are therapists."

At that point, I did what I could to close the conversation politely.

Now, in all fairness to this individual, he may actually be a qualified psychotherapist. Perhaps his his degrees, training and experience far surpass my own. Yet, for some reason. But, my experience warns me not to be optimistic. However, based only on the information I received within the span of our brief conversation, I would certainly not consider him to be a psychotherapist.

You should only be treated with MY therapeutic approach. All others are useless.
Funny, I was always taught that "should" statements were irrational beliefs. But, what do I know, right?

Talk about a conflict of interest!

(See also "Referrals? What are those?" below.)

All you need is MY six month course to be a therapist.
I was so shocked to hear that such a statement was made, I cannot even begin to write about this practice with a high level of potential for damage to the mental health of the English speaking public, here in Jerusalem and surrounds...

Would someone please tell me what the heck Clinical Sociology is?
"A subfield of public sociology is applied sociology, also known as clinical sociology or sociological practice, which applies knowledge derived from sociological research to solve societal problems."

OK. So, how does this qualify clinical sociologists as psychotherapists? Counselors, maybe. But, psychotherapists? Unless, of course, this degree could be used as some sort of front for getting around professional scrutiny? Just a thought...

I will leave this one as it is,...for now.

Referrals? What are those?
If I am unable to treat a client, either because I know that I will not be effective in doing so, not probably trained in the particular area of mental health practice required, or even if I am simply not taking on any new clients, I will refer the client to another therapist. My rule of thumb is to provide a list of at least three therapists. I will not just include those who share my theoretical orientation on this list of referrals, either, especially if I am uncertain as to this prospective clients present issue, or for that matter, the real issue or issues requiring attention.

Some people believing themselves to be therapists will unconsciously, or not so unconsciously, miss the boat when it comes to differentiating between genuine "resistance" and the caregiver's own inability to help the client effectively, if at at.

Unfortunately, parnassah (financial support) can be the culprit, blinding them from the truth (See Deut. 16:19). Yet, parnassah is the worst excuse of them all, and not to be tolerated. This care provider will at best, get lucky, and help someone solve a minor problem, or at worst, cause major, even potentially irreparable damage.

When I had finished graduate school, and moved back to my hometown of San Diego, I wanted to continue my own psychotherapy, I had begun inup north, I called the San Diego Association of Psychologists' [SDAP] referral line. The volunteer on the phone asked me to tell her about my interest in finding a therapist. I told her that I wanted to continue my therapy, and added that I was looking for a therapist with a particular theoretical orientation, and who specialized in working with other therapists.

She tentatively included her name on the list. I write tentatively, as she was concerned with even the appearance of a conflict of interest, serving on the referral line in order to add to her own client base. Yet, when I looked her up in the SDAP's members list, I found that she did, indeed, foot the bill of the requirements I stated to her. Nevertheless, she included a fourth referral, and put her name last on the list. I am not sure how better one could have handled the situation, save for silence regarding her practice. However, what if she did turn out to be the best therapist for me? I would have missed out on the opportunity, if she had been silent.

And probably these most insidious, most dangerous, and and most confusing issue facing therapists, both real and fake....

Profession Competence
The topic heading thus far could also be place under this one, "professional competence."

My favorite pet peeve has yet to be listed, and so it will be stated now. It is one in which even well-meaning, really therapists and counselors cross the line, and that is interpreting assessment results, for assessment devices for which he or she has not had the proper training to do so. And quite frankly one graduate course in assessment in simply not sufficient to interpret the Stanford-Binet or Wechsler scales, let alone the Thematic Apperception Test [TAT] or Rorschach. Of the Rorschach test, some have suggested said that it be applied only under supervision for five years. That may sound a bit extreme to some. But, it will hopefully send home the message that assessment devices are not things which can be picked up and used by anyone. And they are most certainly not toys.

Are you an "addictions counselor?" I know several, and some of them are excellent! I believe that is mainly because they deal with "addictions," and they recognize that they are "counselors." They are not marriage therapists, educational psychologists, nor psychiatrists; they are "addictions counselors."

The same goes for "coaches," probably the most out of control, unmonitored profession there is today. Some coaches are excellent. Here is one of my favorites, Dawna Walter from the BBC reality show "Life Laundry," in which she not only helps people declutter their homes, teaches them strategies to stay declutter, and helps them deal with the emotional issues surrounding their clutter and cluttering behavior. In my opinion, her work is definitely therapeutic, but she is not a therapist, and does not try to be one. She stays within her training, experience, and scope of practice.

Unfortunately, not all coaches maintain the same professional ethics that Dawna Walter does, and end up doing a great deal of damage, without having a clue that they have done so.

Dual Role Relationships
You would be amazed, and perhaps even as disgusted as I am, at just how many "therapists" I have encountered, who are completely ignorant of this concept.
Dual relationship 
From Wikipedia, the free encyclopedia

In the mental health field, a dual relationship is a situation where multiple roles exist between a therapist, or other mental health practitioner, and a client.[1] Dual relationships are also referred to as multiple relationships, and these two terms are used interchangeably in the research literature.[1][2] The American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (also referred to as the APA ethics code[3]) is a resource that outlines ethical standards and principles to which practitioners are expected to adhere. Standard 3.05 of the APA ethics code outlines the definition of multiple relationships. Dual or multiple relationships occur when:
  • a professional and personal relationship take place simultaneously between the psychologist and the client
  • the psychologist has a relationship with a person closely related to or connected to their client
  • the psychologist has intentions to enter into a future relationship with the client or someone closely related to the client
In addition, the standard provides a description of when to avoid multiple relationships (e.g., when the relationship causes harm to the client or impairs the psychologist's competence) and when these relationships are not considered unethical (e.g., when the relationship does not exploit the client or impair competence).[4][5][6]
Before you get too excited about those instances when a duel role relationships are not considered unethical, the citations above lead to professional journal articles related to practice in RURAL areas, in order words, when the duty to treat may override a dual role relationship, which has minor implications regarding the impairment of the service providers effectiveness. Last time I checked, Jerusalem was not considered "rural," just loaded with English-speakers calling themselves therapists, who are hard up for work, and who lack the sophisticated level of language skills necessary to work with native Hebrew speakers.

Informed Consent
That's right! Not only must a therapist receive consent from a prospective client, before assessing and/or treating that client. But, the therapist must provide information related to the structure of the assessment and treatment, such as confidentiality. The prospective client [in the State of California, for example] is entitled to know the therapist's education and training, licenses and certifications, and theoretical orientation. So, don't be surprised if a prospective client asks such questions. It is his right.

If you do not have the answers, then you have no business doing what you are doing.

Not only that, but "informed consent" does NOT mean checking out, what you might think to be "analyzing," friends' prospective dates or roommates or employees WITHOUT their knowledge.

Client Endorsement
Ethical or not, I believe this practice to be damnable.

Imagine a therapist who advertises, and has endorsements from clients listed, even anonymously, on his advertisement or brochure. In fact, let's assume, for the sake of argument, that these clients volunteered to provide their therapist with an endorsement, without being solicited.

Let us go a step further, and say that said therapist announces such endorsements at a speaking engagement

What? At the very least, this "therapist" never thought of the implications this would have in the client's therapy? What about the conflict of interest?

Anna Freud might call this a form of "acting-out" of therapy, on the part of the client. I hate to ask what she might say that the therapist was doing.

Of course, if you are not really a therapist, then you have nothing to worry about, do you? All you have to do is to stop calling yourself a therapist.

The Israeli Ministry of Health is overwhelmed, and for the most part, lacks the necessary resources to monitor such individuals, real therapists crossing ethical lines, and fake therapists, leaving a trail of damage, often untraceable and unprovable.

You can see that this list of headings of potential problems here is endless.

I will assume that many of the fake psychotherapists out there have good intentions. However, this reminds me of the proverb...

"The road to hell was paved with good intentions."

Of those real psychotherapists out there, doing one or more of the above, you have absolutely no excuse.

A note on gishur:

After posting the above, I had an afterthought of sorts. What about Gishur?

Roughly translated, gishur is bridge-building, and is used to describe work often done with couples, to assist them with communication.

I have met both members of clergy and attorneys who are very skilled in this work, even though they are trained in gishur, and not in any other type of counseling. Of course, like any in profession, there is always the potential for the appearance of bad apples.

Those I have met also acknowledge that they are not therapists, nor try to be, and would refer couples to qualified therapists when the need arises. I hope that this includes sexual issues, which are often overlooked, even though marital relations are integral part of a couple's communication, not to mention a deep component of their relationship. I do not know the extent of the training these professionals receive regarding sexual issues, hopefully enough to pick up on the subtle hints members of a couple may reveal that something needs to be addressed in this area.

Sexual therapy is a specialty often underrated, one in which not all psychotherapists have been sufficiently trained work with clients with sexual dysfunction.

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