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I'd love to hear from therapists what they would have done if they were in Paul and/or Gina's place in any of these scenarios or similar ones that they or their associates have encountered in their own practice.
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3/3/08
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(16 of 61)
Re: From therapists' points of view
Mar 6, 2008 5:45 PM
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> I'm a psychologist who conducts Cognitive Behavioral
> Therapy. So, needless to say, I'd do just about
> everything differently.
>
> Paul has created a toxic environment for his patients
> by failing to maintain appropriate boundaries with
> them. I would never wrap a blanket around a
> patient's shoulders, rub the back of a (sexually
> promiscuous) teen (of the opposite sex), allow a
> patient to keep his coffee maker in my office, or
> discuss my guilt surrounding my mother's illness.
> Under no circumstances would I tell a patient that
> t she should have an abortion or entertain a
> discussion about my masturbation. And I certainly
> would never allow my patients to speak to me with
> such blatant disrespect. To do so is reinforcing the
> very behavior that contributes to their already
> impaired interpersonal functioning.
As a patient, I can't imagine talking to my therapist the way these people do, especially Alex and Sophie. Like you said, it only re-enforces the bad behavior.
I think the therapist should not react to his patients' bad behavior physically as he did with Alex. Paul should stay cool, but refer them to other therapists explaining to them politely but firmly that the appropriate doctor-patient relationship had been breached and he can't treat them any longer. That's is, unless he is too desperate for the income these patients bring (which would be wrong!).
I can't believe that he lets that spoiled little brat Sophie talk to him the way she does. How is it possible to teach kids right from wrong when the adults in her life (her mother, Paul) let her talk to them that way. Yes, poor Sophie is a victim of sexual abuse. But she is also a manipulative little rascal who uses the threat of suicide to terrorize the people who care for her. She is extremely cruel to her mother. She is verbally abusive first to her mother, and now Paul. But Paul just smiles sweetly back at her in response to her insults - gross!
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Re: From therapists' points of view
Mar 5, 2008 6:41 PM
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Great reading intelligent posts on tricky issues, babeeblues, AnaHedonia. et al. And Ana, how interesting the example you give about thinking big-picture and what if's down the road with Sophie.
Therapists really have their work cut out for them. They have to be present with patients in the present and help patients come to terms with past issues, and still be thinking about the effect of their words and/or doing/not doing something will affect the patients' future.
Sometimes what might sound "wrong" to someone else or might sound "bad" if brought to the attention of the Licensing Board, might really have been the right thing for that patient. I think therapist need to trust their instincts and be open to taking risks, but also know when to shift gears and go in a different direction. How DO therapists know when to trust themselves and wait for or urge the patient to be ready to go there?
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Re: From therapists' points of view
Mar 5, 2008 12:38 PM
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Thanks, Ana. Helpful, thorough answer.
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Re: From therapists' points of view
Mar 5, 2008 10:37 AM
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babeeblues wrote:
>Does any therapist actually maintain the dogma that there's >never any disconnect between what's best for a particular >patient in a particular situation and general codes of ethics or >"professionalism" or boundaries"? What do (various) ethical >authorties say about situations where there is a disconnect, or >might be? Does the therapist's duty to the patient's care, to the >patient's well-being, take a backseat to rigid compliance with >general ethical rules, "boundaries", "professionalism"?
You raise some good questions. Real therapists struggle with these dilemmas on a regular basis.
Take Sophie's case as an example. The law in just about all states dictate that mandated reporters (which include licensed therapists) are required to report any suspected or acknowledged sexual abuse. Sophie acknowledged that she had sex one time with an adult. Paul believes that what is best for the course of therapy is to not report the incident, which, if he did, could ruin his therapeutic relationship with Sophie. Perhaps many might agree with Paul's judgment in this case. He may indeed be correct by many perspectives.
Fast forward a year or two and imagine Sophie is no longer in therapy, away at college, going through hard times, and becomes indignant about the incident. She blames Paul for not reporting the abuse and reports Paul to the state licensing board. Paul could very easily lose his license, or at least be fined or have his license temporarily suspended.
Therapists can never know whether not reporting incidents will one day lead to problems. Therapists can certainly plead their cases to state licensing boards and, as a result, may reduce the disciplinary action.
Paul's relationship with Laura is more complicated. If he chose to follow through with a relationship - even if it were years after they stopped therapy - he would be very vulnerable to losing his license. Laura strikes me as just the type of unstable client that is capable of turning on Paul, and, given his experience, he should see the warning signs.
These dilemmas have no absolute answers. Therapists make judgments. Regardless of whether the judgments are sound or not, if they violate laws (particularly mandated reporting laws) there is always a chance that at some point the decision not to report will be costly.
Thus, for many therapists the drama of therapy is less about erotic transference or throwing coffee mugs at clients, but about struggling with ethical dilemmas that are more about the therapeutic process and how it relates to the legal and licensing system.
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632
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(12 of 61)
Re: From therapists' points of view
Mar 3, 2008 1:02 PM
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> Good comments and insights, bebeeblues. Great
> question at the end. I hope we hear from therapists
> on that issue.
Thanks. Guess not. Unless you can direct me to other threads where I might find these without discussion of previews from unaired episodes.
Hope I didn't inadvertently scare off discussion. I may have sounded more dubious about the values of ethical codes, boundaries, rules, etc. than I am.
I realize that we have ethical codes because there's a judgment that some things should not be left to the judgment/discretion of a particular therapist with a particular patient in particular situations.
Still, at the same time, that there's likely to be some tension between what's best for one or more parties to some particular cases and even the best code, generalized rules, laws.
Since all of us posted on this thread, we have seen many other instances where, I believe, "crossing"/"blurring" boundaries/rules has resulted in therapeutic breakthroughs. Or so it seems. I suppose some viewers, some professionals, will regard some of these developments as unrealistic. I remain intersted in responses on these matters.
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Re: From therapists' points of view
Feb 28, 2008 6:25 PM
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Good comments and insights, bebeeblues. Great question at the end. I hope we hear from therapists on that issue.
I've been in therapy for a long time with several therapists - I present many comorbid traits so it's been a little tricky for them and me to figure me out and how to best help me. Each previous therapist helped get me to where I am now, with upsides and downsides. I've had huge transference - countertransference - boundary issues most notably with the past two. I've shared those experiences - and what I've learned from them - with the therapist I have now. She has a good understanding of when to adhere to absolutes and when to use good judgement and not be as strict.
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Re: From therapists' points of view
Feb 28, 2008 3:58 AM
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I am not a therapist. However, as noted in discussion betweeen Gina and Paul, there are differing opinions about "boundaries" between patients and therapists, as with much else.
Paul acknowledged mistakes, potential mistakes, issues, and sought professional help on account of some of them.
The situations with these patients are especially charged. Gina herself acknowledged to Paul that lines in their sessions were "blurred"/crossed -- and wanted Paul to understand this underscored her commitment to his care; how far she was willing to go to help him.
Paul's right that Gina's no paragon, as his patient's are often right in their critiques of him. But Paul responded to this breach of boundaries by finally, fully acknowledging his love for Laura: Gina's boundary-breaching seemed realistically therapeutic to me, not toxic. Same, too, with some (hardly all) of Paul's connections with patients.
Does any therapist actually maintain the dogma that there's never any disconnect between what's best for a particular patient in a particular situation and general codes of ethics or "professionalism" or boundaries"? What do (various) ethical authorties say about situations where there is a disconnect, or might be? Does the therapist's duty to the patient's care, to the patient's well-being, take a backseat to rigid compliance with general ethical rules, "boundaries", "professionalism"?
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2/27/08
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Re: From therapists' points of view
Feb 27, 2008 10:30 PM
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Writers take note....Paul's lack of boundaries with his patients is very unprofessional. If it gets any worse I won't be able to watch as I will lose respect for him. He's doing great work with Sophie, however (so far except for leaving pills in the office--that was pretty stupid). If he has sexual relations with Laura her therapy will be set back possibly permanently and she won't want him anymore anyhow. If he does I will stop watching. Interesting drama though.
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8/1/07
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Re: From therapists' points of view
Feb 27, 2008 8:28 PM
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> I'm a psychologist who conducts Cognitive Behavioral
> Therapy. So, needless to say, I'd do just about
> everything differently.
>
> Paul has created a toxic environment for his patients
> by failing to maintain appropriate boundaries with
> them. I would never wrap a blanket around a
> patient's shoulders, rub the back of a (sexually
> promiscuous) teen (of the opposite sex), allow a
> patient to keep his coffee maker in my office, or
> discuss my guilt surrounding my mother's illness.
> Under no circumstances would I tell a patient that
> t she should have an abortion or entertain a
> discussion about my masturbation. And I certainly
> would never allow my patients to speak to me with
> such blatant disrespect. To do so is reinforcing the
> very behavior that contributes to their already
> impaired interpersonal functioning.
Agree. The wall between patient and therapist has been completely breached. They are walking all over him.
--
You're my wife, you can't be seeing the girl I'm dating
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Re: From therapists' points of view
Feb 27, 2008 8:18 PM
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I don't know that you could say that Paul is completely psychoanalytic in his approach. That is clearly his background and training, but I think he is much more relational. One might say too much so - which has led him to his boundary-violations. He seems to grapple with his training and his different approach - as he discussed with Gina, arguing that he cares about his patients and responds to them in a different way than she does. He sees her as too cold and analytic.
I think Paul's heart is in the right place, he is clearly burned out!
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1,030
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Re: From therapists' points of view
Feb 27, 2008 7:58 PM
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> However, any decent therapist would have
> quickly ended Alex' session once he revealed his
> cruel "research" of Paul's personal life.
Yeah. It just doesn't hold water that any therapist would continue with a client who had violated his privacy to such an extreme degree. A therapist's responsibility does not extend to endangering himself or his family. I don't know how they're going to play this out, but it would be quite a feat if they have Paul continue to see Alex and maintain believability.
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2/22/08
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(5 of 61)
Re: From therapists' points of view
Feb 27, 2008 6:45 PM
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I'm a psychologist who conducts Cognitive Behavioral Therapy. So, needless to say, I'd do just about everything differently.
Paul has created a toxic environment for his patients by failing to maintain appropriate boundaries with them. I would never wrap a blanket around a patient's shoulders, rub the back of a (sexually promiscuous) teen (of the opposite sex), allow a patient to keep his coffee maker in my office, or discuss my guilt surrounding my mother's illness. Under no circumstances would I tell a patient that she should have an abortion or entertain a discussion about my masturbation. And I certainly would never allow my patients to speak to me with such blatant disrespect. To do so is reinforcing the very behavior that contributes to their already impaired interpersonal functioning.
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2/27/08
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Re: From therapists' points of view
Feb 27, 2008 6:29 PM
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Sorry about the fact I can't spell:
Psychoanalysis
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2/27/08
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(3 of 61)
Re: From therapists' points of view
Feb 27, 2008 6:25 PM
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> I'd love to hear from therapists what they would have
> done if they were in Paul and/or Gina's place in any
> of these scenarios or similar ones that they or their
> associates have encountered in their own practice.
Last night's session was dramatically riveting, extremely well-written and well-acted and, probably, the least likely to really occur.
It should be pointed out that Paul's clinical training/presentation/modality is psychoanylitic. Very, very few practicing therapists employ this discipline in treatment, mostly because it requires a very long therapy period that can take years. 3rd party reimbursement, ie, insurance companies will not pay for it. Most therapists use what is called "cognitive-behavioral" therapy. The goal of this talk therapy is to connect congnitive distortions to negative perceptions/feelings about self or experiences or relationships and, then, change negative or self-destructive behavior. Recent research has shown this treatment to be highly effective in resolving many, many mental health Axis I disroders, especially depression and anxiety. It also takes a lot less time and is, thus, cost effective, for insurance companies.
Paul's repsonse to Alex inappropriate behavior was classic psychoanylisis, with the therapist being non-responsive,ie, a blank screen, encouraging the client to reflect on experiential feelings/behavior, and, hopefully, allow a cathartic "breakthrough" with real internal insight. The episode last night took that concept to the extreme, as the dramaturgy wonderfully highlights Paul's personal stress/demons encroaching into his professional life as a gifted therapist. However, any decent therapist would have quickly ended Alex' session once he revealed his cruel "research" of Paul's presonal life.
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111
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2/23/08
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(2 of 61)
Re: From therapists' points of view
Feb 27, 2008 6:00 PM
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Very apt thread you've started. Congratulations.
Since so far, no therapists have posted, I'm happy to jump-start the process by linking to what I think therapy of any sort may or may not be able to do for Laura
The previous post there explains, moreover, why Laura would very likely benefit far more from running off with Paul to the Carribbean --- for her happiness and his --- than continuing therapy of any sort with 12 of the most famous psychotherapists in the world.
Michael Gordon, the buggy professor
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