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The Represson Polemic: Constructing Normalcy and Deviance within Therapy Disciplines


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TH E RE PRE SSI ON POL EM I C: CO NST RU CTI NG NO RMA L CY AN D D EV I AN CE WI TH I N T HE RA PY D I SCI PL I NE S By MI CHAEL RYAN A DI SSER TATI ON PRESENTED TO THE G RADUATE SCHOOL OF T HE UNI VERSI TY OF FL ORI DA I N PARTI AL FUL FI L L MENT OF T HE REQUI REMENTS FOR THE DE GREE OF DOCTOR OF PHI L OSOPHY UNI VERSI TY OF FL ORI DA 2004

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Copy rig ht 2004 by Michae l Ry an

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I dedica te this dissertation to my pare nts, Pansy Anna Ke lly -Ry an and V enice Al ton (P e te ) R y a n, Sr ., wh o h a ve de dic a te d th e ir liv e s to the ir c hil dr e n. I a lso de dic a te it to Eric L ee Ry an and Wesley Gilbert Ry an, my children, w ho have f illed my hear t and thoughts with joy s and pains eve ry day of my adult life. My brothers a nd sisters (Alton, Danny Kay Ry an-N iemey er, L ouis, Rit a Ry an-Pinner, a nd L inda Ry an-Wadde ll) have su pp or te d my e ff or ts t hr ou g ho ut, a nd c he e re d me in m y e nd e a vo rs F ina lly I de dic a te my dissertation to all of the non-tra ditional students who will j oin me in fulfilling the dr eam of sailing the ac ademicscholar ship onc e ag ain.

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iv ACKNOWL EDGMENTS I re c e ive d a tr e me nd ou s b oo st f ro m D r. L on n L a nza -K a du c e c ha ir ma n o f m y supervisory committee. Dr. L anza-Ka duce pic ked up on the de pth and intricac ies of po ssi bil iti e s o f t he re se a rc h a nd e nc ou ra g e d me w hil e g ivi ng me le e wa y to d e ve lop H is a ssi sta nc e in t he fi na l st a g e s o f t he wr iti ng ve rg e d o n h e ro ic T he a dv ic e a nd a ssi sta nc e in rese arc h of my other c ommitt ee me mbers (D r. Ronald L Aker s, Dr. Richar d Hollinge r, Dr Co ns ta nc e She ha n a nd Dr Jose ph Spi lla ne ) c on tr ibu te d g re a tly to t he su c c e ss o f t his dissertation. I cannot e x press suff iciently my g ratitude for Dr. Te rry Mills and Dr. Chuck Peek, who sa ved me by substitut ing a t the last minute when a me mber c ould not be there during my hear ings. The thoughtf ul sugg estions and re view by all the above have he lped keep me focuse d while conf ronting the conf ounding mor ass of interand intradisciplinary micro/macr o rese arc h. Dr. Jaber Gubr ium also provided a tre mendous a mou nt o f i nf or ma tio n a nd a ssi sta nc e on the qu a lit a tiv e e le me nts of the dis se rt a tio n w hil e he wa s at the Univer sity of F lorida. While I was ha ppy at his promotion to chair anothe r s o c i o l o g y d e p a r t m e n t I sin c e re ly reg retted his abse nce f or the fina l stag es of the dissertation. I do not know how my dissertation would have been c ompleted without the sociolog ical discussions with my friends, D r. Sy lvia Ansay Dr. Amir Ma rvasti, and Dr Erica Owens. O n numerous occ asions when c omplicated conc epts and ha rd and discourag ing da y s cooled the e mbers of my endea vors, they stoked my passion by providing sorely neede d compassion, insightful obse rvations and he lpful sugg estions.

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v Drs. F elix Be rar do, J ohn Scanzoni, and Her nan Ve ra a ll offer ed me a dvice a nd encour ag ement to complete this work e ven thoug h none we re on my I am ver y g rate ful for the a ssistance a nd advice on teac hing issues te ndere d by Drs. Mar ian B org and Chuck Pe e k. With ou t th e ir he lp I wo uld ha ve ne e de d h ou rs a nd ho ur s o f t ime a wa y fr om m y dis se rt a tio n. I a m de e ply a pp re c ia tiv e of the de vo tio n to sc ho la rs hip a nd to g ra du a te members of the Sociology Depa rtment exhibi ted by all these prof essors. Drs. Ge org e L owe a nd Charley Peek of Te x as Tec h University wer e instrumental in the ear liest phases of planning my dissertation; and their c oncer n from af ar w as ver y hear tening during many times when my prog ress wa s less than I hoped. Many unnamed profe ssors at both Texas Tech U niversity and the Unive rsity of F lorida provided encour ag ement throug h their own e x emplary scholarship a nd devotion to aca demia.

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vi TAB L E OF CONTENTS p age A C K N O W L E D G M E N T S ................................................ iv A B S T R A C T .......................................................... vii i CHAPTER 1 I N T R O D U C T I O N ................................................. 1 2 TH ERA PI STS’ CO NST RU CTI ON S OF TH ERA PI ST D EV I AN CE . . . . . 7 “Soft” Rea ctive De finition of Devianc e . . . . . . . . . . . . . . . . 8 Constructionist Versus the Essentialist View of De viance . . . . . . . . 16 E l i t e E n g i n e e r e d D e v i a n c e ? ......................................... 18 F or ma l a nd I nf or ma l L a be lin g of Th e ra pis ts . . . . . . . . . . . . . . 18 3 HI STO RY OF NO RMA L CY D EV I AN CE, AN D C HA NG E I N T HE RA PY . 22 T h e r a p y a n d C h a n g e .............................................. 22 Emerg ence of Moder n Psy chiatry Psy cholog y and Social Work . . . . . . 24 V a r i e t y o f T h e r a p i e s : T h e 2 0 C e n t u r y ................................ th 29 4 R E G R E S S I O N P O L E M I C.......................................... 39 T h e D e b a t e ...................................................... 39 Contex ts of Thera py -Assisted Self Construction . . . . . . . . . . . . 43 Con se qu e nc e s f or Th e ra pis ts a nd Clie nts . . . . . . . . . . . . . . . 47 L a b e l i n g a n d I m p u t i n g V i c t i m i z a t i o n ................................. 50 5 M E T H O D S ..................................................... 54 S u b j e c t s / I n t e r v i e w e e s / R e s p o n d e n t s ................................... 56 I n t e r v i e w i n g ..................................................... 58 A n a l y z i n g I n t e r v i e w s .............................................. 62

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vii 6 O R I E N T A T I O N S T O T H E R A P Y .................................... 65 I nterview s with L icense d Clini cal Social Worker s . . . . . . . . . . . 66 Ov e rv ie w o f H ow L CSWs D e fi ne Th e ra py Pr a c tic e s a nd Th e ra pis ts . . . . 76 I nterview s with Psy cholog ists and an Educa tional Counselor . . . . . . . 81 Over view of H ow Psy cholog ists and a Counselor De fine The rapy Practice s and T h e r a p i s t s ................................................. 95 I n t e r v i e w s w i t h P s y c h i a t r i s t s ....................................... 101 Ov e rv ie w o f H ow Psy c hia tr ist s D e fi ne Th e ra py Pr a c tic e s a nd Th e ra pis ts . . 107 7 MEMORY, SUPP RESS I ON, AND REPR ESSI ON . . . . . . . . . . 109 M.S.W .s on Memory Repression, and Re g ression Ther apy . . . . . . . 126 Ph.D.s on Memory Repression, and Re g ression Ther apy . . . . . . . . 126 M.D./Ph.D.s on Memory Repression, and Re g ression Ther apy . . . . . . 127 8 A C C O U N T A B I L I T Y A N D E T H I C S ................................ 129 M.S.W .s on Acc ountability and Ethics . . . . . . . . . . . . . . . 140 P h D s o n A c c o u n t a b i l i t y a n d E t h i c s ................................. 141 M.D./Ph.D.s on Accountability and Ethics . . . . . . . . . . . . . . 142 9 L E G A L I S S U E S A N D T H E R A P Y .................................. 143 C e r t i f i c a t i o n a n d L i c e n s u r e ........................................ 145 Ra mo na v I sa be lla a n d T h i r d p a r t y S u i t s ............................. 158 M a n d a t o r y R e p o r t i n g o f A b u s e ..................................... 170 1 0 C O N C L U S I O N S A N D D I S C U S S I O N ............................... 182 O r i e n t a t i o n s t o T h e r a p y ........................................... 183 I mportance of Memory Suppression, and Repre ssion . . . . . . . . . 186 A c c o u n t a b i l i t y a n d E t h i c s ......................................... 188 L e g a l F a c t o r s ................................................... 191 A P P E N D I X .......................................................... 193 A C O N T A C T L E T T E R ............................................. 193 B I NFO RMED CONSENT FOR I NDI VI DUAL I NTERVI EW . . . . . . . 194 C D E M O G R A P H I C D A T A ......................................... 196 D C O N T A C T P H O N E C A L L ........................................ 197

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vii i E T Y P E S O F P R O B E S U S E D ....................................... 198 T o p i c s ( W i t h P o s s i b l e Q u e s t i o n s ) ................................... 198 I s s u e s ......................................................... 200 F UNDERSTANDI NG THE SUB J ECTS’ PERS PECTI VES . . . . . . . 202 L a n g u a g e o f M o r a l E x a c t i t u d e ...................................... 202 L a n g u a g e o f P r e c i s i o n ............................................ 207 R E F E R E N C E S ....................................................... 211 B I O G R A P H I C A L S K E T C H ............................................. 219

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ix Abstrac t of Dissertation Prese nted to the Gra duate School of the Unive rsity of F lorida in Partial Fulf illment of the Requirements for the Deg ree of Doc tor of Philosophy TH E RE PRE SSI ON POL EM I C: CO NST RU CTI NG NO RMA L CY AND DE VI ANCE WI THI N THERAPY DI SCI PL I NES By Michae l Ry an Dec ember 2004 Chair: L onn L anza-Ka duce De p ar t m en t : S o ci o l o gy My re se a rc h a dd s to the so c iol og y of de via nc e L a be lin g a nd re a c tio ns to devianc e by thera pists are e x amined. The debate over or ientations toward the disc overy of re pr e sse d me mor ie s, a nd re a c tio ns to t his de ba te a re us e d a s a sta rt ing po int fo r t his examination of how devianc e is construc ted by thera py prac titioners. I nterview s of cer tified and/or lice nsed pra ctitioners in the three major thera py disciplines of mental he a lth (c lin ic a l so c ia l w or ke rs c lin ic a l ps y c ho log ist s, a nd ps y c hia tr ist s) a re su bje c te d to qualitative ana ly sis. This inquiry discusses the nar ratives of ten thera pists who revea led four ma jor are as for conce ptual analy sis. These ar e orie ntations to therapy ; memory suppression and repr ession; acc ountability and ethics; a nd the intera ction of leg al issues and ther apy Whil e little differ ence was found be tween the narr atives whe n examined by discipline, are nas of individual diffe renc es we re unc overe d.

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x Training did not seem to aff ect or ientations to therapy The ther apists all relate d narr atives stressing problem solving in the pr esent. The ir definitions of g ood prac tice included maintaining confide ntiality doing no ha rm to the client, and f ollowing a n a g e nd a c omi ng fr om a nd a bo ut t he c lie nt r a the r t ha n th e the ra pis t. F e w o f t he the ra pis ts used any prac tices that ar e esse ntial for extracting repr essed memor ies. The line be tween normative pra ctices a nd devianc e wa s seen to be c rossed whe n the above wer e violated. Whil e prof essional and leg al sanc tioning of de viant actions wa s advoca ted, the the ra pis ts w ho c omm it b re a c he s w e re se e n a s im pa ir e d. Re me dy wa s e xpre sse d in te rm s of how to g et these individuals “r epair ed” a nd back to nor mative pra ctice. O rg anizational or instituti onal re medies we re se ldom recommende d (e.g ., chang e in socialization, closer monitoring by local boar ds, national reg istries of devianc e, etc .). Recla mation rather than pr oa c tiv e a c tio n w a s a dv a nc e d in a ll b ut t wo int e rv ie ws Co nd uc tin g the re se a rc h a lso provided insig hts into problems encountere d in cross-disciplinary study —namely the study of thera py discipline (and e ffe cts of leg al sanc tioning) f rom a sociolog ical vanta g e.

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1 CH APT ER 1 I NTRODUCTI ON Th is d iss e rt a tio n e xami ne d h ow the la be lin g of de via nc e is a ff e c tin g me nta l he a lth thera py I t contributes to understanding the construc tion of deviant thera py prac tices. To this end, it considered the following : how thera pists with di ffe rent tra ining a nd various kinds of prac tices think about devianc e in their wor k (i.e., how the y draw the line betwee n “g ood” and “ bad” a pplications/therapists); how prof essional ethics a nd training a ff e c t th e ra pis ts’ c on str uc tio ns ; a nd ho w t he ra py a nd le g a l de ve lop me nts tha t r e g ula te prac tice play off e ach othe r. B eca use important leg al deve lopments have ke y ed on childhood sexual abuse and the disc overy of memories, the controve rsy over r eg ression techniques tha t rec over “ repr essed” memory provides a stra teg ic site for study ing how devianc e is construc ted and nor mative pra ctices a ffe cted. Be fore the 1960s, the term “ child abuse” was not in g ener al usag e. I n 1967 there wer e 7,000 ca ses of re ported c hild abuse and ne g lect, but by 1981 there wer e 1.1 million repor ted; and in 1989, 2.4 million (Hacking 1991). Child abuse had to be constructe d as devianc e (Pfohl 1977), a nd was re sponded to ac cording ly Not surprising ly part of the rea ction to the problems associa ted with child abuse involved the rapy Some therapy techniques w ere expanded or de veloped, including reg ression thera py to meet the nee ds of victims. Be cause the discover y of child abuse ref lected c hang ing de finitions and constructions as much a s abusive beha viors, many victims entered a dulthood without

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2 having had their a buse trea ted or e ven re cog nized. The promise of r eg ression thera py was that it could addre ss how past abuse w as a f actor in curre nt problems. The incr ease in the popularity of re g ression thera py can be documented. A revie w of the prof essional and a cade mic journals cove red in Sociofile r evea ls that before 1965, only one ar ticle containe d the word repr ession." F rom 1965–1975 there wer e 142 entries, 1976–1985 c ontained 483, and 1986–1995 ha d 672 entries. Th is d iss e rt a tio n ta ke s a dv a nta g e of the c ha ng ing c on str uc tio ns of c hil d a bu se to study controve rsial thera py techniques a nd shed lig ht on how the deliver y of thera py may be construc ted as de viant. The c oncept of “Repre ssion” as used in this rese arc h involves lessening acc ess to an unplea sant memory with the following char acte ristics: 1) tr a uma tic or ne g a tiv e e ve nt/ s o c c ur re d to the pe rs on 2 ) m e mor y of tha t/t ho se e ve nt/ s cannot be rec overe d by normal memory proce sses, 3) the r epre ssed memory aff ects the person' s prese nt behavior, a nd 4) the wa y to cure the ef fec ts of repr ession is to make the event c onscious and re live it. My study adds to the sociolog ical tra dition of study ing the construction of devianc e and the eff ects of de viance labels. Some examples of rese arc h in that tradition illust rate the wide r ang e of topics that infor ms our knowledg e about de viance Erikson (1966) e x amined the c onstruction of witchc raf t by Puritan society Construction of devianc e betwe en off icer s by police interna l org anizations was studied by Punch (1985). The c onstruction of computer crime by lawmake rs was de tailed by Hollinge r and L anza-Ka duce ( 1988). Gubrium and H olstein (1990) found that de viance in families can be construc ted by thera py org anizations. Cons truction of addic tion by prac titioners and

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3 rese arc hers wa s rec ounted by Aker s (1991). Holstein (1993) found that mental illness ca n be construc ted by attorney s in competenc y hear ings. A more c omplete exposit ion of how the study of thera py fits within a compre hensive de viance fra mework is pre sented in the ne x t chapter By way of introduction, suffice to say that the study of devia nce pose s two centra l issues acc ording to Akers ( 1977, 13) “how and why cer tain kinds of behavior and people become define d and re acte d to as deviant” and 2) “ how and why some people c ome to eng ag e in ac tions or ac quire the c hara cter istics defined a s deviant.” Muc h of the study of devia nce a nd crime f ocuses on the se cond issue. The labeling or socialrea ction perspe ctive dra ws our attention to the former and foc uses on “the behavior of those who label, react to, and oth e rwi se se e k to c on tro l of fe nd e rs ” (Cullen & Ag new 2003, 295; empha sis in the orig inal) Social groups create de viance by mak ing the rules whose infraction constitutes deviance and by apply ing those rules to par ticular pe ople and la be lin g the m a s o uts ide rs F ro m th is p oin t of vie w, de via nc e is not a quality of the a ct the per son commits, but rather a c onsequenc e of the application by others of r ules and sanc tions to an “offe nder.” The de viant is one to whom that label has suc cessf ully been a pplied; deviant beha vior is b e ha vio r t ha t pe op le so la be l. ( B e c ke r 1 96 3, 9; e mph a sis in o ri g ina l) The labe ling pe rspec tive is simi lar to the c onflict approa ch in emphasizing the fo rm a tio n a nd a pp lic a tio n o f d e fi nit ion s. I nd e e d, the tw o a pp ro a c he s h a ve be c ome so closely identified in arg uing tha t social interac tions to deviance a re une qually applied a g a ins t th e le ss p ow e rf ul g ro up s th a t so me so c iol og ist s se e c on fl ic t a nd la be lin g the or ist s as almost intercha ng eable (Ha g an 1973, Wellford 1975). The que stion of how labels ar e applied, the ref ore, r evolves a round the issue of power The be havior of le ss-power ful g roups or individuals is more likely to be def ined

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4 Co des of et hi cs f or t her api s t s ar e s i mi l ar t o each ot her T hes e c od es ca n be f ound t hr ough t he nat i onal 1 o rg a n iz a tio n s o r o n line a t: 1) N at i on al As s oci at i on of Soc i al W or k er s : h t t p: / / ww w. s oci al wor k er s or g / pu bs / code / code as p 2 ) A m e ric a n P syc h o lo g ic a l A sso c ia tio n : h ttp :// w w w .a p a .o rg /e thic s/c o d e 2 0 0 2 .htm l 3) Amer i ca n Ps y ch i at r i c As s oci at i on : h t t p: / / 222. ps y ch or g / apa _membe r s / et h i cs _opi n i on s 53101 .c fm as d ev i an t ; m o re -p o we rf u l gro u p s o r i n d i v i d u al s ar e i n a b et t er p o s i t i o n t o re s i s t l ab el i n g, or to neg otiate when or how beha viors are labeled ( Hawkins & Tiedema n 1975). Th e stu dy of the ra py a nd the ra pis ts i nv olv e s g ro up s a nd ind ivi du a ls t ha t po sse ss e du c a tio n, sta tus a nd so me le ve l of po we r. Th e y a re no t f re e to d isr e g a rd e xter na l e ff or ts to reg ulate their pr actice s and must work within the exist ing le g al structure As pr of e ssi on a ls, the y e njo y c on sid e ra ble a uto no my ov e r t he ir wo rk a nd be lon g to p ro fe s s i o n al as s o ci at i o n s t h at ar e o ft en s u cc es s fu l i n i n s i s t i n g o n s el fre gu l at i o n t h ro u gh cer tification and c odes of e thics. When professionals fa il to reg ulate themselve s 1 sufficie ntly there is gr eat pr essure for e x terna l constraints. Th e ra pis ts h a il f ro m di ff e re nt t ra ini ng ba c kg ro un ds a nd the ra py c uts a c ro ss dif fe re nt d isc ipl ine s a nd sc ho ols of tho ug ht. Ab bo tt ( 19 88 3 25 ) r e min ds us tha t w e mus t “start study ing w ork” r ather than the prof ession. He c alls for the study of the history of the work, w ho was involved a nd wher e they came from, how mar kets for the ir servic es wer e cr eate d, and how c onflicts shaped those w ho prac ticed. Deviant ther apy prac tices ar e the c oncer n of both profe ssional associations and the law. The profe ssional associations to which thera pists belong pr omulga te ethica l codes and standa rds of pra ctice in a n eff ort to reg ulate ther apists and thera py Professional associations also provide cer tification. Such eff orts repr esent a form of se lf–reg ulation. My study focuse d on how the pra ctice of thera py has bee n aff ecte d by this self–reg ulation,

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5 and what thi s e ff e c t on the ra pis ts h a s d on e to c ha ng e c on c e pti on s o f m e nta l he a lth prac tice. Deviant ther apy prac tices ca n also g ive rise to leg al controls that g o bey ond se lf –r e g ula tio n b y the pr of e ssi on a l a sso c ia tio ns O ne wa y thi s c on tr ol i s e xer te d is throug h state licensur e. L eg al controls have also bee n imposed throug h court c ases [e.g ., Tar as ov v R e ge nts of t he Un iv e rsi ty of C ali for nia (1976) a nd Ra mo na v I sa be lla (1994)] and throug h leg islation (e.g ., mandatory repor ting of abuse) Although the rapists have long be en ac countable to their clients for de viant prac tices, more r ece nt case law has established their pote ntial liabilit y to others. Tarasov was a landmark c ase in whic h a the ra pis t w a s h e ld l ia ble fo r h is c lie nt’ s in jur ie s to a thi rd pe rs on be c a us e the the ra pis t failed to re port cre dible threa ts made by his client. Ramona e sta bli sh e d th a t th e ra pis ts could be he ld liable in tort for dama g es ca used by a client’ s acc usations stemming fr om thera py techniques w hich manufa cture d memories of c hildhood sex ual abuse Statutes now mandate repor ting of suspected c hild abuse, cr eating a quanda ry for ther apists. They are require d to report suspec ted child abuse but need to dete rmine which a ccounts a re c re dib le to s ta y wi thi n s tr ic tur e s to ma int a in t he c lie nt’ s c on fi de nti a lit y I n th e pr oc e ss, the y a re po te nti a lly lia ble fo r t or t su its if the ir te c hn iqu e s le a d to fa lse or un re lia ble acc ounts of abuse. The leg al problem is compounded by the power differ ential betwe en thera pists and clients, and by differ ent levels of sug g estibilit y in clients. The role of cour t case s and public aw are ness may be af fec ting ther apists’ prac tices in these disciplines, as explored in the interviews. One focus of this study is on how the prac tice of the rapy has be e n a ff e c te d b y the se le g a l c on tr ols a nd pr of e ssi on a l g uid e lin e s.

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6 T wo t y pes of de v i an ce a n d t wo t y pes of c on s t r u ct i on a r e di s cu s s ed i n t h i s di s s er t at i on T h e t y pe of 2 d ev i an ce t ha t i s f o ca l i s devi ance w i t hi n t her ap y, wh i ch c an mi s l ea d or h ar m c l i en t s a n d ot h er s T h i s t y pe o f d e v ia n c e is co n tra ry to the e thic a l stan d a rd s o f ea c h o f t h e the ra p y d isc ip line s a n d so m e tim e s is act i onabl e. T he d ev i a n ce o f p erp etra t o rs o f ch i l d h o o d sex u a l a b u se is a lso a n e le m e n t d isc u sse d in this d i ss ert at i o n. T he co nstructi o n that i s f o ca l i nv o l ve s how t he t her ap i s t r es po ndent s cons t r uct h ow t h er apy shoul d be do ne, and whi ch t herap y practi ces and t herap i st s are l ab el ed as d evi ant U nf o rt unat e f o r t he sake of c l ar i t y t h e dev i an ce of pe r s on s w h o c ommi t c h i l dh ood s ex u al a bu s e an d t h e t h er ape u t i c met h od of co nst ruct i ng a n ew l i fe by conf r ont i ng a pas t ev ent ar e a l s o es s ent i al f act ors Rat her t han l abel t hem as t y p e “ A ” o r t y p e “ B ” o r s o m e o t her art i f i ci al de m arcat i o n, co nt ext wi t hi n m y t ext i nd i cat es whi ch t y p es ar e u n d e r d isc u ssio n in a p a rtic u la r se g m e n t. An i n s t i t u t i on h a s be e n de f i n e d s oc i ol og i c a l l y a “ a ma j or s ph e r e of s oc i a l l i f e or s oc i e t a l s u bs y s t e m, 3 des i gn ed t o m eet bas i c h uman nee ds” ( M aci oni s 200 4, 301 ) ; as “ a c ol l ect i ve s ol ut i on t o a probl em of s oci al l i f e [t hat ] i ncl ud es a var i et y of group s and organi zat i o ns t hat ad d res s a p rob l em of social l i f e” (Lauer & Laur er 199 8, 124 ) ; an d al s o as “ s t abl e s et of r ol es s t at us es gr oups, an d orga ni zat i ons . wh i ch provi des f o r b eh av i o r i n so m e m aj o r are a o f so cial l i f e” (N ew m an 2 0 0 0 2 9 ). M en t al hea l t h c an b e c o nc eive d as a so cial i nsti t uti o n un d er e ac h o f t he ab o ve d efi nit i o ns: A T h e w a y o f b e h a v ing is t h ro u g h the the o ry a n d o rg a n iz a tio n o f p syc h o lo g y. T h e hu m a n ne e d is m e n ta l he a lth. B T h e p ro b le m o f so c ia l l ife is m a inta inin g a n e ff ic ie n t p o p u la c e a n d w o rk fo rc e C T he s oci al s t r uct ur es ( r ol es s t at us es gr oups, an d orga ni zat i ons ) ar e f ound i n t he di s ci pl i nes t hat i ncl ude ps y chi at r y cl i ni cal ps y chol ogy an d cl i ni cal s oci al wor k— al l of wh i ch hav e s i mi l ar et hi cal s t andar ds of ac t i on but di f f er ent s t at us es f un ct i ons an d way s of i nt er act i on i n pur s ui t of t hei r comm on goal o f t reat i ng m ent al i l l ness and s o m et i m es, pro vi d i ng t heo ret i cal and m et ho d o l o gi cal res o urces f o r t he mai nt ena nce of ment al he al t h. T he cul t ur e i s a mer ged one s t emm i ng f r om ne ur ol ogy an d psy chol ogi cal f o und at i o ns. Fi nal l y t he t echno l o gi es of t he i nst i t ut i o n of m ent al heal t h are t ho se whi ch have evo l ved and ar e e vol vi ng f r om ne ur ol ogy ps y chol ogy an d t he nee ds of publ i c s er vi ce. My re se a rc h a na ly zed int e rv ie ws wi th l ic e ns e d a nd /or c e rt if ie d th e ra pis ts t o investiga te how the labe ling of devianc e within the insti tution of mental health is done 23 (c on str uc te d) T his a pp ro a c h u se d n a rr a tiv e a na ly sis s up ple me nte d b y c on te nt a na ly sis and conve rsation ana ly sis. Cards that identified conc epts fre quently found in the literature wer e off ere d to the interviewe es. The inter viewee s’ selec tions helped structure the nar rations. The g oal was to a llow them to define the c oncepts, set pr iorities for the int e rv ie ws a nd min imi ze t he int e rv ie we r’ s r ole A c c or din g ly the int e rv ie ws we re loo se ly str uc tur e d, bu t a ll o f t he m pr ov ide d f or na rr a tio ns on a se ri e s o f t op ic s: 1 ) o ri e nta tio ns to thera py ; 2) memory suppression, and r epre ssion; 3) acc ountability and ethics; a nd 4) l e g a l i s s u e s a n d t h e r a p y.

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7 CH APT ER 2 TH ERA PI STS’ CO NST RU CTI ON S OF TH ERA PI ST D EV I AN CE The study of devia nce c onfronts the proble m of defining devianc e and ide ntify ing who is considere d deviant. Goode ’s exposit ion (1994, 1997) pre sents a fr amewor k for c on sid e ri ng de via nc e a nd the ra py H is f ra me wo rk be g ins by dis c us sin g a pp ro a c he s to d ef i n i n g d ev i an ce Go o d e ( 1 9 9 4 1 2 -1 5 ) r ej ec t s fi v e “ n ai v e” an d / o r “ m i s l ea d i n g” de fi nit ion s b a se d o n a bs olu te mor a l st a nd a rd s, sta tis tic a l a na ly se s, so c ia l ha rm criminality and “positive” devianc e. He then conc entra tes on two “fr uitful (but flawe d)” a pp ro a c he s th a t f oc us on so c ia l no rm s ( no rm a tiv e de fi nit ion ) a nd so c ia l r e a c tio ns to be ha vio r ( re a c tiv e de fi nit ion ). Go od e no te s th a t th e no rm a tiv e de fi nit ion is t he mos t commonly acc epted a pproac h. “Nor ms define a ppropriate acts a nd conditions for a soc iety ’s member s” (He itz eg 1996, 3). “The normative de finition locates the quality of devia nce not in ac tions or conditions themselves but in the fac t that they violate the norms of the culture or su bc ult ur e in w hic h th e y ta ke pla c e a nd e xist” (G oo de 19 94 1 5) I t “ loc a te s d e via nc e in the discrepancy betwee n an ac t or a c ondition and the norms” pre sent at that plac e at that time (Goode 1994, 16) Goode a lso notes that it im plies relativity –norms will differ f rom g roup to g roup and time to time. “What makes a g iven ac tion or condition deviant is the fa c t th a t it is a vio la tio n o f t he c us tom r ule la w, or no rm whe n a nd whe re it o c c ur s .” (Goode 1994, 16). One of the major proble ms that Goode (1994, 16) links to t he norma tive definition is that it “ignore s the distinction between violations of norms that g ener ate no spe cial

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8 attention or ala rm and one s that cause audienc es to punish or conde mn the actor .” F or ov e r 8 0 y e a rs s oc ia l sc ie nti sts ha ve no te d th a t r e la tiv e ly lit tle a tte nti on ha s b e e n p a id t o societal re actions to devianc e (D ewe y 1922, Kitsuse 1968). The r eac tive definition addre sses that omission. “W hat makes a n act or a condition deviant . is how it, and the individual who enac ts or possesses it, are rea cted to by actua l people, audie nces, or others who punish or conde mn the individual” (Goode 1994, 17). The r eac tive definition of devianc e re quires “a ctual, conc rete instances of punishment and conde mnation” (Goode 1997, 26). One of the major pr oblems with over-r eliance on the re active de finition is t hat it de-empha siz es the orig inal behavior or condition that g ives rise to the c ondemning or punishing re action. F or example, Aker s and Sellers (2004) arg ue that labe ls are a ttached to behaviors a nd that devianc e ca nnot be studied by only looking a t the social re action. “Sof t” Re active Defini tion of Deviance Goode of fer s a compromise by adopting a “sof t” or “ modera te” r eac tive approa ch to defining devianc e, the c onstruction of devia nce, a nd rea ctions to deviance I n s um, by de via nc e I me a n . be ha vio r o r c ha ra c te ri sti c s th a t so me people in a soc iety find offe nsive or re prehe nsible and that g ener ates—or would g ener ate if discove red—in these people disappr oval, punishment of, condemna tion of, or hostilit y toward the actor or possessor. Goode 1997, 37. Goode ( 1997) adopts his “soft” rea ctive def inition of deviance to incorpora te three fea tures that he c laims advanc e the c onceptua liz ation of devia nce. F irst, since no rules a re a bs olu te “ on e sh ou ld b e a ble to i nf e r f ro m r e a c tio ns by a wi de ra ng e of a ud ie nc e s to be ha vio r a nd c on dit ion s w ha t th e no rm s a re ” (2 6) O ne of the g oa ls o f t his dis se rt a tio n is to learn f rom thera pists what “the norms ar e.” T hat includes g ener al normative orientations to thera py that contextualiz e under standing s of devianc e in thera py The

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9 interviews e x plore how the rapists understa nd the norms and how tha t refle cts various audienc es. Goode notes that “I t is the audience which dete rmines whethe r something or someone is deviant: no audie nce, no la beling there fore no devianc e” ( Goode 1997, 107) A sec ond advanta g e that Goode (1997, 26) c laims for his soft rea ctive def inition of devia nce is that it rec og nizes that “the ena ctor of pote ntially deviant beha vior, or the possessor of potentially discrediting char acte ristics must operate in a sea of imputed neg ative judg ments.” Another of the g oals of this dissertation will be to expl ore, f rom the perspe ctive of the thera pists, how reac tions by audienc es af fec t the thera pists’ norms and be ha vio rs The third adva ntag e is that the soft re active de finition allows Goode to esca pe from the dilemma pr esente d by “sec ret” or undete cted de viance I f most norm-violating behavior or conditions rema in undiscovere d, they are not rea cted to. To the stric t rea ctivist, they would not be deviant. On the other ha nd, the normative a pproac h, which define s secr et norm violations as deviant be cause they would be re acte d to if they wer e dis c ov e re d, mis se s th e imp or ta nt r ole tha t so c ia l r e a c tio n h a s in c on tr ibu tin g to t he ir sti g ma tize d s ta tus “ Al tho ug h s oc ia l r e a c tio n d oe s n ot c re a te the a c tua l be ha vio r .. ., it does lend to it a stigma tiz ed status, and it influenc es ce rtain fe ature s of that ac tivity and the lives of men a nd women who e ng ag e in it that would be lacking in the absenc e of neg ative labe ling” (Goode 1994, 21). Goode conce des that “the rea ctions of audienc es do not nece ssarily cre ate the be havior in question out of thin air,” but that soc ial rea ction a ff e c ts p e op le wh o e ng a g e in t ha t be ha vio r r e g a rd le ss o f w he the r t he ir de via nc e is detec ted. Secr et devianc e play s a role in f orming the norms which other individual thera pists (as members of the audienc e) pr ofess a nd that are reve aled in their pr actice s. A

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10 g oal of the disser tation is to l ear n about re actions by thera pists to various therapy prac tices and pr actitioners, r eg ardle ss of whethe r norm violations have be en dete cted. Wha t do the ra pis ts r e a c t to str on g ly wh e n it c ome s to de via nc e wi thi n th e ir ra nk s? Th e lit e ra tur e on de via nc e su g g e sts tha t G oo de c ou ld h a ve g on e fu rt he r i n de ve lop ing the po int So c ia l r e a c tio n h a s so c ia l ut ili ty in s e ve ra l w a y s. Du rk he im (1893/1933) noted how it could r einforc e shar ed norms. To him, share d norms rathe r than threa ts of punishment, were functional for social control. Er ikson (1966) demonstrated how social re actions helpe d establish and maintain the mora l or normative bo un da ri e s f or g ro up s. I n th is s e ns e s oc ia l r e a c tio ns to d e via nc e a re e du c a tiv e fo r t ho se wh o a re c omp lia nt a s w e ll a s th os e wh o a re de via nt. A g oa l of thi s d iss e rt a tio n w ill be to e xplor e ho w v a ri ou s so c ia l r e a c tio ns to t he ra py pr a c tic e s a nd the ra pis ts, inc lud ing so me officia l leg al and pr ofessional re actions, have aff ecte d thera pists’ own views about devianc e and pr actice Audience s play a cr itical role in Goode ’s discussion. Their re actions help identify the norms, and a ctors have perc eptions about how var ious audience s fee l about devianc e. Goode identifie s differ ent potential audienc es at diff ere nt levels of ana ly sis–indivi dual a c tor s, po te nti a l vi c tim s, so c ia l in tim a te s, wi tne sse s/b y sta nd e rs me mbe rs of sma ll g roups, societa l members, for mal social control of ficials and sy stems, and distant ob se rv e rs H e no te s th a t “ a tti tud e s to wa rd a nd re a c tio ns to p ote nti a l de via nc e a re he ld a nd e xpre sse d b y pe op le wi th v a stl y dif fe ri ng de g re e s o f p ow e r– po we r t o h a ve the ir views of wha t is right and w rong win out over those of other pe ople” ( Goode 1994, 23) He g oe s o n to a sse rt tha t w ha t ne e ds to b e kn ow n is “ which forms of behavior and what

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11 conditions stand a high chance of earning conde mnation and punishment for the individual ” (23) Goode identifie s three dimensions that dete rmine the likelihood of something being labeled de viance : the nu mb e rs who ar e likely to punish or condemn a phe nomenon, the power of those who disappr ove of the phenomenon, a nd the int e ns ity of their be liefs. Punishm ent or c ondemnation is more likely to occur if more pe ople def ine something as deviant, if they have r elatively more powe r, and if the y hold strong be liefs about the inappropria teness of the devianc e. The c entra lity of the role of audie nces in labe ling de viance become s more complicated by the cha lleng e of r elativity that Goode incor porate s into his approach. H e no te s th a t a ud ie nc e s a re re la tiv e a nd the “ g re a te st a mou nt o f v a ri a tio n o c c ur s from one specific pe rson to another ” (G oode 1994, 25). The rela tivity in audience is compounded by rela tivity in individual actors and situations. Some individuals are in better positions to r e sis t de via nc e la be ls. “ Hi g h s ta tus ind ivi du a ls a re a llo we d a g re a t de a l mo re le e wa y in what they do and ar e; they are n’t judg ed as ha rshly as lower -status people a re, a nd they have r esourc es to defle ct cr iticism t hat might be heade d their wa y ” (G oode 1994, 27). Erikson (1962) indica tes that some who eng ag e in beha vior that is labeled a s devianc e c a n a vo id b e ing la be le d a s d e via nt i nd ivi du a ls. Simi la rl y s ome sit ua tio ns a re mor e lik e ly to esca pe labe ling. “ The setting m ak es a gr ea t d ea l o f d i ff er en ce i n h o w a u d i en ce s j u d ge behavior s, actors, c onditions, and their possessors” ( Goode 1994, 28) The setting s of thera py have be en examined by others, ele ments such as the eff ects of the “fifty minute hour,” ther apists not providing a nswers to dire ct question but asking questions as a re sponse to questions they are asked, e tc. (L indner 1955, Goldman

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12 1996, Fr ank 1998, F raw ley -O' Dea 1998). Other major ele ments of the socia l environment whic h bear upon thera pists are found in leg al ruling s, the org anizational structure and messag es of their discipline, and the media exposure of ac tions and attitudes of public opinion. On e va ri a tio n o n r e la tiv ity is p ote nti a lly imp or ta nt t o a stu dy of de via nc e in t h er ap y I n d i v i d u al t h er ap i s t s m ay k n o w o f a ct s wh i ch h av e b ee n l ab el ed d ev i an t t h ro u gh societal norma tive standards ( law and e thics boards) a nd even know of thera pists who ha ve be e n s a nc tio ne d a nd sti g ma tize d f or the se a c ts ( or wh o c ou ld b e ). Ye t, s ome thera pists may be re luctant to aff ix the devianc e labe l. The re sear ch explores whethe r thera pists dis tinguish betwe en the a ct of de viance and the de viant actor –they may be willing to conde mn the sin but not t he sinner. T hey may g rant wide berth to many prac tices and othe r pra ctitioners. Ther apists may be slow to judg e fe llow therapists since all thera pists are potentially vulnera ble to err ors of prof essional judg ment and fe w may want to have their own prof essional judg ment questioned or r eac ted to strong ly Moreove r, thera pists may be re luctant to put their occ upation in a bad lig ht. Airing even others’ dirty laundry in public (i.e., opening the thera py rela tionship t o considera tion by oth e r a ud ie nc e s su c h a s th e me dia ) m a y ho ld i mpl ic a tio ns fo r t he mse lve s a s w e ll a s f or a ll thera pists. The analog y would be to the “blue curta in” that insulates law e nforc ement and the conc omitant reluctanc e of police to report the de viance of fe llow office rs (Westley 1970; Crank 1997). The interviews will shed lig ht on how thera pists reac t to potential a ud ie nc e s. Chang es in thera py (discussed in more detail in the next chapter) may aff ect how thera pists label deviance and devia nt prac titioners. The introduction of Rog eria n thera py

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13 stressed unc onditional posit ive re g ard. A s behaviorist and pr oblem-solving the rapie s be c a me c omm on pla c e th e fo c us c e nte re d o n c ur re nt b e ha vio rs ra the r t ha n in tr ins ic tr a its or past conditions. The a ctors ar e not labele d as bad, a nd the beha viors are to be trea ted or mit ig a te d, no t c on de mne d. Ha s th e e tho s o f t he ra py c ha ng e e no ug h s o th a t th e ra pis ts do not view beha viors g ener ally as matters of devianc e—including profe ssional be ha vio rs ? Ha s a ne w e tho s d e ve lop e d s o th a t a c tor s a re no t se e n a s d e via nt e ve n if p r o b l e m b e h a v i o r s a r e ? Th e stu dy of de via nc e a mon g the ra pis ts r a ise s so me qu e sti on s a bo ut a ud ie nc e s, actor s, and situations. Although many people may condemn blata nt abuses of the rapy re la tio ns hip s ( e .g ., ha vin g se x with c lie nts ), oth e r a sp e c ts o f p ra c tic e ma y be muc h le ss clea r-c ut. Victims may not be a lar g e or pow erf ul audience in the attribution of devianc e in therapy As clients, they seek the rapy beca use of va rious problems which a re of ten not concr ete; tre atments and outcome s are not standardized. The inde pendent pr ofessional jud g me nts tha t th e ra pis ts a re e xpe c te d to e xer c ise a re ne c e ssa ry g ive n th e un c e rt a int y surrounding the thera py context. C lients also have r elatively less power than the “experts” they seek out, a nd they are not in a g ood position t o know about which the rapy pr a c tic e wi ll o r w ill no t he lp t he m. T he un c e rt a int y ma y be fu nc tio na l f or the ra pis ts i n that members of the larg er soc iety are not in good positions to condemn var ious techniques a nd prac tices that may be espe cially tailored to fit the par ticular ne eds of a client. I n other wor ds, the number of potential condemne rs is reduc ed, they lack the expertise (and he nce the power ) of the pr ofessionals who pr actice thera py and they are on g rounds too shaky for strong condemna tion.

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14 The e x alted pre stige autonomy defe renc e to profe ssional judgment, a nd latitude in self-re g ulation and judg ment that have be en ava ilable for psy choana ly sts and other reg ression thera pists may be at r isk. Reflection and r efle ctivity are undoubtedly occur ring among psy choana ly sts and reg ression thera pists as they confr ont chang es in social conditions describe d above. T he labe ling of parts of r eg ression thera py as devia nt has c a st a sh a do w o n th e ra pis ts w ho us e the se te c hn iqu e s. Sin c e thi s w a s th e ma in pe rs pe c tiv e of ps y c hia tr y a t th e he ig ht o f i ts p ro fe ssi on a l do min a nc e d e nig ra tin g thi s prac tice may have c ontributed to some of the loss of its dominance ove r the other d i s c i p l i n e s a n d o t h e r l e s s f o r m a l t yp e s o f t h e r a p y. The issues ar e compounde d by the norm of c onfidentiality in therapy rela tionships. I ndeed, br eec h of conf identiality may be one of the normative violations tha t is c on de mne d ( a nd c on de mne d s tr on g ly ) b y ma ny pe op le in c lud ing oth e r t he ra pis ts and powe rful socia l control offic ials. Confidentiality allows for instanc es of de viance within therapy to remain sec ret. More over, “ victims” of deviant ther apy who think about repor ting the the rapist fa ce some constraints. Those in ther apy are suspected of having c op ing or me nta l is su e s, wh ic h ma y be sti g ma tizin g in t he mse lve s. Th e ir pr iva te problems bec ome public conc erns if the y repor t, and they may be less cr edibly rec eived than would be the pr ofessional if a dispute arises a bout what happe ned. More over, thera pists derive powe r fr om their forma l training and their individual experienc e of fr a min g iss ue s ( wh ic h is a c omp on e nt o f t he ir wo rk ). Th e y a re un iqu e ly in a po sit ion to pr e se nt a c a se tha t pu ts t he m in the be st l ig ht— the y c a n u se the ir e xpe rt ise to d isc re dit c lie nt b e ha vio rs a nd c a st d ou bt a bo ut m oti ve s o f c lie nts ma kin g a c c us a tio ns

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15 Thera pists constit ute a ke y audienc e for lear ning a bout the norms and socia l rea ction to potentially deviant ther apy prac tices. They may be eng ag ing in de viant prac tices, re acting to the devianc e of othe r thera pists, or adjusting their ow n prac tices beca use of br oader social re actions to deviant pra ctices or prac titioners. Goode’ s lessons about rela tivity sug g est that a study of devia nce in ther apy needs to expl ore a cross diff ere nt kinds of therapists and diff ere nt situations. Therapists can vary by ty pe of tra ining ( e.g ., social work, psy cholog y psy chiatry ), extent of training (e.g ., MSW Ph.D., M.D.), nature of pra ctice ( e.g ., solo, gr oup, self-e mploy ed, sala ried), and natur e of c lientele (e .g ., specia lty populations like children or the elder ly versus g ener al clientele s). Another ke y audienc e for the study of devia nce in ther apy arises w ithin the officia l social control sy stem. Some of the social re action that is important for understanding devianc e in thera py emana tes from off icial social c ontrol ag ents. I ndeed, formal soc ial control re verse s the power arr ang ements in way s that may aff ect perspe ctives on devia nce. Prof essional pra ctices a re r eg ulated by law and by profe ssional g roups which pr omulga te ethica l standards for their member s. Howeve r, diffe rent states/jurisdictions can adva nce dif fer ent laws (e .g ., psy chiatrists in Florida w ill work with differ ent laws fr om those in New Yor k) and diff ere nt professional a ssociations can prese nt differ ent standar ds for ther apists (e.g ., psy chiatrists will belong to differ ent associations than will social wor kers) This contributes to the per ception of the nebulous nature of normative de finitions. Given the rela tivity thera pists may have dif fer ent understanding s about devianc e in their wor kplace s.

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16 Goode a sserts that “it is important to identify the par ty [or parties] judging the behavior or condition . the re levant audie nce” (Goode 1997, 29). I n addition to the leg al sy stem which ser ves as a n audienc e, the na tional, state, and loca l org anizations of thera py disciplines (see f ootnote 1) interve ne to pre vent outsiders including moral e ntr e pr e ne ur s f ro m r e g ula tin g the ir pr a c tic e s [pe rs ua siv e le g iti ma te a c tiv e c re dib le fig ures who la unch a c ampaig n to discredit an a ctivity (108)]. The socie tal norms for thera pists are pre scribed or proscr ibed throug h the forma l standards of e thics of ea ch of these ther apy disciplines. Other c omponents of the audie nce a re the thera pists who are labeled, the ir clients and victims and their soc ial intimates, other direc t observer s of the act( s) judg ed devia nt or of the labe ling pr ocess, membe rs of the ma ss media, member s of society who follow the proc ess throug h media, and othe rs who re ad or he ar a bout the behavior labeled de viant but are at a soc ial distance pr ecluding their being influence d by the judg ment in any way Some “par ties or audienc es, fr om the participa nt to the detac hed obser ver, w ould condemn the be havior, the c ondition, the actor or the possessor, wer e they to come fa ce to f ace with them” (28-9) Constructionist Ver sus the Essential ist View of Deviance Goode ( 1997) re jects an e ssentialist view of devianc e–one w hich holds that essential diffe renc es exist which can be use d to categ orize phenomena including devianc e. I nstead he adopts a moder ate c onstructionism which rec og nizes that many cate g ories ar e socia l and mutable ra ther than de rived to re flec t inherent prope rties or “esse nces.” The c onstructionists hold t hat “de finitions have no absolute, objec tive va lid ity ; th e y a re me a nin g fu l on ly w i t h i n t h e c o n t e x t o f t h e c r i t e r i a s p e l l e d o u t b y a particula r cla ssification scheme ” (G oode 1997, 34).

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17 Con str uc tio nis ts e xpe c t th a t so c ia l c on dit ion s e vo lve F or e xamp le th e y wo uld expect thera py to chang e and the problems thera pists deal with to chang e. De finitions of devianc e in thera py are also expected to evolve as problems de velop and nor ms shift. Th e c ha ng e s ma y oc c ur a t th e the ra pis t le ve l ( e .g in div idu a l r e a c tio ns a nd re sp on se s to issues and vicissitudes of pra cticing in an otherw ise cha ng ing soc ial and phy sical climates), a t the mental hea lth inst itutional level (e.g ., imposit ion of revise d standards a nd sanctions by the thera py org anizations), and/or at the inter -instituti onal level ( e.g ., rea ctions to emerg ing la ws and to exposure by the media) The discove ry of child abuse g ener ally (Pfohl 1977) and the ong oing disc overy of sexual child abuse cr eate d a new context and prompted cha ng e in the lar g er soc iety and among thera pists. Mental health profe ssionals spent multi ple hours ac cessing client/patient’s memorie s as a f irst step in transforming a client/patient’ s dy sfunctional or un ha pp y lif e T he ir pr e se nt p ro ble ms a re ro ote d in pa st e ve nts so tha t me mor ie s se e m to hold the key for suc cessf ul interventions. An institut ional familiarity with Fre udian techniques a nd notions of repre ssion may have a lso contributed to a conc entra tion on eff orts to locate memor ies of those who ha d been vic timiz ed by child abuse. Reg ression the ra py a nd the se a rc h f or re pr e sse d me mor ie s w a s de rigeur fo r t he ra py T he pu bli c a wa re ne ss a nd the e sti ma te d p re va le nc e of c hil dh oo d a bu se su g g e ste d a n e xplos ion in perc eptions of numbers of possible victims, m aking it more nec essar y for ther apy The techniques use d to expl ore the se memories ha s g iven rise to succ essful lawsuits by thirdparties who w ere direc tly aff ecte d by the thera py sessions.

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18 Elite-Engin eer ed Deviance? “ De fi nin g be ha vio r a s d e via nt i s v a ri a ble wi th r e sp e c t to the de g re e to w hic h it is sp on tan e ou s a nd gr as sro ots or organized and enginee red ” (G oode 1994, 56). The lit e ra tur e pr ov ide s li ttl e e vid e nc e of a ny kin d o f s po nta ne ou s g ra ssro ots g ro un ds we ll t o re in i n d e via nc e in t he ra py I ns te a d, the so c ia l r e a c tio n e ma na te d f ro m c ou rt s, leg islatures, and pr ofessional a ssociations which we re the g uardia ns of profe ssional standards of ethics. The a ttribution of deviance whether of par ticular ther apists or of trea tment prac tices, is most manifest in chang es in the ethica l standards a nd in the imposit ion of laws that af fec t the proce dure of thera py I n other wor ds, the definitions of devianc e play ed out at elite leve ls. The leg al and pr ofessional de velopments occ urre d du ri ng a nd ma y ha ve be e n e nc ou ra g e d b y a n a c a de mic c on fl ic t a mon g ps y c ho log ist s about the utility and validity of work on the repr ession of memory (see chapte r 4). Th e inc re a se d a tte nti on g ive n to re pr e ssi on by the me dia wa s d oc ume nte d in chapte r 1. The institution of media helped spa rk popular, le g al, and ther apy rec og nition and intere st in the chang ing c ultural norms of ther apy prac tices and in pra ctitioners who deviate f rom these nor ms. I t reports salient leg al issues and play s a role in making salient the ca ses that re flec t these issues throug h broad e x posure. Public attention was f ocused on the problems that media hig hlight, including the discover y of child abuse and conc erns about sexual child abuse. This attention bring s other instituti ons into play as the e x amine the issues and proble ms from vantag e of the ir separ ate a nd unique per spectives. F orm al and Inf orm al Lab eling of Therapists State and fe dera l statutes can be used for officia l labeling Fe dera l law mandate s the re porting of suspec ted abuse [C hild Abuse Prevention and T rea tment Act (CAPTA)]

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19 T he cas es ci t ed i n t he t ext ar e t he om ni bus ca s es r el at i ng t o har m t hat t her api s t s ca n pr eve nt or t hat t hey 1 can i nst i gat e. T here are many cases whi ch have b een ci t ed i n t he art i cl es conce rni ng regr ess i o n and re p re ssio n o f m e m o ry th a t ha v e p ro v id e d p re c e d e n c e in su its ar ising fro m a lleg e d d a m a g e p re c ip itate d b y a t he rap i st T he f o l l o w i ng are a few o f t he m o re n o t ab l e that i nv o l ve d l i ab i l i t y t o t hird p arti es d am ag ed as a resu l t o f d ev i an t t he rap y pra cti ce s: A C o u c h v. D e S ilva (6 0 2 N .E .2 d 2 8 6 O h io 1 9 9 1 ) (m ish a n d le d re c o v e ry o f m e m o ry b y the ra p ist) B. D oe v M cKay ( 678 N E. 2d 50 ( I l l App. Ct 1997) ( t or t f or l os s of c on s or t i u m oc ca s i on ed by t he rap i st s’ ac t i o ns) C D ill o n v. L e g g 4 4 1 P .2 d 9 1 2 (C a l. 1 9 6 8 ) (e n b a n c ) (p a tien t ac k n o w le d g e d m isd ia g n o sis tha t co u ld b e us e d b y inj u re d third p a rty to e sta b lish lia b ili ty o f t h e ra p ist) D Jam es W v Sup eri o r Co urt (93 C D O S.54 4 9 Jul 16 19 9 3 ) ( d eni al of i m m uni t y f rom s ui t ab o ut u n fo u n d e d c h a rg e s b y c lien t ag a ins t a th ird p a rty) E M at eu v. H agen (K i ng C o unt y Sup eri o r Co urt 91 2 0 8 0 5 3 1 Sea t t l e) ( t herap i st ’ s use of age re g re ssio n b io e n e rg e tics, p syc h o d ra m a t ra n c e w o rk visu a liza tio n an d gu id e d im a g ing w a s o v e rly s ug ges t i ve) which wa s orig inally enac ted in 1974 (P.L 93-247) a nd was last re authorized on J une 25, 2003, by the Kee ping Children a nd Fa milies S afe Act of 2003 ( P.L 108-36)]. Many sta te s h a ve sim ila r p ro vis ion s in the ir c od e s. For mal labels ema nate f rom court c ases. The courts ac t as an a udience which applies devia nt labels direc tly to therapy and ther apist. These f ormal norms g overn 1) thera pists’ testimony when c alled as e x pert witnesse s, 2) prohibition of use by prosec utors of informa tion attained by some thera py techniques w hich incre ase c lient sug g estibilit y and ca n cre ate f alse memorie s, 3) mandate s to report suspec ted abuse or dang er to self or others by thera py clients/patients, and 4) the tolling of the statute of limit ations for torts experienc ed whe n a child. Chief among the ruling s which direc tly apply to therapists and tec hniques labele d deviant ar e the Tar as off and Ramona case s. I n Tar as off v R e ge nts (1976) the c ourt ma nd a te d a the ra pis t to re po rt po ssi bil iti e s f or ha rm by the c lie nt w hic h a re dis c ov e re d in thera py or be he ld liable for da mag es which the client ca uses. Ra mo na v I sa be lla e t al (1994) f irst held thera pists accountable to third-party tort su its Th e c ou rt a wa rd e d b oth c omp e ns a tor y a nd pu nit ive da ma g e s. 1

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20 F M o n to ya v. B e b e n se e (7 6 1 P .2 d 2 8 5 C o lo ra d o C o u rt o f A p p e a ls, 1 9 8 8 ) (d u ty t o c a re fo r h a rm to t hird p arty f ro m f o rese ea b l e fals e c ha rge s) G T yson v. T yson (1 1 9 8 6 W ash .2d ) (d elayed d i sco ve ry and l aten t i nju ry case s) H W C W v. B i rd (84 0 S.W 2 d 50 19 9 2 T exas C o urt of A p p eal s) (prob l em s wi t h cl i ent ’ s t est i m o ny a fter us e o f so d ium a m yta l) I n addition to the leg al ruling s which af fec t therapy there are leg al ruling s which re su lt f ro m c ha ng e s th a t ha ve oc c ur re d in the pr a c tic e of the ra py A mon g the se a re tho se which dea l with therapists as expert witnesses and those which re sult from some of the techniques of thera py disclosed as potentially aber rant by the national media [e.g ., the McMar tin case of New Jersey (McMa rtin, Virg inia, et al. v. Children’s I nst., et al. 494 U.S. 1057; 110 S. C t. 1526; 108 L Ed. 2d 766; 1990 U.S.), the Fr anklin case [Franklin v. Dunca n (WL 684390 9 Cir. 1995)], and the I ng ram c ase [Ray mond v. I ng ram 47 Wash. th App. 781, 737 P.2d 314 (1987)]. For e x ample, in many jurisdictions testim ony will not be a dmi tte d th a t is ba se d o n in fo rm a tio n th e pla int if f o r p ro se c uto r r e tr ie ve d v ia hy pn os is o r p s y ch o ac t i v e d ru g t re at m en t T h er ap i s t s wh o s e t es t i m o n y i s b as ed o n k n o wl ed ge g ained f rom these tec hniques will not be qualified as e x pert witnesse s. For this diss erta tion resea rch, only those ruling s which dir e c tly perta in to the p r a c t i c e o f t h e r a p y ( Tar as off and Ramona ) we re spe cifica lly raised in the inter views. Arg uably some other c ases ha ve had a salient informal e ffe ct on thera pists and the prac tice of the rapy The intervie ws provided the oppor tunity for ther apists to volunteer w h i c h r u l i n g s o r l a w a f f e c t e d t h e i r t h i n k i n g a b o u t d e v i a n c e i n t h e r a p y. The institution of mental health is also involved in formally defining devianc e. Eac h of the ther apy disciplines, in their standards of ethical pr actice cited in cha pter 1, inc lud e s a n o rg a niza tio na l in jun c tio n to do no ha rm ( pr im um no n n oc e re ). B asing thera py on a fa lse premise pote ntially harms the c lient/patient when ac cepting and

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21 focusing on memory which is a produc t of sug g estibilit y rathe r than a ctual eve nts. I ncre asing client/patient sug g estibilit y is adding another impediment into his /her life. This cre ates a weltanschauung which must at some point conflict with rea lity and ser ve as a bar rier to a dapting to present r eal situations and proble ms—one of the main pur poses of thera py I n addition to the harm done to the c lient/patient, having the client/patient ac t up on fi nd ing s e lic ite d b y qu e sti on a ble te c hn iqu e s to re so lve a pr ob le m w hic h d id n ot i n actua lity exis t, even in the pa st, interfer es with prese nt interac tions with ot hers who w ere included in the fa lse memory Third-pa rty lawsuits can a rise in situations where thera py clients confr ont others as a result of the the rapy that they rec eive. Go od e (1 99 7) a rg ue s f or a c on te xtua l c on str uc tio n o f p ro ble ms. The c ontext ualist constructionist’s conce rn is mainly in understanding how d e f i n i t i o n s o f s o c i a l p r o b l e m s a r e g e n e r a t e d s u s t a i n e d t a k e n s e r i o u s l y, and ac ted upon; and how c erta in claims of seriousne ss are advanc ed by specific ag ents and re acte d to, or ig nored, by differ ent audienc es. Goode 1997, 60. This orientation informs the org anization of the next t wo cha pters. I n Chapter 3, I examine how the social proble m of dea ling with mental diff iculties has bee n g ener ated, sustained (or e x terminated) taken se riously and ac ted upon in the past. I n Chapter 4, I e xami ne ho w r e g re ssi on the ra py a nd re pr e ssi on te c hn iqu e s h a ve be c ome de fi ne d a s a so c ia l pr ob le m, h ow the pr ob le m is su sta ine d b y tho se the ra pis ts w ho us e the te c hn iqu e s, and how other s attack the techniques a s needing to be exterminated or modified, a nd I indicate the se riousness of this problem. Afte r a me thodology chapte r, the bulk of the rema ining c hapter s are conce rned w ith data on how the a udience of thera pists view the ra py a nd de via nc e a s w e ll a s r e a c t to the la be lin g a s a pr ob le m.

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A num b er of t hese previ o usl y dis card ed t herap i es ar e no w at l east m argi nal l y accep t ed and s o m e m em b ers 1 of t he A meri can P s y chol ogi cal Ass oci at i on ar e pr ot agoni s t s of many of t hem. A f ew of t hes e l at er re a p p e a re d in m o d ifi e d fo rm s— n o ta b ly ele m e n ts o f t h e w a te r-im m e rs io n the ra p ie s, e le c tric sh o c k the ra p y, a n d m a n y d ru g tre a tm e n t t h e ra p ie s. 22 CH APT ER 3 HI STO RY OF NO RMA L CY D EV I AN CE, AN D C HA NG E I N T HE RA PY Therapy and Change I f the pa st is any g uide to the future today we c an be c erta in of only one thing: The day will come when pe ople will look back at our curr ent me dic ine s f or sc hizo ph re nia a nd the sto ri e s w e te ll t o p a tie nts a bo ut t he ir a bn or ma l br a in c he mis tr y a nd the y wi ll s ha ke the ir he a ds a nd mut te r i n disbelief. (Whitaker 2002, 291) Or g a nize d c on c e rn fo r m e nta l or e mot ion a l il lne sse s a nd the ra py ha s e xiste d in Americ a for only a little over 100 y ear s (Napoli 1981). I n 1892 the Amer ican Psy cholog ical Associa tion (APA) was f ormed, e stablishing a f unctional national org anization for thera pists. W hile there wer e ea rlier a ttempts at centra liz ation (some of which lasted f or y ear s), only afte r the birth of the APA did America have a national c omm un ity of me nta l he a lth sp e c ia lis ts t ha t ha s su rv ive d to the pr e se nt. Sin c e its inception, and e ven thoug h many of the ther apeutic the ories and me thods advanc ed (or at le a st t ole ra te d b y the APA ) h a ve la te r f a lle n o ut o f f a vo r, the APA ha s c on sis te ntl y 1 rec eived r ecog nition as the dominant org anization within t he instituti on of mental he alth. Distinctive era s of thera py befor e that unify ing e vent ar e diffic ult to dis cer n. The prac tice of the rapy did not have the or g anizational structure of an identifiable instit ution require d for tra cing what has be en labe led devianc e as g ener ations prog resse d. I ndeed, there was e ven less sepa ration of phy sical trea tments for disease and morbidity from

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23 tr e a tme nts of me nta l il lne ss t ha n is pr e se ntl y pr a c tic e d. Di sti ng uis hin g me nta l he a lth trea tments from phy sical hea lth treatments is g ener ally impossibl e. The medical model of health has pr edominated, a nd in ear ly history was the only method in use (Ac kerkne cht 19 55 ). Th e br e a dth a nd sc op e of dif fe re nc e s b e tw e e n p ra c tic e s w ie lde d b y the ra pis ts, then and now, c ompounds the difficulty in disti ng uishing e ras. Pre sently instit utional rules and g uidelines do provide standa rds for ma king c omparisons. Ther e we re no instit utional rules and g uidelines in place befor e the f ounding of the Amer ican Psy cholog ical Associa tion—there we re only cente rs for tr eatment, or disposal, of persons wh o w e re ha vin g me nta l he a lth pr ob le ms. The historica l literature r evea ls how difficult it is to di stinguish ea ch historical era That diffic ulty extends to di scer ning w hich pra ctices w ere considere d normative. Even today there are advoca tes and pra ctitioners using many of the methodolog ical prac tices that we re in plac e hundre ds of y ear s previously (bef ore f alling out of favor and in some case s being labeled de viant). Tre atments still rang e enor mously from phy sical int e rv e nti on s ( su c h a s a dmi nis te ri ng ph a rm a c e uti c a ls o r p e rf or min g e le c tr os ho c k) to int e rv e nti on s th a t in c lud e mor e ne bu lou s f a c tor s ( su c h a s r e tr ie vin g me mor ie s o f p a st events). Despite this lack of org anization among the rapists of the distant past and a wide ra ng e of tol e ra nc e fo r d ive rs e ty pe s o f p ra c tic e tod a y th e re is c le a r e vid e nc e of c ha ng e in the predominant theories a nd methods used in thera py during cre dibly distinct eras of thera py Thera py has a history of trea tments and theories w hich have often be en re viled or re g arde d unfavor ably by succe eding thera pist ge nera tions. W hat may be re g arde d by la te r t he ra pis ts a s d e via nc e in t re a tme nt p ra c tic e s ma y ha ve be e n r e g a rd e d a s a

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24 br e a kth ro ug h in kn ow le dg e I nd e e d, so me of the se pr a c tic e s a ssu me d le a din g ro le s in trea ting menta l illness (e.g ., insulin shock therapy lobotomies, and water emer sion). I nd ivi du a l th e ra pis ts p re c ipi ta te d c ha ng e s in the pr e do min a nt m e tho ds of tr e a tme nt i n their pursuit of solutions to mental and/or emotional problems that hindere d normative (or a t least functional) adapta tion to troubled social surrounding s and self ide ntities. The fa ctors which le ad to thera py shifts are historica lly varia ble and a re complicated. I n eac h era individual practitioners a dapt to these shifts in their own wa y s. Th e ir pr of e ssi on a l r ole s a s th e ra pis ts c omp or t to the po ssi bil iti e s th a t a re in t ha t ti me so c ia lly a nd str uc tur a lly c on fi nin g wh ile a da pti ng no t pa rt ic ula rl y to a the or e tic a l id e nti ty bu t mo re to t he pr a c tic a l st a nd a rd s w hic h w or k f or the ir c lie nts a nd fo r t he mse lve s. Em erge nce of Modern P sychiatry, P sychology, and Social Work I n the 19 centur y neurolog y and psy chiatry split i nto separa te medica l disciplines. th These two w ere later joined by psy cholog y as the disciplines most conce rned w ith mental health. This provided the infrastruc ture of the late 19 and the 20 centur ies for building th th and org anizing disciplines for the reg ulation of diag nosis and trea tment prac tices. Modern psy chiatry has bee n descr ibed as da wning at the beg inning of the 19 th centur y (Mar mer 1994). T here was a return to the H ippocra tic belief in the biolog ical ba sis of me nta l di so rd e rs w hic h w a s a tte nd e d b y the ri se of ps y c hia tr y a s a sc ie nti fi c a lly org anized discipline with roots in neurolog y This somatoge nic view f ocused on the be lie f t ha t pa tho log ic a l bo dil y c on dit ion s a nd br a in t iss ue dy sf un c tio ns we re so le ly responsible for mental disorder Mental illness thus became the exclusive domain of ph y sic ia ns H e re dit y be c a me the sa lie nt v a ri a ble fo r u nd e rs ta nd ing me nta l he a lth iss ue s.

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25 P sychiatry’s Em erge nce from Neurology Whil e psy chiatry had roots deve loped from humanists like Ag rippa, Pinel and Tuke (a long w ith a few other isolated r efor mers of the nineteenth c entury ) pave d the way for the tr ansition of psy chiatry into its prese nt form. Their voic es spelled the e nd of justification of punishment for the menta lly ill and provided for moral trea tment and cur e thr ou g h h uma nis tic te c hn iqu e s. Th e te rm ne ur olo g ist c a me to r e fe r t o o rg a nic ph y sic ia ns g e ne ra lly working in hospitals. P sy chiatrists took over the ne urolog ists' old position as the outpatient borde r g uard of the medica l profession, handling the sy mptoms and diseases that see med not quite rea l. . Psy chiatry beg an wh e n a g ro up of e nte rp ri sin g me dic a l r e fo rm e rs a rg ue d in the e a rl y nineteenth c entury that madmen oug ht to be remove d from the jurisdiction of the leg al authorities and pla ced unde r that of the me dical prof ession. Madmen a re sick, the y said; g ive them to us and we will cure the m. A ne w t he or y a nd the ra py jus tif ie d th e sh if t, a nd pr iva te bo die s a nd sta te leg islatures we re soon dotting the country side with insane asy lums. (Abbott 1988, 22) The En try of P sychology By the middle of the ninete enth ce ntury almost all America n psy chiatrists believe d that psy cholog ical proble ms had phy siologica l cause s (Cocker ham 1992). Conventional medical sc ience resisted investig ating how phy sical sy mptoms could procee d from emotional cause s (ra ther than the other wa y around) until J eanMartin Charc ot presente d a pape r on hy pnotism t o the Fr ench A cade my in 1882. Whi le adva ncing a tre atment plan which took into considera tion factors othe r than a natomy and phy siology his methods pr od uc e d p ro ble ms o f t he ir ow n. Un de r C ha rc ot p a tie nts c a me in w ith pr ob le ms [psy chosomatic c onversion sy mptoms, P TSD (post traumatic stre ss disorder), a nd other emotional response s to their unhappy lives]. He ga ve them a c erta in deg ree of leg itimacy (e ve n c e le br ity ), bu t:

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26 He too k a wa y the ir dig nit y a nd the ir ho pe T he y we re pr e sse d in to m a ss confor mity put into sol itary confine ment, turned into chronic even lif e lon g pa tie nts T hr ou g h h y pn oti c su g g e sti on . h y ste ri c a l pa tie nts wer e alr eady becoming iatrog enic monsters. ( Showalter 1997, 36-7) L oo se nin g of the me dic a l mo de l of tr e a tme nt p ro c e e de d s te a dil y bu t sl ow ly there afte r. The g rea test blow to the para digm of the medica l model was the one that set thera py on a path e mphasizi ng psy cholog ical conc epts of per sonality lear ning, a nd mot iva tio n— ps y c ho a na ly sis T he se c on c e pts we re joi ne d to the te c hn iqu e of hy pn oti sm, which had be en first a dvance d a ce ntury befor e by F. Anton Me smer (w ho has bee n deeme d the fa ther of psy chother apy by psy choana ly sts) (Acke rknec ht 1955). The blow wa s d e liv e re d b y the wr iti ng s o f S ig mun d F re ud (o ri g ina lly a ne ur olo g ist ) a nd his e a rl y coauthor J oseph B reue r (discusse d below in Chapter T hree ). Thinking about the natur e of me nta l il lne ss w a s r e vo lut ion ize d b y F re ud a nd B re un e r a t th e e nd of the nin e te e nth centur y Their “ dy namic” psy cholog y included patients who w ere neurotics a s the ps y c ho tic s w ho ha d tr a dit ion a lly be e n tr e a te d b y ps y c hia tr y (H or wi tz 20 02 ). “ Dy na mic theories posited that ne uroses we re c ontinuous with normal behavior” (Horw itz 2002, 1). At the end of the ce ntury (1896) Ar thur Rufus Treg o Wy lie was the f irst America n psy cholog ist to be employ ed in a c linical setting. H e later beca me superintende nt of The I nstitut e for the Fe eble Minded in Nor th Dakota ( Street 1994). The En try of Social Work Psy chiatrist J ohn Conolly in 1856 wrote “ The Tr eatment of the I nsane Without Mecha nical Restra ints” in Engla nd which wa s responsible for the g rowing disfavor acc orded tha t method of trea tment on both sides of the Atlantic (Stree t 1994). Dorothea L y nde Dix, arg uably one of A merica ’s g rea test humanists of the nineteenth c entury was

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27 A m o ng t he p ho t o s o f R i chard A ved o n (19 9 3 ) ar e p i ct ures of t he m ent al l y i l l i n So ut heast ern Lo ui si ana 2 M e n ta l In stitutio n in 1 9 6 7 T h e se p h o to s d o c u m e n t t h a t e v e n th a t re c e n tly wareho usi ng and negl ect were f o un d i n so m e o f t he l arg e m en t al ho sp i t als. instrumental in expos ing de plorable a nd brutal conditions of the menta l hospitals in t he U. S. d ur ing tha t ti me “ Th ro ug h h e r e ff or ts s he pe rs on a lly fo un de d o r e nla rg e d s ome thirty -two mental hospitals . .” (Coc kerha m 1992). She was the most influential a dv oc a te of the pr inc ipl e of pu bli c re sp on sib ili ty fo r t he me nta lly ill a nd g ot t he me nta lly ill out of jails and poorhouses into asy lums. S he also doc umented filth, brutality and deg rading conditions in ex isting hospitals (Street 1994). I ronica lly the numbers of hospitals that sprang up under he r influenc e and the enormous incr ease in the numbers of pa tie nts de c ima te d th e ra tio of e xpe ri e nc e d th e ra pis tsa nd -s ta ff to p a tie nts le a din g the se larg e mental hospitals to become more c ustodial than treatmentoriented. N eg lect and war ehousing sometimes resulted, similar to that found in the 17 centur y but without the th dr a c on ia n me a su re s. 2 Be gi n n i n g i n Bo s t o n i n 1 8 7 7 “c h ar i t y o rga n i z at i o n s o ci et i es ” b ega n i n v es t i gat i n g pr ob le ms o f t he po or a nd pr ov idi ng vis its a nd a dv ic e to a ssi st t he m ( Ka ne 19 83 ). Pa id positions and educational pr og rams for what bec ame soc ial work pra ctitioners deve loped fr om t he se so c ie tie s. B y the tur n o f t he c e ntu ry s e ttl e me nt h ou se s ( e .g ., Jane Ad da ms’ Hull House in Chicag o and L illian W ald’s He nry Street Settlement House in Ne w York) be g a n a dd re ssi ng the so c ia l pr ob le ms a sso c ia te d w ith he a lth c on dit ion s a nd he a lth problems. The phy sician who is g ener ally considere d to be the founde r of medic al social wo rk Ri c ha rd Ca bo t, i n th e fi rs t de c a de of the tw e nti e th c e ntu ry sa w t he ne e d f or pe op le who would ac t along side and in tea mwork with the phy sicians to bridg e the g ap betwe en

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28 the wo rl d o f m e dic a l pr a c tit ion e rs a nd the ir imp ov e ri sh e d p a tie nts (K a ne 19 83 ). At fi rs t many of these w ere nurses, but in 1913 social wor kers we re disting uished from doc tors and nurse s as those whose f ield of study was c hara cter human re lationships, and community life. I n addition to joini ng hospital staff, other settings soon be g an see ing so c ia l w or ke rs a s st a ff me mbe rs s uc h a s me nta l he a lth c lin ic s, sc ho ols ju ve nil e c ou rt s etc. Social worke rs deve loped org anizationally first as The Americ an Society of Hospital Social Workers, founde d in 1918, then in a number of other a ffiliations including the omnibus National Association of Social Workers ( NASW) in 1955. Educa tionally stipends were first awa rded f or the study of social wor k by the National I nstitut e of Me ntal Hea lth in 1947. Al tho ug h th e g ro wt h a nd de ve lop me nt o f p sy c ho a na ly sis a nd so c ia l w or k in to inc re a sin g ly po we rf ul a nd ind e pe nd e nt o rg a niza tio ns pr oc e e de d f ro m th e la te nin e te e nth and throug hout the twentieth ce nturies, these de velopments by no means provide d a fa tal blo w t o th e me dic a l mo de l f or me nta l he a lth I nd e e d, the me dic a l mo de l ha s b e c ome reinvig orate d with advanc es in drug thera py Psy chophar macolog y has bec ome a major form of tre atment. Fur ther, the D iag nostic Statist ical Manua ls have provide d fix ed sy mptomology for diag nosis, rece nt advanc es in brain a rea mapping have pr ovided new possibili ties for tre atment, and r ece nt advanc es in g enetics ha ve ra ised new que stions a b o u t h e a l t h i n a l l r e a l m s o f t h e b o d y, e m o t i o n s a n d c o g n i t i v e h e a l t h A d d i t i o n a l l y, rec ent adva nces in g enetics a nd brain imag ing a re only two of the promising are as for medical inter ventions in mental health.

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29 Variet y of T herapies: The 20 Century th All in all, there a re a t least two hundred the rapie s and numerous ps e ud oth e ra pie s a va ila ble in c on te mpo ra ry Wes te rn so c ie ty a ll i nte nd e d to counter act psy cholog ical stress a nd behavior al abnor mality (Cocker ham 1992) By the twentieth ce ntury despite the fa ct that a lar g e number of thera pists were still rec eiving training in Europe, ther e wa s a diffe rent motivation for tre atment in the two c on tin e nts E ur op e a ns we re mor e c on c e rn e d w ith ho w t o c on tr ol t he ir po pu la tio ns wh ile Americ ans we re more conce rned w ith how to increa se ec onomic productivity (Cushman 1992). B uilding cha rac ter “ throug h self-discipline, thrift, ha rd work, c leanliness and relig ious instruction” beca me the Europe an model for mental hea lth while in America the “multilay ere d rela tionship between politics and ‘pe rsonal g rowth’” led to stresses on pe rs on a lit y “ the su m of pe rs on a l qu a lit ie s th a t c a us e d o ne to b e lik e d b y oth e rs . to stand out in a crow d” (Cushman 1992, 35). At the turn of the c entury and conc urre nt with Fre ud’s deve lopment of psy choana ly tic theory and the importanc e of c onfession and sug g estion, Emil Kraepe lin wa s d e ve lop ing the c la ssi fi c a tio n s y ste m f or me nta l il lne ss t ha t is sti ll i n u se F ro m hi s clinical obser vations he deve loped a thre efold c lassification (de mentia pra ecox, para noia, a nd ma nic -d e pr e ssi ve ps y c ho sis ) t ha t is the sy mpt oma tic sy ste m th a t ( wi th s ome ref inements and c hang es in terminolog y ) still occupies much of the thought, pr actice and theory of thera pists today Th e de mis e of sp ir itu a lis m a nd oc c ult ph e no me na wa s r e po rt e d a ft e r t he 19 04 fi rs t Con g re ss o f E xpe ri me nta l Psy c ho log y in G e rm a ny I t ha d b e e n r e pla c e d b y a sc ie nti fi c approa ch empha siz ing obse rved f acts a nd explanatory theories ( Street 1994). At the 1904

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30 St. L ouis W orld’s F air, menta l health was r epre sented with pape rs by psy cholog ists on the cur rent state a nd future pr ospects of psy cholog y followed by section mee tings on Gene ral Psy cholog y which conc erne d experimental, compar ative, and a bnormal psy cholog y (Street 1994) The “ new psy cholog y ” of the 1920s, psy choana ly sis, had direc t effe cts on Am e ri c a n li fe T his ne w p sy c ho log y “ re pr e se nte d a re vo lt” a g a ins t th e a c a de mic psy cholog y with phases of psy choana ly sis, emphasis on endocr ine g lands, and, late r, behavior ism (Burnha m 1988). I n L ondon at the Ta vistock Clini c, psy choana ly tic thera py fo r i nd ig e nt c lie nts re c e ive d it s f ir st c lie nt a nd we nt o n to be c ome kn ow n f or wo rk in psy chosomatic medic ine, social psy chiatry and child and f amily thera py (Street 1994) During the first quar ter of the 20 centur y psy cholog y was staking its own th do ma in i n th e fi e ld o f m e nta l he a lth I ts d e ve lop me nt h a s b e e n e xami ne d b y Na po li: More a nd more, c linical psy cholog ists found themselves in competition with psy chiatrists, poorly trained te sters, and c omplete cha rlatans. . To win public support they wer e impelled to 1) stake a cla im to ex clusive competenc e and 2) show their ser vice ha d widespre ad applica tion. . C o n t ra s t i n g t h em s el v es t o t h i s s o u rc e o f c o m p et i t i o n ap p l i ed p s y ch o l o gy proudly cited their ow n use of the sc ientific method, labora tory e xpe ri me nta tio n, a nd sta tis tic a l te c hn iqu e s. . [A pp lie d p sy c ho log y ’s ] re a lm o f i nq uir y . w a s v a ri ou sly se e n a s b e ha vio r, ha bit s, mot ive s, fe e lin g s, or so me c omb ina tio n o f t he se (3 0 & 31 ). Ap pli e d p sy c ho log ist s insisted that hosti le emotions and beha vior wer e not direc tly produce d by the e nv ir on me nt b ut g re w f ro m w ith in t he ind ivi du a l a s a re su lt o f f a ult y pa tte rn s o f a dju stm e nt ( 39 -4 1) Ps y c hia tr ist s . we re in n o p os iti on to tr e a t a ll o f A me ri c a ’s be ha vio r p ro ble ms. Th e ir nu mbe rs we re sma ll, the ir training spotty and their vie w of the situation my opic. (Na poli 1981, 53) Psy c hia tr y wa s c on fr on te d w ith ind us tr ia l ps y c ho log ist s a nd ind us tr ia l so c iol og ist s in the 1930s and to maintain its dominance in the fie ld of mental hea lth in the cities

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31 c ha ng e s w e re ma de T he imp or ta nc e of the ra pe uti c te a mw or k b e c a me e vid e nt. Na po li holds that therape utic teamwor k was c ase or iented: The c oncept of thera peutic tea mwork . g rew from the be lief that eve ry case require d a thre e-pr ong ed appr oach. I deally the team c aptain, the psy chiatrist, provided psy chother apeutic tr eatment; the c linical ps y c ho log ist a dmi nis te re d te sts ; a nd the so c ia l w or ke rs de ve lop e d c a se his tor ie s. I n p ra c tic e h ow e ve r, the du tie s o f t he ps y c hia tr ist be g a n to merg e. I t beca me incre asing ly difficult to distinguish betwee n trea tment and ca se history in part bec ause psy choana ly tic psy chiatry had an intrinsically historical method and in par t beca use social wor k was adopting psy chiatric theory as the c onceptua l foundation for its own profe ssional aspirations. (Na poli 1981, 54-5) F re ud did no t li ve to s e e ho w p sy c ho a na ly sis c a me to d omi na te the me nta l he a lth scene and bec ame pr ofessionalized. Psy choana ly sis was transfor med in the y ear s from 1917 to 1940, from the c a lli ng of a se lf -c ho se n g ro up of a va ntg a rd e ps y c hia tr ist s a nd ne ur olo g ist s to a profe ssion with it s own institut ions for training and ce rtification, separ ate f rom medicine a nd psy chiatry y et with close ties to both. The Am e ri c a n in sis te nc e on me dic a l tr a ini ng c a me in p a rt fr om t he wi sh to attain the scie ntific authority associate d with the medical pr ofession. . Psy c ho a na ly sis e njo y e d a n e no rm ou s, ne w, op tim ist ic vo g ue v a stl y expanding its thera peutic domain and its influenc e in medica l schools and in the newly founded N ational I nstitut e of Me ntal Hea lth. (Hale 1995, 381-2) Psy c hia tr ist s st ill he a de d mo st m e nta l ho sp ita ls b ut c ri tic ism s o f t he his tor ic a l, clinical and philosophica l gr ounds of psy choana ly tic theory opened the door for nonmedical tre atments (Ha le 1995). The alienating fre edoms of the industrial ag e had prog resse d in the U.S., bring ing w ith them “moral illiteracy confusion, isolation, loneliness, and selfpreoc cupation, lea ding to the ne ed for the social pra ctice of psy chother apy ” (Cushman 1992). During and rig ht after the war there was a shuffling of ac cepte d theories on trea tments. I nroads we re ma de by psy cholog ists during this period into the prof essional

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32 dominance of the psy chiatrists and ne urolog ists. Medical trea tment stil l had other avenue s for a pproac hing me ntal health. I n 1940, succe ssful use of insulin shock thera py wa s in tr od uc e d f or pa tie nts wi th s e ve re me nta l il lne ss ( Str e e t 19 94 ). I n 1 94 7 p sy c hia tr ist s in M a ry la nd a nn ou nc e d th a t pr e fr on ta l lo bo tom y ha d le d to the re le a se of se ve ra l pa tie nts who had pr eviously been dia g nosed as incur able. This pra ctice be came widespre ad in the 1940s, but in 1950 one of the for emost prac titioners, Walter Fre emen, a nnounced tha t he wo uld no lon g e r p e rf or m lo bo tom ie s o r t op e c tom ie s b e c a us e of the ir ha rm fu l a ft e re ff e c ts (Street 1994) There afte r, these pr ocedur es lost more and more favor and we re r eplac ed by e le c tr os ho c k th e ra py a nd ps y c ho ph a rm a c e uti c a ls, wh ic h a re us e d to da y to t he sa me purpose f or similar patients in some hospitals. Use of insulin shock, elec troshock, and lob oto mie s a nd top e c tom ie s w e s r e du c e d a s d ru g the ra pie s a ssu me d a sc e nd a nc y in t he se sever e ca ses of menta l illness. I n 1953 and 1954, Thora zine (chlorproma zine) and Serpasil (re serpine) wer e appr oved by the U.S. Food a nd Drug Administration for use a s having led to rema rkable prog ress in schizophrenics ( bipolar) a nd some other psy chotics. The re sults were inde ed re marka ble—for a time. The problems that dopa mine and se ro ton in b loc ke rs ha ve c a us e d c hil dr e n a nd so me oth e r p a tie nts (s e e Whit a ke r 2 00 2) is curr ently being addre ssed by rese arc hers, journa lists, and even Cong ressional c ommitt ees a g a i n s t a w e l l f i n a n c e d p h a r m a c e u t i c a l i n d u s t r y. Whil e psy chiatrists wer e the pr imary purvey ors of menta l health at the star t of World W ar I I psy cholog ists and social worke rs filled nee d for pe rsonnel and c ontributed a no nme dic a l, p sy c ho the ra pe uti c pr of e ssi on a lis m to the me nta l he a lth ins tit uti on T his need le d the war psy chiatrists to abandon “ their cla im to ex clusive rig hts in thi s field, fa lli ng ba c k to the po sit ion tha t th e y mus t on ly ha ve ov e ra ll s up e rv isi on of ps y c hia tr ic

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33 patients” (N apoli 1981, 143). B ehavior modification, derive d from psy cholog y ’s experimentally established under standing of lea rning fac tors, beca me the ar ena of appea l during the war y ear s. Carl Roge rs’ humanistic psy cholog y fea turing g roup thera py and nondirec tive “insig ht therapy ,” provide d a non-F reudia n approa ch to psy chother apy (Na poli 1981). Psy cholog ists became e ven more influential when a psy cholog ical boar d was c rea ted by President Truman to de al with propag anda a nd economic a nd political activities during the Cold W ar ( Street 1994). Dur ing the se y ear s, psy chiatrists wer e not the only thera pists to enga g e in trea tments which bec ame labe led deviant. F or example, in 1 95 1 a Se a ttl e ps y c ho log ist wa s c on vic te d b e c a us e he us e d s e xua l in te rc ou rs e ostensibly to cure the g uilt complex es of thre e of his fe male clients (Stre et 1994). I n 1955 a fe dera l commission reported that over half of the 1.5 milli on hospital beds in the U.S. wer e used to c are for pe ople with mental illness, and dec lare d that mental illness was the g rea test single he alth problem in the United States (Stree t 1994). Alterna tives were soug ht and patients we re inc rea singly rele ased into their c ommuniti es. “The mental hospitals relea sed most of their patients fr om 1965 to 1975, and many closed fo r g oo d” (H ob so n & L e on a rd 20 01 3 9) Ps y c ho a na ly sis wa s st ill a po te nt f or c e in mental hea lth and illness. I n 1956 an Amer ican c ritic noted that more pe ople used ps y c ho a na ly sis a s a n e xpla na tio n o f h uma n b e ha vio r t ha n a ny thi ng e lse in m od e rn tim e s, e xce pt t he g re a t r e lig ion s ( Ka zin 1 95 6) N e ve rt he le ss i ts d omi na nc e wa s w a nin g a nd in 19 79 it b e c a me bu t on e of the div isi on s ( Di vis ion 39 ) o f t he Am e ri c a n Ps y c hia tr ic Association. Be tween 1960 a nd 1985 near ly all the fa ctors that had c ontributed to the rise of psy choana ly tic psy chiatry wer e in par t reve rsed: doubts g rew about the sc ie nti fi c va lid ity a nd e ff e c tiv e ne ss o f p sy c ho a na ly sis ; a lte rn a tiv e s to

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34 the ps y c ho a na ly tic ps y c ho dy na mic sty le a ro se ; ps y c ho a na ly sis los t it s ide nti fi c a tio n w ith ps y c hia tr ic re fo rm ; so c ia l c on dit ion s f or ps y c ho a na ly tic pr a c tic e c ha ng e d; p a rt ly be c a us e of a la c k o f d e mon str a ble re su lts g overnme nt and private funding for psy choana ly tic training and re sear ch dwindled; some psy choana ly sts retrea ted from the ne w thera peutic fie lds they had stake d out, among them, psy chosomatic medic ine and the trea tment of schizophrenia. (H ale 1995, 300) By the mid-1960s, the medica l model of hea lth and psy choana ly sis was being questioned on many fronts. L eading the attac k wer e R.. D. L aing Thomas Szasz and Er ne st B e c ke r. B e c ke r ( 19 64 3 ) i ns ig htf ull y a rg ue d th a t th e re wa s a re vo lut ion in psy chiatry due to the invasion of philosophy and the soc ial scienc es into the rea lm of mental hea lth and illness, formerly dominated by the medica l view of human ills. He a rg ue s th a t “ me nta l il lne sse s” a re “ br oa dly c ult ur a lly be ha vio ra l, r a the r t ha n n a rr ow ly medical, phe nomenon.” Psy choana ly sts failed to make pla in that the world of e x terna l objects has to be “ cre ated” as we ll. Bec ker pr oposed a tra nsactional sy stem rather than a completely medical or psy choana ly tic one. I ncre asing ly mental hea lth professions moved towar d ecle ctic appr oache s beg inning in the mid-1960s. Ec lecticism emphasized “the ide a that methods orig inating in d if fe re nt s c ho ols of the ra py ma y be c omb ine d f or ma xima l th e ra pe uti c e ff e c tiv e ne ss" (Arnkof f & Glass 1992, 671). I t signa led an ope nness to chang e. Not surprising ly additional thera pies wer e deve loped. For example, cog nitive-beha vioral thera py came of ag e in 1970s. I t is based on establishing war m and su pp or tiv e re la tio ns hip s w he re log ic r ule s o f e vid e nc e a nd Soc ra tic qu e sti on ing (t o encour ag e patient to re veal, que stion, and corr ect the a ssumptions responsible for his/her bleak outlook and that usua lly takes six t o twenty wee kly visits). I t is prefe rre d over dr ug

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35 thera py by many thera pists for dealing with mild t o modera te ca ses of de pression (Hobson & L eonar d 2001, 165-6). The ne ed to deve lop effe ctive interve ntions gre w in part out of a n expanding ne ed for menta l health servic es. B etwee n 1970 and 1995 Hor witz (2002) estimates that eac h y ear about 15% of the adult population of the United States soug ht some ty pe of pr of e ssi on a l tr e a tme nt. Cor re sp on din g ly th e nu mbe r o f m e nta l he a lth pr of e ssi on a ls qu a dr up le d d ur ing tha t ti me fr a me to m e e t th is d e ma nd (s e e Ce nte r f or Me nta l H e a lth Service s 1996 and 1998 cited in Hor witz 2002, 4). Educa tion and training in therapy also cha ng ed. I n 1968 the first prog ram that re p l ac ed t h e d i s s er t at i o n wi t h fu rt h er p ra ct i ca l t ra i n i n g l ed t o a n ew d o ct o r o f p s y ch o l o gy deg ree (Psy D) (N apoli 1981). I n 1973 this progr am was a ccr edited by the Amer ican Psy cholog ical Associa tion as an alter native to the tra ditional doctorate ( Napoli 1981). “Althoug h the Psy D prog ram a t the University of I llinois has since be en discontinued, the I llinois prog ram c arr ied the for ce of a re specte d fac ulty in a pre stigious university a ri g or ou s c ur ri c ulu m, a nd a n a pp e a ra nc e of so lid ity tha t pa ve d th e wa y fo r o the r p ro g ra ms to follow" ( Paterson 1992, 836). D issatisfaction with profe ssional training as conduc ted in traditional PhD prog rams continued to de epen, how ever and insistence on c hang e wa s expressed in many way s. At the same time, the public ne ed for psy cholog ical ser vices continued to g row (Pate rson 1992). Medic al dominance outside the hospital and the dominance of psy choana ly sis as the major for m of diag nosis and trea tment were being challeng ed by psy cholog ists and social worke rs espe cially dating from the e arly 1960s. Psy cholog ists and social worke rs took on new menta l health roles, some of which had

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36 previously been pe rfor med by medical pe rsonnel, af ter the Community Mental He alth Act of 1963. (Abbott 1988, 121). Although the medical pr ofession’s he g emony is being challeng ed, it continues espec ially in some are as. Not until 1974 did the first psy cholog ists become tra ined and authorized to presc ribe psy choac tive drug s (Street 1994). Seve ral state psy cholog ical associations have been instrumenta l in bringing to their leg islators the question of whether specia lly trained psy cholog ists shoul d be allowe d to prescr ibe medicine. The lessons fr om history indicate that ther apy will continue to evolve. I n the 1700s, structural f actor s led to a re volution in how therapy was done and who wa s doing it [ as noted by Fouc ault (1961/1965; 1973/1994) and Stree t (1994)]. I deolog y of The Enlighte nment led to humane tre atment of the 1800s ( Gallag her 1980; Cushman 1992; and Stree t 1994) and a round the turn of the 20th centur y to dy namic psy chiatry and psy choana ly sis (Acke rknec ht 1955; Abbott 1988; Burnham 1988; Cocker ham 1992; Cushman 1992; Marmer 1994; Stree t 1994; Showalter 1997; and Horw itz 2002). The rise of te chnolog y and industry for World War I I culminating in the ne ed for ps y c ho log ic a l in pu t le d to the e me rg e nc e of ps y c ho log y a s a ma jor fa c tor in m e nta l he a lth and illness in the U.S. (Napoli 1981; Cushman 1992; St ree t 1994; and Hale 1995) Cha ng e s in ph ilo so ph y a nd so c ia l sc ie nc e s o f t he 19 60 s a nd 19 70 s le d to be ha vio ri sm, ecle cticism, asce ndancy of applied psy cholog y in mental health, and to the f urther de cline of medica l and psy choana ly tic dominance ( Be cker 1964). How ther apy is done continues to evolve. Re cent c ontroversie s over r epre ssion and re g ression thera py espec ially those involving c hildhood sex ual abuse may eff ect that e vo lut ion L a be lin g so me pr a c tic e s o f t he ra py a nd so me the ra pis ts a s d e via nt p os e s a

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37 Sec t i o n 5 o f t he A m eri can M ed i cal A ss o ci at i o n “ P ri nci p l es of M ed i cal E t hi cs” di rect s p sy chi at ri st s (and 3 o t her do ct o rs ) t o “ co nt i nue t o s t ud y ap p l y and ad vance sci ent i f i c kno wl ed ge (and) m ake rel evant info rm a tio n a v a ilab le to p a tien ts, co llea g u e s, a n d the p u b lic . .” ( T h e P rin c ip le s o f M e d ic a l E thic s W ith A nn o t ati o ns E sp ec i all y A p p l i ca b l e to P sychiatry 2 0 0 1 ed i t i o n, ht t p : / / 2 2 2 .psych .org / ap a_ m em b ers/ethics_ o p i ni o ns53 1 0 1 cf m ). T h e p re a m b le o f t h e A m e ric a n P syc h o lo g ic a l A sso c ia tio n E thic s C o d e sta te s tha t p syc h o lo g ists “striv e to hel p t he publ i c i n dev el op i ng i nf ormed ju dgment s an d choi ces conc er ni ng beha vi or. I n doi ng s o, t hey p e rfo rm m a n y ro le s, su c h a s re se a rc h e r, e d u c a to r, d ia g n o sticia n t h e ra p ist, su p e rv iso r, c o n su ltan t, admi n i s t r at or s oci al i n t er v en t i on i s t a n d e x per t w i t n es s ” ( Amer i ca n Ps y ch ol og i ca l As s oci at i on 2001, ht t p : / / www ap a. o rg/ et hi cs/ co d e2 0 0 2 ht m l ). challeng ed that ther apists and their prof essional org anizations must manag e. The interviews c onducted f or this resea rch a re de signe d to shed light on how the rapists are manag ing tha t challeng e. The sy mbolic interac tionist roots of labe ling theor y (Ake rs & Sellers 2004) sensitiz e us to the prospe ct that devianc e standa rds ar e neg otiated. The la beling perspe ctive shar es with conflict a ccounts the pr emise that more pow erf ul individuals and g roups have more influenc e on those ne g otiations. Therapists are not powerle ss, so we might expect them to influenc e how ther apy and mental he alth are define d by lay individuals. Therapists’ own inter nal deba tes and c onflicts will affe ct the neg otiated de fi nit ion s. The methods ther apists use and a dvocate provide a n instrumental and evolving infrastruc ture for lay understanding of mental he alth. As the major r esourc e for kn ow le dg e a bo ut t he la te st t he or ie s a nd me tho ds re g a rd ing me nta l he a lth iss ue s, thera pists have attained hig h status in America n society They are consulted by individuals and org anizations for g uidance in attaining sa tisfaction and pr oductive achie vement in individual daily life. B e sid e s d ir e c t me tho ds su c h a s o pe nly pu bli c izin g e me rg ing me nta l he a lth the or ie s a nd str a ta g e ms, the ra pis ts a lso pr ov ide a n in dir e c t in fl ue nc e T hr ou g h th e ir 3

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38 W el t ans chauung : one’s phil o sop hy or co ncep t i o n of t he uni vers e and of l i f e (W eb st er’ s D i ct i o nary 19 7 6 ). 4 re se a rc h a nd e xpe ri e nc e s w ith a nu mbe r o f c lie nts or pa tie nts th e ra pis ts d isc ov e r a nd us e standards a nd coping methods for unde rstanding what mental he alth is and how it can be a tta ine d o r k e pt. Th e se sta nd a rd s a nd me tho ds a re a sse sse d b y the g e ne ra l pu bli c a c c or din g to h ow he lpf ul t he y a re pe rc e ive d to be fo r c lie nts or pa tie nts Wh e n th e re su lts lead to a be tter life f or the c lients, they are copied a nd used by other membe rs of socie ty Th os e wh o ma y ha ve no pe rs on a l c on ta c t w ith the ra pis ts a re thu s a lso inf lue nc e d b y the se sta nd a rd s a nd me tho ds M e nta l a nd e mot ion a l weltanschauungs and methods for 4 a tta ini ng me nta l he a lth g oa ls a re sh a pe d in a c c or da nc e wi th t he se the or ie s a nd the se examples. Controversies surr ounding the repr ession of memories a nd reg ression thera py a mon g the ra pis ts, the ir pr of e ssi on a l a sso c ia tio n, a nd ou tsi de rs (t he pu bli c a nd la w) c re a te c on fu sio n. De via nc e wi ll b e ne g oti a te d a nd de fi ne d w ith in t his c on fu sio n. Th is a na ly sis now turns to the deba te about re pression and r eg ression.

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39 CH APT ER 4 R E G R E S S IO N P O LE M IC The Debate The de bate ove r re presse d memories and r eg ression thera py techniques to re cover tho se me mor ie s p ro vid e a po int of e ntr y fo r e xami nin g ho w d e via nc e in t he ra py is constructe d. The use of reg ression tec hniques to rec over me mories of c hildhood sex ual abuse is espe cially controve rsial. Article s in journals from many social scienc e disciplines have not only challeng ed or de fende d the technique s used to discover repr essed memor ies, but have a lso questioned whether repr ession itself is a valid conc ept to be used in thera py (L oftus 1993; By rd 1994; Glea ves 1994; Gold, Hug hes, & Hohnec ker 1994; Olio 1994; Nelson & Simps on 1994; Goldzband 1995). Some social scientists note that there is c onsiderable evidenc e that wha t many people think ar e memories ar e in fa ct imag es of e vents that neve r took place They are false memories There is no corre sponding e mpirical evide nce tha t the phenomenon c alled “r epre ssion” has any rea lity at all (Holmes 1991; Of she & Watters 1993; and Pope & Hudson 1996). Some have c riticized resultant lawsuits alleg ing se x ual abuse based on r eca lled memories since no e x periments have demonstrated c onclusively that memories ca n be re presse d and the n r e lia bly re c ov e re d ( L a nn ing s 1 98 9; H olm e s 1 99 1; O fs he 19 92 ; L of tus & Ros e nw a ld 1993; and Wright 1994). My literature revie w disclosed conc eptual diffe renc es as to which the rapy prac tices ar e conside red de viant and conf ronted que stions about which thera pists will be

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40 labeled a s deviant within differ ent thera py disciplines. This dissertation uses interviews of re cently cer tified or license d thera pists (since 1995, since r esponsibility to third parties was rule d in 1994) to examine the construction of de viance about thera py prac tices and pr a c tit ion e rs F reud’s Understanding of Repre ssion Sigmund Fr eud introduce d the term “ repr ession.” The re ha s been a n ong oing c on tr ov e rs y ov e r S ig mun d F re ud ’s un de rs ta nd ing of re pr e ssi on H e su pp lie d th e fi rs t seed of controve rsy in 1893 when he w rote on re pression “I t was a que stion of things that the patient wished to for g et, and ther efor e intentionally repr essed f rom his conscious thought a nd inhibited and suppressed” (B reue r and F reud 1893/1961, 10). As written, this passag e does not imply that repr ession is an unconscious menta l proce ss. Howeve r, the pa ssag e bec ame c ritical in later y ear s due to a footnote w ritten by Anna F reud. I n the footnote to the pa ssag e Anna Fr eud wr ote that the word intentionally mere ly indicates the e x istence of a motive and c arr ies no implication of conscious intention" ( Br euer and F reud 1893/1961, 10). Today the distinction between c onscious and unconsc ious removal of me mory from the c lient’s acc ess (re pression ver sus suppression) is of g rea t importance. I n the leg al re alm, tolling a tort (i.e ., deter mining the leng th of time remaining befor e leg al reme dy can no long er be soug ht) is gove rned by the leg al distinction between r epre ssed memories and suppr essed memor ies (memorie s which have been bloc ked fr om rec all as op po se d to tho se wh ic h th e ind ivi du a l de c ide s n ot t o r e me mbe r b ut h a s th e a bil ity to reme mber).

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41 P rese nt State of the Debate Writi ng in favor of the conc ept of re pression, psy choana ly st David Calof (1993) descr ibes his child abuse c lients as having dissociative sy mptoms such as sleepwa lking and memory disturbance s and sig ns of post-trauma tic stress, such a s flashbac ks, sleeping dis tur ba nc e s a nd nig htm a re s a nd de pr e ssi on or oth e r m oo d d ist ur ba nc e s. Th e se a re bu t a few of the many sy mptoms t hat have been a ttributed to consequenc es of r epre ssed memories of CSA (c hildhood sex ual abuse ) (e .g ., Ba ss & Da vis 1988; Blume 1991; Fr edric kson 1992; and Whit field 1995). On the other hand, Da vid Holmes review ed 60 y ear s of attempts at proving the e xiste nc e of re pr e ssi on H e no te s: Not only do these finding s fail to provide support for the conc ept of repr ession, but they are the opposite to what would be pr edicted on the basis of re pression. . Even if repr ession does func tion in the way that the ra pis ts w ho wo rk wi th r e c ov e re d me mor y su pp os e is it p os sib le to repr ess re peate d, longterm abuse s, some of which be g an in infanc y and lasted we ll into adult y ear s? . Of c ourse, without the conc ept of repr ession, the edific e of psy choana ly sis collapses. (Holmes 1991) Post t rauma tic stress sy ndrome is often c ited as a c ause of repr essed memor ies. There are a number of ar ticles in rebuttal. F or example, Skow specifie s that there w ere thousands of Holoca ust victims who remembere d their stress in g rea t detail. There are only a fe w ver y vocal or ators who make the ca mpus circuit claiming they do not reme mber (Skow 1994) Rape victims also do not repr ess eve ry thing. Of she noted that with combat and sa vag e ra pes there is traumatic amne sia but notes that suffe rer s know they have suf fer ed the e x perie nce, but ha ve lost the details (Of she 1992). Paul McH ug h, direc tor of De partment of Psy chiatry and B ehavior al Science at J ohns Hopkins

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42 Un ive rs ity o bs e rv e d ( in Wr ig ht 1 99 4) tha t r a the r t ha n me mor ie s b e ing blo c ke d o ut i n c a se s o f s e ve re tr a uma c hil dr e n r e me mbe r t he m a ll t oo we ll. A n umb e r o f i nd ivi du a ls w ho “ dis c ov e re d” re pr e ssi on of me mor y (i e s) of CSA have la ter a verr ed that their me mories wer e not of a ctual eve nts but were a product of the ra py se ssi on s. On e su rv e y fo un d 2 2% of 63 0 c hil dr e n in c a se s o f a lle g e d s e xua l a bu se later r eca nted (Sorense n and Snow 1991). Whateve r the re asons for this cha ng e in belief the pre sence of such a number of r etra ctors provide s support to the arg ument that, at the ve ry le a st, so me pr e vio us ly s tr on g ly be lie ve d me mor ie s o f C SA a re fa lse in c lud ing tho se wh ic h ma y be a re su lt o f d e via nt t he ra py pr a c tic e s ( vio la tin g the e thi c a l di re c tiv e to thera pists to “above all, do no har m”). I ntera ctive re lationships, social structures, a nd developmenta l socialization are essential ele ments for unde rstanding the ana ly sis of memories—as r epre ssed, forg otten, de la y e d, de fe rr e d, ma nu fa c tur e d, or jus t f a lse —a s w e ll a s f or un de rs ta nd ing ho w t he se conce pts are c onstructed by thera pists. I n view of the incre ased sa lience of repr essed memories in discourse s about thera pies and the pole mic over usa g e and va lidity for thera py this diss erta tion is relevant as a sociolog ical study on the construc tion of reg ression thera pies, prac tices within therapy disciplines, and devianc e within thera py prac tice. Co nst r uc ti on o f a N e w Sel f De bil ita tin g me nta l sy mpt oms tha t pe rs ist int o a du lth oo d h a ve be e n li nk e d to childhood sexual abuse by numerous re sear cher s since F reud initially used the c oncept of repr ession. The role of the ther apist is to assist in the proce sses of dec onstruction and rec onstruction rathe r than produc ing a template to match the the rapist' s own ideolog y and

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43 experience s. Throug h the intera ction of client a nd thera pist, memories of childhood ph y sic a l or e mot ion a l st re ss o r t ra uma a re dis c ov e re d. Tr e a tme nt i nc or po ra te s th e se finding s. When the memory “discove red” is one that the client may have f org otten, pe rh a ps fo r m a ny y e a rs e me rg e nc e du ri ng the ra py e ng e nd e rs the qu e sti on of the e xten t to which the memor y was of a ctual occ urre nces or was produc ed or a ltered in the the rapy proce ss. Contexts of Therapy-Assisted Self Construction Correla tions between a number of a dult sy mptoms and CS A have been statistically examined by numerous socia l scientists. Regr ession theorists may suspect and ac tively probe f or re presse d memories in clients with any sy mptom that shows such a corr elation (see Pope & H udson 1996; W eene 1993; Pope & Hudson 1992; Rorty Yag er, & Rossoto 1994; Kinzl Traw eg er, G uenther & B iebl 1994; Wool ey 1994; Bordo 1993; and Young 1993). F or example, in some studies a hig h perc entag e of c lients who have bu lim ia a lso re po rt ha vin g be e n s e xua lly a bu se d w he n a c hil d. Whe n a c lie nt a dmi ts bulimia or exhi bits sy mptoms of bulim ia to a ther apist, the thera pist may suspect sexual a bu se of the c lie nt w he n a c hil d a nd a c tiv e ly pu rs ue wh e the r t his c lie nt w a s a lso so abused. Such a thera pist would suspect that the memory of that abuse may be re presse d even if not reporte d by the client. Among these ther apists, some can a nd do lead the client to a memory of an e vent that in actua lity did not occur. The y do this by techniques pr omo tin g su g g e sti bil ity wh ic h in c lud e a n a ir of a uth or ity be c a us e of the the ra pis ts’ presumed sta tus as “experts.” The most arde nt supporters of r epre ssed memory sy ndrome c ite the same f ew studies of bulimia and neg lect to re port other studies finding no or little corre lation

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44 be tw e e n CSA a nd bu lim ia St a tis tic a l c or re la tio n o f s y mpt oms su c h a s b uli mia wi th C SA in such ca ses have been tr eate d as ca usal. The ther apist then participa tes with the client fr om a n in iti a lly qu e sti on a ble pe rs pe c tiv e in d e te rm ini ng ne w a da pti ve ide olo g ie s, attitudes, and beha viors to alleviate or era dicate the prese nt maladaptive sy mptoms. Thera pists who discover memorie s of CSA sugg est that a c lient's pr evious failure to a dd re ss h is o r h e r t ro ub le s r e su lte d f ro m me mor y re pr e ssi on tha t w a s d ue to t he str e ss or trauma of the a buse. Repre ssed memories may thus be seen a s simil ar to a virus in the mind. I t infects the life of the c lient and multipli es adve rse e ffe cts throug hout the life course into any of seve ral menta l or emotional sy mptoms of dy sfunctionality Using sy mptoms as indicators of CSA, these thera pists rigorously probe f or re pression. I n doing this, sometim es inapplica ble g roup statistical data a re a pplied to individual clients—finding that statistical support that larg e number s of adults with a par ticular sy mptom were a lso sex ually abused a s children a nd then asser ting that this means that individual clients who exhi bit that sy mptom were a lso abused. Some memories that wer e alleg edly repr essed we re in fa ct manufa cture d during the ra py a nd a re fa lse me mor ie s. Ev ide nc e of thi s c a n b e fo un d in the fo llo wi ng wa y s: Som e c lie nts ha ve la te r r e c a nte d th e a lle g e d r e pr e ssi on a nd fi xed re sp on sib ili ty fo r t he ir ear lier cla im of rec overe d memory on their sug g estibilit y That the memory was indee d manufa cture d rathe r than of a n actua l occur renc e has be en discove red in some of the following way s: 1) from data provided by family members who doc ument the imp os sib ili ty of a n a bu se oc c ur ri ng in t he liv ing tim e a nd c on te xt of the a lle g e d a bu se (e.g ., when the a lleg ed per petra tor was not pre sent during that time period or circ umstances of household life pre cluded suc h an ac t or ac ts from being undiscovere d);

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45 2) fr om medical examinations during the targ eted time; 3) throug h court ruling s; and 4) from the de monstrable ef fec ts of cer tain discovery and tre atment technique s and pr oc e du re s th a t in c re a se su g g e sti bil ity of the c lie nt t o th e po int tha t th e re is l itt le lik e lih oo d th a t su c h a me mor y c ou ld b e un a ff e c te d ( e .g ., hy pn os is, dr ug the ra pie s, direc ted imag ery etc.) Reac tions to the Repre ssion Debate Pivotal cases which ha ve led to leg ally instigate d chang e in thera py g rew out of controve rsies over repr essed memor y of childhood sexual abuse. The ty pe of the rapy that has bee n centr al in the elicitation of memorie s is reg ression thera py and the pr actice s which it often e ntails. I look at two major ar eas in this debate : The possibilit y of har m a n d t h e c e n t r a l i t y o f t h e c o n t r o v e r s y o v e r r e g r e s s i o n t h e r a p y. P ossibi lity of h arm S i t u a t i o n s w e d e f i n e a s r e a l b e c o m e r e a l i n t h e i r c o n s e q u e n c e s ( W I. Thomas 1931/1966) The pivotal axis of contention about reg ression thera py has to do with the question of whethe r a c lient’s imag es of c hildhood sex ual abuse are acc urate memories or ina c c ur a te a rt if a c ts o f t he ra py pr a c tic e s. Re g a rd le ss o f w hic h, the ima g e s c a n b e re a l in the ir c on se qu e nc e s f or the c lie nt a nd po ssi bly oth e rs a s w e ll, e sp e c ia lly if he /sh e is encour ag ed to re solve the memory by confr onting a n alleg ed per petra tor. I n many instances e ffe cts do not stop with the mental health of the c lient; consequenc es for alleg ed perpe trators a re dire They are so even if the imag es ar e mer ely imag es and not a ctual memories.

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46 Si gm und Freud i nt rod uced t he co ncep t of repress i o n of m em o ri es. H i s changi ng co ncep t i o n of i t and t he 1 deba t e t h at f ol l owe d i s de t ai l ed i n Cha pt er 3. For many thera pists the streng th of the belief s of clients is a potent tool for motivating cha ng es in beha vior, emotion, and ra tionality whateve r the va lidity of that pa rt ic ula r b e lie f m ig ht b e H ow e ve r, ov e rre lia nc e on thi s to ol h a s so me tim e s r e su lte d in neg lect of tre atment base d on the re ality of present c on te xts. T he c lie nt’ s state of belief in the ac tuality of past eve nts can re sult in harmful conseque nces f or themselves a nd others. Thera pists may violate the ther apeutic e thical principle of doing no ha rm by reinfor cing and dire cting trea tment toward a n occur renc e that did not happen, a t least not outside of the client’s own misconc eption. Ce nt r ali ty of t he r e pr e ssi on po le m ic The disserta tion ex plores orie ntations to therapy prac tice in three thera py dis c ipl ine s to le a rn ho w t he dis c ipl ine s d e a l w ith re pr e sse d me mor ie s— a c on c e pt t ha t is itself controve rsial. The c oncept of “re pression” a s used in this resea rch involves the 1 following char acte ristics: 1) a/some trauma tic or neg ative eve nt/s occurr ed to the per son in childhood, 2) memory of that/those eve nt/s is bl ocked f rom rec overy by normal me mor y pr oc e sse s, 3) the me mor y a ff e c ts t he pe rs on s p re se nt b e ha vio r, a nd 4) the wa y to c ur e or e a se the e ff e c ts o f t he me mor y is t o ma ke the e ve nt c on sc iou s a nd to c on fr on t it in the pre sent. Some major sy mptoms of dist ress or me ntal illness from these unre solved me mor ie s a re c a lle d “ dis so c ia tiv e dis or de rs .” Di sso c ia tiv e dis or de rs a re de fi ne d a s a class of disorde rs in which people lose contac t with portions of their consciousness or memory resulting in disruptions of their sense of ide ntity

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47 For over 80 y ear s therapists of diff ere nt theoretica l para digms ha ve ar g ued about the conc ept of re pression and me thods of elicitation. The re cent e x pansion of the controve rsy is manifested by the spiraling incre ase in the numbe r of a rticles cove ring reg ression thera py and childhood sexual abuse ( CSA) that can be found in profe ssional journals which a re de dicated to ther apy disciplines. Professional ethics ha ve bee n ree x amined in re action to this aca demic outpouring The leg al profe ssion has also rea cted to this controver sy over r eg ression thera py and child abuse I n the last few deca des there has bee n a lar g e incr ease in leg al ca ses involving the ter ms “child abuse” and “r epre ssion of memory .” Those le g al issues wer e revie wed in the pr evious cha pter. Consequences for Th erapists and Clients The que stion of whether repr essed memor ies ac tually exis t haunts reg ression thera py Finding that memories used f or thera py wer e fa lse memories, whic h wer e rec overe d or manufa cture d during thera py would open the ther apist to charg es of de viant prac tice and w ould construct the ne w self of the client ar ound a fa lsehood, a we ak base at best. A theore tical ar g ument could be a dvance d that partially acc ounts for the re cover y of fa lse memories during thera py The re presse d memory of CSA (no rec ollection) as opposed to one that ha s been suppr essed ( rec ollection that is put aside) is functional for both the thera pist and the client. F irst, potential ga ins for the ther apist are examined, and then g ains for the client. Finding repr essed memor ies incre ases the c ontrol of the ther apist. The client may have c ome to thera py seeking advice or instruction on life tec hniques that they he or she

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48 is no t u si ng, i s u si ng in effi cie nt ly o r i s u naw are o f (i .e. m eth od s fo r se lf -effi cacy ). By focusing on a “r epre ssed” memor y the locus of powe r shifts to the thera pist. The client become s depende nt on the thera pist who revea led this hidden proper ty —the memory which is bey ond the scope of selfeff icac y —as the root, ba se, and infr astructur e on which all their problems a nd inadequa cies c an be r ationalized and conf ronted. P s y ch o t h er ap i s t s p ar t i cu l ar l y p s y ch o an al y s t s ar e t au gh t t o en co u ra ge un int e rr up te d n a rr a tiv e s, re mov ing the mse lve s to the ba c kg ro un d, (H ols te in & Gu br ium 2000). Even in e ncoura g ing the se uninterr upted nar ratives, c ommon therapy elicitation techniques ( e.g ., silences a nd turn passing ) ca n reinfor ce de pendenc e and a ct to disallow the client’s own pe rce ption. I f the ther apist is passing his/her tur n with a silence the c lie nt m a y c ome to f e e l th a t he /sh e ha s n ot s e e n o r c on ve y e d a ll t ha t is ne c e ssa ry the top ic and may be dra wn to confa bulate, or se arc h for links that do not convey what he/she had been tr y ing to c onvey until the therapist takes his/her turn. D epende nce on the thera pist’s reconstruc tion of acc epted c onversa tional tactics come s to dominate. The client is likely impelled to trust that there is more to be discovere d. Whatever the thera pist's intentions in using these methods, the thera pist becomes essential and pr eeminent in the que st for cha ng e. This per petuates de pendenc e on the thera pist. I t is therefor e in the selfinterest of the thera pist to find repression. Reg ression thera py not only keeps discove ry of self f ocused on a particula r problem—it also ser ves to k e e p th e c lie nt d e pe nd e nt a nd in t he ra py fo r m a ny se ssi on s. Th e ra py ma y ne c e ssi ta te a pr otr a c te d p e ri od fo r t he the ra pis t to a ssi mil a te i n fo rm at i o n an d as s i s t t h e c l i en t i n o rga n i z i n g t h o u gh t s an d em o t i o n s T h e t h er ap i s t 's persona l approa ch to thera py influence s the content of se ssions through c hoices of w hich

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49 narr atives to enc ourag e. Only throug h a number of sessions does the c lient become a war e of the proc liviti es and unde rstanding s of his/her ther apist and assimilate them in a joint construction of the client-self Multipl e sessions ar e thus requir ed. Ho we ve r, if the me mor y ha s b e e n s up pr e sse d b y the c lie nt, thi s p ro c e ss i s le ss eff icient for the thera pist. The client re tains a g rea ter de g ree of control a nd selfactua liz ation. Since the memory has bee n available for the c lient to reca ll when the situation feels rig ht, safe, a nd/or comfor table, the ther apist perf orms a diffe rent role —an adjunct role I n this sit uation the thera pist is a resourc e for the client’s de cisions about wher e his/her life should go r ather than a c omponent that is absolutely nece ssary for pe rs on a l im pr ov e me nt. Th e the ra pis t c a n p ro vid e the no nth re a te nin g c omf or ta ble atmosphere that the client re quires to dec ide that it is ti me to confr ont the suppressed memories; howeve r the ther apist is not the source of a re c ov e ry of the me mor y to conscious deliber ation. Whil e finding repr ession incre ases c lient depende nce on the thera pist, the client g a ins in t wo wa y s. Th e fi rs t g a in f or the c lie nt i s th a t th e re pr e sse d me mor y pr ov ide s a convenie nt scape g oat for a ny thing not g oing r ight in life. I f the memory has bee n unretrie vable, pe rsons and proc esses other than the individual can be held to blame. Any possible lack of se lf-ac countability may thus be rationalized. A new starting point thus emer g es that excuses the c lient from re sponsibili ty for pr evious failed inter actions and perc eived f ailures of his or her ow n self construc tion processe s. This ex cuses inter action fa ilu re s a nd e mot ion a l a nd me nta l f a ilu re s d a tin g fr om t he tim e tha t th e me mor y fi rs t beca me inacc essible (whe n the incident/s occ urre d).

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50 Bl ac k ’s Law D ic tio na ry define s tolli ng the statute as a law that interr upts the running of 2 a sta tut e of lim ita tio ns in c e rt a in s itu a tio ns a s w he n th e de fe nd a nt c a nn ot b e se rv e d w ith pr oc e ss i n th e fo ru m ju ri sd ic tio n. Th e sta tue of lim ita tio ns is d e fi ne d a s “ A s ta tut e e sta bli sh ing a tim e lim it f or su ing in a c ivi l c a se b a se d o n th e da te wh e n th e c la im a c c ru e d ( a s w he n th e inj ur y oc c ur re d o r w a s d isc ov e re d) T he pu rp os e of su c h a sta tut e is to require diligent pr osecution of known c laims, thereby providing finality and pr e dic ta bil ity in l e g a l a ff a ir s a nd e ns ur ing tha t c la ims wi ll b e re so lve d w hil e e vid e nc e is rea sonably available and fr esh” (Ga rner 1999) The more mundane g ain is found in the leg al re quirement for tolling the statute of lim ita tio ns fo r d isc ov e ry of CSA Wh e n th e c lie nt h a s su pp re sse d th e me mor y a nd is 2 only bring ing it out when in a “saf e” a tmosphere f or re call and f or conf rontation, the alleg ed per petra tor ca n be held leg ally acc ountable, in most state tort courts, for three y ear s after the client re ache s majority (tolled afte r the c lient rea ches ma jority not from the time of the incide nt (Hag en 1991). H oweve r, if the memor y has bee n repr essed, the acc ountability is not tol led until the client “discove rs” the me mory or ca n rea sonably be expected to have discovere d it, whatever his/her ag e at that time (H ag en 1991, and Wil liams 1996). Labelin g and I m putin g Victim ization On the ba sis of a lit e ra tur e re vie w, thi s se c tio n o f t he dis se rt a tio n r e ve a ls problematic a spects of c onstructions of selves g ener ated dur ing the debate on CSA and re pr e sse d me mor ie s. Expe ri e nc ing se xua l a bu se ha s b e e n d e e me d a se ve re ps y c hic trauma ( Olio & Corne ll 1993). Reg ression thera pists and resea rche rs re port that sexual abuse c auses a n emotional shock to the child' s psy che, e ffa cing sexual mores and ca using sever e suff ering (Ashton 1995; Blume 1991; B reire 1990; Herma n 1992; Kihlstrom 1996; & T err 1994).

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51 Ac c or din g to t he the or y be hin d r e g re ssi on the ra py th is s ho c k in tur n c re a te s a mental incapa city for c oping w ith the event(s) of the a buse and c auses the c onsequent repr ession of the memory (ies). The abuse is dee med a ne cessa ry and suff icient ca use of the re pression. L enore Terr a psy chiatrist, writes that r epre ssed memories of sexual abuse a nd other tra umatic memories insinuate the mselves into the biologica l and psy cholog ical life of a per son and the memorie s themselves come to have lives a nd transfor mations of their own (T err 1994). Ad din g to t he a rg ume nt o ve r t he e ff e c t of (a ) t ra uma (s ) e xpe ri e nc e d w he n a c hil d is the arg ument over w hether the client should be c onsidered a victim. The importance of thi s a rg ume nt r e vo lve s o n th e la be lin g pr oc e ss. Calling someone a victim encour ag es others to see how the labe led per son ha s b e e n h a rm e d b y fo rc e s b e y on d h is o r h e r c on tr ol, sim ult a ne ou sly es t ab l i s h i n g t h e ‘ fa ct ’ o f i n j u ry an d l o ca t i n g re s p o n s i b i l i t y fo r t h e d am age ou tsi de the ‘v ic tim .’ Th e dis c ou rs e of ‘v ic tim iza tio n’ is t hu s p ra c tic a lly situated social ac tion that promotes prac tical def initions of eve ry day circ umstances. ( Holstein & Miller 1990, 106) Thus, authors of se lf-help books a nd some reg ression thera pists have sometimes become labeler s. I n reg ression thera py the labels, “ victim” and “vic timiz er,” locate the “fa ct” of the har m and the re sultant mental or emotional problems which ma y occur as bey ond the client’s c ontrol. Asserting victimhood of the client shifts responsibility for prese nt problems from the c lient and to the alleg ed per petra tor who may have c aused the repr ession and re sultant mental problems. Proponents of thera py techniques w hich do not include re g ression thera py may be seen by those who do as ne g lecting the primary (or or igina l) ca use of pr esent proble ms. Those other thera pists, thus may be cha rg ed by reg ression thera pists of having blamed

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52 the victim (the client) f or problems that we re in fa ct ca used by others. A ne g ative conseque nce of the “victim” labe l is that victim s are often blame d for their own victimiz ation (Ry an 1976). What is missed by such an a naly sis is t hat many of the other thera pists do not l abel the c lient as a victim at all, but as someone who should be instructed and e ncoura g ed to take c are of their pr esent proble ms—to develop self-e ffica cy a n d a b i l i t y t o f e n d o f f a d v e r s i t y. L abeling a client a s a victim of re presse d memory (ies) stre ng thens client depende nce on the reg ression thera pist. The use of the la bel “survivor s” for those who aver victimiz ation from CSA become s a ling uistic device. This ter m is more capa ble of a c tiv a tin g e mot ion a lly c ha rg e d v ie ws of the c lie nt a nd the a c c us e d p e rp e tr a tor tha n w ou ld be the c a se wi th m or e ne utr a l la be ls. Us e of the “ su rv ivo r” la be l im pli e s th a t th e CSA too k p la c e f or ho w c ou ld t he c lie nt b e a su rv ivo r i f n o a c t ha d ta ke n p la c e I n mo st c a se s, for va rious rea sons, the reg ression thera pist does not seek to verif y an ac tual act. Othe r possible labels for the person a verr ing r epre ssed memories of CSA (i.e., the “a ccuse r,” “powe rless,” “ memory impaired” ) ar e more direc t in context ual desc ription. For example, a client could be descr ibed as a n accuse r who may have be en abuse d when a child and re ndere d po we rle ss (at lea st until acc usations are made) or he/she c ould be an a c c us e r w ith a ma lf un c tio nin g me mor y T he se oth e r t e rm s a re so me tim e s r e fe rr e d to in the lit e ra tur e on re g re ssi on b ut “ su rv ivo r” is a lmo st i nv a ri a bly the la be l c ho se n b y tho se authors who a ssert the va lidity of re presse d memories of CSA. Org anizations and their ag ents make it their business to desc ribe our lives and experienc es so that they can a ddress, a ssess, and ame liorate the challeng es of da ily living. I n the proc ess, they become source s of experiential definition--pur vey ors of identity so to speak. (H olstein & Gubrium, 2000, 154)

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53 During reg ression thera py the life of the client bec omes define d within a master ide nti ty c on sis tin g of a pa rt ic ula r “ se lf fr om t he ra py ” —a ma ste r s ta tus a s CSA survivor I n s ome c a se s th is s ta tus be c ome s so c omp e lli ng tha t th e c lie nt b e c ome s f ixat e d in da ily life to the exclusion of other aspe cts of self. T his master status may mitigate a nd interfe re with the formation of a more ve rsatile self tha t responds to situated contexts and the mul tip le or g a niza tio na l lo c a l c ult ur e s, wh ic h th e c lie nt e nc ou nte rs in t he fl ow of da ily living. Diver sity of re sponse possibilit ies may be cir cumscribe d. I n th is d iss e rt a tio n, dis tin c tio ns he ld i n d if fe re nt t he ra py dis c ipl ine s o n th e se constructions of ther apeutic la bels of devia nce a re pr ovided throug h analy sis of interviews with ther apists. This qualitative analy sis focuses in par t on their takes on the constructions of r epre ssion of memory the importance of re g ression as a thera py tool, and the dis c ov e ry of re pr e sse d me mor ie s.

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54 CH APT ER 5 METHODS The re sear ch methodolog y is qualitative and informe d by the work of Holstein and Gubrium (1995). I t uses “open inter views” a nd cente rs on ac tive techniques r ather than highly structure d questions. The ac tive interview is “loose ly direc ted” ( 29). I t consists of both subjective and obje ctive ele ments. The objec tive element de als with what is being vo lun te e re d a nd dis c us se d. I t is su bje c tiv e be c a us e it a ff e c ts how response s are interpre ted: “The focus a nd emer g ing da ta of the r esea rch pr oject provide orientation and fra ming r esourc es for developing both the subject and his or he r re sponses” (1415). The standpoint from whic h information is offe red is continually develope d in r e la tio n to on g oin g int e rv ie w i nte ra c tio n. .. T he su bje c t be c ome s a na rr a tiv e re so ur c e fo r b oth the int e rv ie we r a nd the re sp on de nt, a g uid e po st for how to a sk and answe r fur ther que stions. ... C halleng ed by the interviewe r, pointed in promising dire ctions, and at lea st partially awa re of the interpre tive terra in at hand, the r espondent be comes a kind of rese arc her in his or he r own rig ht, consulting re pertoire s of experienc e and o r i e n t a t i o n s l i n k i n g f r a g m e n t s i n t o p a t t e r n s a n d o f f e r i n g ‘ t h e o r e t i c a l l y’ coher ent desc riptions, accounts, a nd explanations. (Holstein and Gubrium 1995, 29) The “ open intervie w” c an be “ constraine d by the interview er’ s topical ag enda, objectives a nd querie s” (29) Active inter viewer s “may sug g est orientations to, and linkag es betwe en diver se aspe cts of re spondents’ experienc e, adumbr ating —even inviting—interpre tations that make use of particula r re source s, connec tions, and outlooks. I nterview ers may explore incompletely articula ted aspe cts of experienc e, enc ourag ing responde nts to develop topics in way s releva nt to their own experience ” (H olstein and Gubrium 1995, 17).

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55 One less r eac tive way to sugg est topics is through the use of c oncept c ards. Con c e pt c a rd s se rv e a s th e re so ur c e s, c on ne c tio ns a nd ou tlo ok s w hic h s e t lo os e para meters f or discover ing or ientations. I nterview ees c an re view conc ept ca rds and pick those that are within their fra mes of re fer ence as a me ans to initiate the “ope n interviews.” The intervie wer opera tes within this contex tual fra mework to he lp draw out inf or ma tio n. Sin c e a n in te rv ie w i s u na vo ida bly c oll a bo ra tiv e th e int e rv ie we r a tte mpt s to k e e p h i s / h e r c o l l a b o r a t i v e i n p u t t o a m i n i m u m b y a d v a n c i n g q u e r i e s o n t h e c o n c e p t s o n l y throug h neutra l probes unless aske d a dire ct question. I nterview ees ma y take the c on c e pts in t he dir e c tio ns the y c ho os e T he int e rv ie we r’ s in pu t in to t ha t pr oc e ss i s limit ed to probing for the inter viewee s’ meaning s. “Que stions, prompts, comments, and clar ifications point respondents to par ticular topics, inviting distinctive nar rative trea tments” (Holstein and G ubrium 1995, 28). Open, a ctive intervie ws are espec ially useful for conducting narr ative ana ly ses. “The challeng e is to identify simil arities ac ross the moments [narratives] into an ag g reg ate, a summation” (Riessman 1993, 13). “T he stop-andstart sty le of ora l stories of persona l experience g ets pasted tog ether into something diffe rent” (14). “ I n the end, the analy st crea tes a meta story about what ha ppened by telling wha t the interview na rra tives signify editing a nd resha ping w hat was told, and turning it into a hy brid story . ” (13) I n my stu dy th a t st or y is t he ta le of the re sp on de nt’ s p la c e a s a the ra pis t (a tti tud ina lly a s w e ll a s r a tio na lly ) w ith in t he c on te xt of the ra py pr a c tic e s a nd in profe ssional circle s g rappling with the definition of devianc e. Tha t context i ncludes leg al and socie tal constraints on the ne g otiation involved to determine which pr actice s are deviant and how the line betwe en “g ood” and “ bad” the rapy is drawn.

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56 Th is q ua lit a tiv e a pp ro a c h h a s im pli c a tio ns fo r h ow to s e le c t in te rv ie we e s, ho w t o conduct inter views, how to ana ly ze information, how to use that informa tion to select additional interviewe es, which topics to pursue and how to interpr et the data once it has be e n g a the re d. “ I nv e sti g a tor s mu st c on tin ua lly mod if y ini tia l hy po the se s a bo ut s pe a ke rs ’ beliefs a nd g oals (g lobal coher ence ) and r ecur rent theme s that unify the text (themal c o h e r e n c e ) ” ( R i e s s m a n 1 9 9 3 6 7 ) T h e a p p r o a c h h a s i m p l i c a t i o n s f o r a s s e s s i n g i t s u t i l i t y: We c a n p ro vid e inf or ma tio n th a t w ill ma ke it p os sib le fo r o the rs to deter mine the trustworthiness of our work by a) de scribing how the interpre tations were produce d, b) making visible what we did, c ) specify ing how we a ccomplished succ essive tra nsformations, and d) ma kin g pr ima ry da ta a va ila ble to o the r r e se a rc he rs .. N a rr a tiv e a na ly sis allows for sy stematic study of per sonal experience and mea ning: how events ha ve bee n constructe d by active subje cts. (Riessman 1993, 70) Sub jec ts/Interviewees/Re spon dents A strateg ic sampling approa ch wa s used in which the size of the sa mple and the kinds of information soug ht were g uided by finding s from prior inter views. The or igina l desig n called f or interview s with rece ntly licensed a nd/or ce rtified ther apists from the three basic oc cupational/ther apeutic disc iplines—psy chiatry psy cholog y and socia l work. The rea son for the inter views wa s to ex plore how the rapists construc ted devianc e. Approa ches to ther apy varie d g rea tly within discipli nes, indicating that during training the thera pists were e x posed to a va riety of tec hniques. Disciplinary backg round did not emerg e as be ing r elated to or ientations to perce ived devianc e or a bout repre ssion of memories or the viability of re g ression thera py For a study of how de viance was constructe d, there was little benef it in locating a set number of subjects from e ach of the three disciplines. The sampling g oal bec ame one of identify ing a diverse g roup of the ra pis ts r a the r t ha n a se t nu mbe r o f t he ra pis ts f ro m di ff e re nt d isc ipl ine s.

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57 Potential respondents we re loc ated throug h public rec ords of the D epar tment of Hea lth and state licensing boards, inter net direc tories (e .g ., National I nstitut e of H ealth at htt p:/ /w ww .n lm. nih .g ov /me dli ne plu s/d ir e c tor ie s. htm l and Medic are at http:// www1.medic are .g ov/Phy sician/Searc h/Phy sicianSear ch.asp? ), and libra ry files on commence ment exercises by school and discipline. Alumni associations indicate d that they would contac t individual gra duates to ask if the y would participa te, but would not provide a list. Departments conta cted did not provide lists of contac t information for g ra du a te s. Sin c e I wa s c on c e rn e d a bo ut t he c on fi de nti a lit y of int e rv ie we e s, I did no t us e any resour ce tha t would connec t a par ticular potential intervie wee with my study All respondents intervie wed we re a dults. A demog raphic s form conta ined the question of whethe r or not the subjec t was 21 y ear s of ag e or olde r. Chronolog ical ag e of the re spondents was not of pa ramount importance The time per iod within the education proce ss—at the end of formal tra ining a nd while eng ag ing in a car eer in counseling —was the fa ctor of importa nce r ather than chr onologic al ag e. Re sp on de nts we re no t se le c te d o n th e g ro un ds of g e nd e r, ra c e o r e thn ic ity Wh ile some diffe renc es in responde nts have be en found w ithin the lit era ture on methods and interac tional responses, my study was not direc tly conce rned w ith who was be ing int e rv ie we d, oth e r t ha n th a t th e y we re the ra pis ts. Us ing the da ta g a ine d f ro m th is re se a rc h, fu tur e re se a rc h o n th is t op ic mig ht i nc lud e a qu a nti ta tiv e re se a rc h a g e nd a to de te rm ine the sc op e of c on tr ibu tio n o f t he se a nd /or oth e r d e mog ra ph ic e le me nts to thera py prac tice and the construction of de viance Ten ther apists were interviewe d. The number was de termined during the interviews ba sed on how ofte n the thera pists provided simil ar infor mation. This is called

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58 saturation. F our had ba ckg rounds in social work; f our we re psy cholog ists (one of whom had a ba ckg round in educ ational counse ling) and two we re psy chiatrists. They wer e pr a c tic ing in t wo so uth e rn sta te s. Th e na tur e of the ir pr a c tic e s v a ri e d. Mo st w e re in private pr actice but some were working within other medica l org anizations. Other descr iptive fea tures will be discussed w hen pre senting the re sults. Int e r vie wing G ain ing Ac c e ss Th e po te nti a l r e sp on de nts we re fi rs t c on ta c te d w ith the le tte r r e pr od uc e d in Appendix A. Page s included with the letter w ere the informed c onsent document (Appe ndix B) and an optional que stionnaire to attain basic demog raphic data a bout individual participants (Appe ndix C). Those conta cts wer e followe d with a phone c all. That introductory phone ca ll followed four or five da y s after the letter w as sent. An example of the for mat of the c alls is found in Appendix D. I n s ome wa y s th e big g e st c ha lle ng e to t his re se a rc h s te mme d f ro m di ff ic ult ie s in secur ing a cce ss and coope ration fr om potential interviewe es. The c halleng e manife sted itself in severa l way s. Obtaining information on which potential inter viewee s could be contac ted (a nd how) wa s a diffic ult task, especia lly in reg ard to psy chiatrists. I t was difficult to discern w hen some ther apists rec eived tra ining a nd when they wer e ce rtified or license d from many of the re cords whic h wer e consulted. O ne mental he alth counselor did not believe that she f it the para meters be cause the letter of introduction ref err ed to her as a D octor (she was not). She wa s so relucta nt after that point that she was excluded. A licensed c linical social worke r stated that she did not know when she c ould take an hour fo r t he int e rv ie w s inc e sh e wa s w or kin g tw o jo bs —a t a ho sp ita l a nd he r o wn pr iva te

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59 prac tice—and a lso had two children. T he psy cholog ist whom I had thoug ht would have mor e kn ow le dg e on the a re a s o f m y re se a rc h in te re st, du e to h e r d iss e rt a tio n to pic s a id she wa s too busy in her pe rsonal and w ork life to be inter viewed e ven for just an hour. Ma ny of the re c e ntl y tr a ine d th e ra pis ts h a d r e loc a te d to dis ta nt s ite s. Th e ir letters we re r eturne d and they could not be conta cted by phone or e mail. Many other prospec tive interviewe es would not retur n calls (e ven thoug h an initial contact letter had been se nt to provide notice). With psy chiatrists, I found that the re ceptionists and nurses pe rf or me d a “ g a te ke e pin g ” fu nc tio n w hic h d isa llo we d c on ta c tin g the ps y c hia tr ist s d ir e c tly or by phone. When I persona lly handed a seale d letter c ontaining the contac t information wi th t he ps y c hia tr ist ’s na me a nd a sk e d th a t it be g ive n to him th e nu rs e tor e it o pe n in front of me and beg an re ading it. W ith many psy chiatrists, letters a nd phone ca lls were not returne d, even w hen I had bee n assure d that the psy chiatrist had r ece ived my letter or no tif ic a tio n o f m y ph on e c a ll. I did no t ha ve thi s p ro ble m w ith the oth e r d isc ipl ine s. Sociologically In ter viewin g the Inter viewers of Clients One que stion that had to be addre ssed was, “ How do y ou g et thera pists to open up to a so c iol og ist ? ” Th e ir pr of e ssi on a l f un c tio n is to g e t oth e rs to open up to them I re pr e se nte d a dif fe re nt p a ra dig m a nd dis c ipl ine M a ny the ra pis ts w ou ld b e mor e a t ho me perf orming the role of interviewe r than intervie wee and they wer e we ll-verse d in the art of interview ing a nd would rec og nize the techniques that a re use d to elicit information. Th e ra pis ts l ike ly ha ve so me kn ow le dg e of the so c iol og y a s a dis c ipl ine fr om t he ir out-of-discipline unde rg radua te cour ses. They do not consider de viance in the same wa y as do sociolog ists. The interviews used c ommunications tactics that would ensure a common understanding of mea ning. F or example, use of the word “ deviant” w as

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60 avoided. I n sociolog y “devia nt” is understood to be a word that ha s a neutra l meaning a nd do e s n ot c on no te ne g a tiv e a sp e c ts. Thera pists are more often foc used on dea ling with devia nt behavior a nd individual thought pr ocesse s and emotions than on g rappling with larg er soc ial and leg al def initions of de via nc e T he ir int ro du c tor y so c iol og ic a l kn ow le dg e do e s n ot e ns ur e tha t th e y wi ll appre ciate this line of r esea rch. The experience s of the intervie wee s rests on a pe rson-toperson a pproac h. This perspec tive brac kets understa nding w ithin an individual contact level which ma y have blunted r ealization of how a soc iologica l approa ch provide s an op po rt un ity fo r t he ra pis ts t o s e e the mse lve s in re la tio n to the ir wo rk a nd to m e nta l he a lth m o r e g e n e r a l l y. One c halleng e wa s to entice the the rapists to step out of their chose n role—a doer of thera py —into persons who could re late all the knowle dg e they had ac cumulated on thera py and doing thera py The g oal was to e licit their narr atives without manipulation. Casual conve rsations with therapists and other s raised the prospec t that the interviews would e x plore topics that we re e x tremely sensitive for some. Some re sponses ma y be e mot ion a l or be c olo re d b y e mot ion a l f e e lin g s. Te c hn iqu e s c ou ld b e us e d to reduc e that kind of re action, but the ana ly sis would have to incorpor ate the pr ospect. F or e xamp le p ro be s w ou ld h a ve to b e wo rd e d c a re fu lly to a vo id e mot ion a l r e sp on se s a nd to ma int a in r a pp or t. F e a t ur e s o f t he I nt e r v ie ws Open inter views we re c onducted. All intervie ws wer e conf idential. The participa nts were told that they could skip are as of discussion or ter minate the intervie w at any time—information that also appe are d on the informed c onsent for w hich they

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61 signe d and we re g iven a sig ned exact copy The intervie ws wer e tape rec orded a nd lasted at least 60 minutes. No intervie wee decide d to terminate the inter view within that span an d s ev er al ex t en d ed co m m en t s fo r s ev er al m i n u t es t h er ea ft er Af t er t h e t ap e r ec o rd i n gs we re tr a ns c ri be d, the y we re e ra se d. I n th e tr a ns c ri pti on ph a se a ny inf or ma tio n th a t might compromise the c onfidentiality of the pa rticipant wa s excluded. The tra nscripts wer e rec orded w ith pseudony ms rather than ac tual names. All re cords a nd data a re ke pt confide ntial and ar e contr olled and prote cted by the investig ator. Concept ca rd we re use d to introduce topics and to a llow interviewe es to selec t pr ior iti e s. My re vie w o f s oc ia l sc ie nc e jou rn a ls h a d p ro vid e d me wi th r e le va nt c on c e pts tha t th e ra pis ts c ov e r w he n d isc us sin g the pr e se nt s ta te of Am e ri c a n th e ra py e sp e c ia lly some that rela ted to repr ession and re g ression. The topics on those c ards c onsisted of “Ac countability Ba cklash, Discove ry Epidemiology and Abuse L abeling L aw a nd Thera py Mandate d Reporting Memory and The rapy Pr im um Non Noc e re (A bo ve Al l Do No Ha rm ), Pr of e ssi on a l D omi na nc e a nd He g e mon y Re pr e ssi on Re tr a c tor s, Sug g e sti bil ity Su rv iva l g ro up s, Sur viv or s, Tr e a tme nt p ra c tic e Sy mpt oms Sy nd ro me s, To lli ng the Sta tut e of L imi ta tio ns T re a tme nt P ra c tic e s, a nd Vi c tim ho od .” Th e c on c e pts wer e ty ped on 1 3/4" x 3" c ards a nd laminated. B efor e g iving the c ards to the interviewe e, the de ck wa s shuffled se vera l times to show that they wer e in no par ticular or de r. Th e int e rv ie we e wa s th e n to ld t o s e le c t th e fi ve c a rd s h e or sh e wo uld lik e to discuss. By the end of the interview most or all of these c oncepts did g et discussed. When prompts were used, they wer e neutr al and a llowed the intervie wee as much latitude fo r d ir e c tio n o f i nte rp re ta tio n a s p os sib le So me of tho se pr omp ts a re fo un d in Ap pe nd ix E.

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62 A na ly z in g I nt e r v ie ws Met hods for Analyzin g Data Nar rative a naly sis was the primar y tool for ana ly zing the intervie ws. I t was supplemented by qualitative content a naly sis. Discourse or c onversa tional analy sis was used af ter seve ral intervie ws to assess whe ther the inter views we re c apturing the information nee ded to ana ly ze the construction of de viance Nar rative a naly sis is used for interpre ting da ta. Nar ratives a re de scribed by Gubrium and Holstein (1997) as “a ccounts that off er some sc heme, e ither implicitly or expli citly for or g anizing and unde rstanding the re lation of objects and e vents descr ibed.” Riessman (1993) noted, “ Nar rative a naly sis—and there is no one method here —has to do with ‘how protag onists int erpr et things’ (B runer 1990, 51), and w e ca n g o about sy stematically interpre ting their interpre tations.” I sy stematically interpre ted the na rr a tiv e s my su bje c ts r e la te d in the ir int e rv ie ws by loo kin g fo r e le me nts in c omm on wi th the topics found in my literature revie w to be of importanc e for an under standing of the labeling of some ther apists and thera py prac tices as de viant. I also explored narr atives rela ted to wher e the line wa s drawn be tween a cce ptable and una cce ptable pra ctices or actions that we re the basis for those la bels. My rende ring of the re sults centers on f our rec urring narr atives: orientations to thera py ; memory suppression, and r epre ssion; acc ountability and ethics; leg al issues and ther apy Qualitative conte nt analy sis sometim es dra ws infer ence s on both the appea ranc e or nonappe ara nce of attributes in messag es. I used qualitative c ontent analy sis on the data to help de fine the similarities and diff ere nces f ound on the nar ratives. Disc ourse or conver sational ana ly sis focuses on how the interview proce eded tha t produce d the

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63 conver sation or discourse I t attends to issues like pauses, re petitions, volum e, spee d, body lang uag e, etc This kind of analy sis provides context for interpre ting the na rra tives. I t c a n a lso be us e d to c he c k to se e wh e the r t he int e rv ie w i nte ra c tio n p e rm its the su bje c ts’ discourse to be voiced without it being constraine d by the interview er. To ma ke sure the interviews we re y ielding the kinds of stories from the r espondents which c ould be used for na rra tive analy sis, the conver sations from the first two intervie ws wer e ana ly zed. I found that the intervie ws wer e ac cessing the kind of data that I neede d to perfor m narr ative ana ly sis about the construction and r esponse to devia nce ( see A ppendix F). Am I Ge tting Conversations and Narratives That I Can Use? I transcr ibed the data from the f irst two interviews to appr aise whe ther the interviews we re c ollecting rele vant data f or the re sear ch foc us. Be fore the data w ere c oll e c te d, I ha d p re su me d th a t I wo uld sta rt by loo kin g a t th e re sp on se s o n th e c on c e pts one at a time, and compar e them by disciplinary backg rounds of the inter viewee s (i.e., social worke rs ver sus psy cholog ists versus psy chiatrists). When viewing the ac tual data, I rea liz ed that the c oncepts would ha ve to be c ompare d acr oss therapists—a ther apist by the ra pis t a na ly sis —b e c a us e e a c h o f t he se the ra pis ts r e la te d h is/ he r e xpe ri e nc e s f ro m a unique per spective tha t preva iled throug h most of the interview. H ow the intervie wee responde d indicated how he /she shaped the content of his/her answe rs about the c oncepts. Eac h thera pist in t his set of interviews pr ojected importa nce to c erta in topics to a discerna ble deg ree indicating that he/she wa s intent that I understand the nuance s of his/her point of view. Tha t these var ied from inter viewee to interviewe e is one of the rea sons for pursuing a qualitative a pproac h.

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64 The fir st interviewee provided a lang uag e couc hed in terms of mora l exactitude. The sec ond responde d with very minimal prompts i n a lang uag e of c ompetent pre cision. I t was cle ar to me tha t eac h of the intervie ws was a unique pre sentation and that a n e xami na tio n o f t he c on c e pts mus t in c lud e ho w t he y we re tol d a s w e ll a s w ha t w a s to ld (i.e., na rra tive analy sis should som etimes be supplemente d with conver sational ana ly sis). Appendix F contains an e x ample of c onversa tional analy sis drawn fr om my data. The discour se ana ly sis of the first ca ses also conf irmed the utility of the c oncept car ds. The first intervie wee s selecte d three of the same conce pt car ds: Accounta bility and Et hic s, Sy mpt oms a nd Tr e a tme nt P ra c tic e s. I ha d n ot a sk e d th e m to pu t th e c on c e pts in or de r o f p re fe re nc e a nd wa s in fo rm e d th a t th e y ha d n ot. I did no t r e fe r t o th e c a rd s u nle ss our discourse on a topic ca me to an end w ithout the topic having sur fac ed in the cour se of the interview This proce dure a llowed the conve rsation to flow fr om the initial question on the ra py int o li ne s d ir e c te d b y e a c h in te rv ie we e ’s int e re sts I fi rs t c omp a re d th e ir discussion of these c oncepts a nd then contra sted them in terms of ther apy in ge nera l and then as they rela ted to the use of r eg ression and r epre ssion. My g rea test surprise in these f irst interviews wa s that none of them r ecog nized the Ramona case until aft er I e xplained the Ram ona case to them (to see if they wer e aw are of thi s la ws uit b ut n ot b y na me ). Th e y he mme d a nd pa us e d a nd pa sse d s pe a kin g te rm s in the conve rsation. They wer e also unfa miliar with other ruling s reg arding third-par ty law su its I le a rn e d th a t I ha d to a pp ro a c h th e se top ic s d if fe re ntl y A lth ou g h th e the ra pis ts we re no t di re c tly a wa re of the la ws uit s, e ith e r t hr ou g h th e ir tr a ini ng or the ir ob je c tiv e s, the y ha d d e ve lop e d s tr a ta g e ms t ha t w ou ld s a fe g ua rd the m f ro m th a t th re a t. T he se be c a me t h e p o i n t o f e n t r y f o r e l i c i t i n g t h e i r n a r r a t i v e s a b o u t l e g a l i s s u e s a n d t h e r a p y.

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I n pro b i ng f o r devi ance versus norm at i ve p ract i ce I had ref rai ned f rom us i ng t he wo rd “deviance” and 3 had us ed t erm s l i ke “ i nap p rop ri at e, ” “ no nno rma t i ve, ” and “ q uest i o nab l e p ract i ces. ” A f t er i nt rod uci ng t he con ce pt i n t h es e t er ms I w ou l d u s e t h e wor ds “ bad” or “ g ood” wh i l e mak i n g qu ot e mar k s w i t h my h an ds a n d stre ssin g the w o rd s so tha t i t wa s c le a r th a t I w a s u sin g the se w o rd s a s a lab e l o f co n v e n ie n c e to en compa s s t h i s c on ce pt N on e of t h e t h er api s t s i n t er v i ew ed appe ar ed t o h av e a pr obl em wi t h t h i s de v i ce f or savi ng t i m e and one even af f i rme d : “ W e’ re goi ng t o l ab el i t goo d . . Y eah. ” Fo r f l ui d i t y i n reading t he r es t of t h e t ex t t h e qu ot es s y mbol i zi n g t h e s t r es s es ma de i n t h e i n t er v i ew s a r e r emov ed. 65 CH APT ER 6 OR I EN TA TI ON S TO TH ERA PY A ND DE VI AN CE The ther apists orient to therapy in various way s. This chapter discusses orientation to thera py in terms of the mea ning of thera py for the inter viewee s, and wha t they think about deviance in therapy The ther apists’ descr iptions of their own prac tices and their thoug hts about therapy in ge nera l are reve aled a nd discussed. To help or der the pr e se nta tio n, the int e rv ie w d a ta a re g ro up e d b y the ty pe of oc c up a tio na l c re de nti a ls. Thera py trea tment prac tices that ar e labe led “g ood” or “ bad” w ere deter mined by the labels that the inter viewee s themselves re lated. Devianc e is also deter mined from an 33 examination of the contrasts in their labe ls of g ood or bad pr actice s and thera pists. Additionally I examined the trea tment prac tices of my subjects to help delinea te methods that they have f ound to be normative f or their discipline. The subjec t of trea tment prac tices would come up from the inter viewee direc tly or in r e sp on se to a qu e sti on on wh a t th e y tho ug ht a bo ut t he m. I us e d th e op po rt un ity to qu e sti on a bo ut s ug g e sti bil ity in g e ne ra l a nd a bo ut p ra c tic e s th a t ha ve of te n b e e n li nk e d to sug g estibilit y (e.g ., hy pnosis, drug thera py g uided imag ery and survivor g roups).

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66 Interviews w ith Licensed Clin ical Social Workers Eac h of the lice nsed clinica l social worke rs (L CSW s) was a ble to provide a persona l definition of thera py afte r thinking f or a f ew se conds bef ore a nnouncing his or hers. This is notable in that ea ch of the L CSW s used an inter jection (i.e., “ hmm,” “uhm,” “I g uess . ,” or “uhh”) to provide extra sec onds for thoug ht before answe ring Although the y did therapy ever y day these ther apists expressed surprise tha t it had been such a long time since he or she had thoug ht about some of the ba sic components of the instit ution of mental hea lth (i.e., what ther apy means, wha t are their fe eling s on some of the conc epts adva nced in my questioning e t al.). With the e xce pti on of the int e rv ie w o f L CSW A my th e re we re us ua lly fa ir ly define d opinions and attitudes toward these topics. Amy ’s interview reve aled a differ ent aspec t of trea tment prac tice. Amy came from the most medica l vantag e point. Her duties in the teac hing hospital whe re she worke d wer e split betwee n assisting doc tors char g ed with treating phy sical ailments and r esident psy chiatrists who we re e mbarking on thera py c a re e rs H e r i np ut r a ng e d f ro m ma kin g su re tha t pa tie nts ha d r ide s h ome a ft e r t he ir hospital stay to alerting the psy chiatrists when she detec ted problems which r elated to the proce ss of mental hea lth. She dealt with patients befor e they wer e admitted to the hospital, through the ir stay in the hospital, and to adjustment difficulties enc ountere d subsequent to their stay I n talking a bout making r ounds with medical prof essionals (i.e., doctors—including psy chiatrists, psy cholog ists, and nurses), Amy rela ted numerous instances in which she appea red to ha ve the g oals of a pr ototy pical socia l worker as outlined in the social worke rs (Working Statement 1981, 6):

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67 1. He lp p e op le e nla rg e the ir c omp e te nc e a nd inc re a se the ir pr ob le ms o l v i n g a b i l i t y. 2. He lp p e op le ob ta in r e so ur c e s. 3. Make or g anizations responsive to people. 4. F a c ili ta te int e ra c tio n b e tw e e n in div idu a ls a nd oth e rs in t he ir e nv ir on me nt. 5. I nf lue nc e int e ra c tio ns be tw e e n o rg a niza tio ns a nd ins tit uti on s. 6 In f l u e n c e s o c i a l a n d e n v i r o n m e n t a l p o l i c y. S h e d es cr i b ed t h er ap y s u cc i n ct l y an d wi t h s o m e f i n al i t y i n t er m s o f h ea l i n g: Mik e Ok a y y ou wo rk wi th s e ve ra l di ff e re nt d oc tor s. We’ ll g e t to a sk so me qu e sti on s a bo ut t ha t. I t’ ll b e int e re sti ng —th e ps y c hia tr ist s in particula r. B ut, let me ask some kind of g ener al questions. What is therapy for you ? W h a t d o e s t h e r a p y m e a n ? Am y : Hm m. T o my min d, the ra py is a pr oc e ss b y wh ic h w e he a l ol d hurts that are interfe ring with our prese nt day life. Mik e : Me nta l a nd e mot ion a l? Amy : Probably both. As “a patient re source manag er in a teac hing hospital,” Amy say s her f unction and duties are involved in “looking f or dischar g e planning needs, f or how we can de liver mor e e ff ic ie nt s e rv ic e wh ile the pa tie nt' s in the ho sp ita l.” Som e of the wa y s sh e do e s th is are quite mundane ( e.g ., making sure the pa tient has somebody to pick them up on dis c ha rg e ). Som e a re muc h mo re c omp le x an d in vo lve d in te rv e nti on s [e .g ., de a lin g wi th mor e inv olv e d s e rv ic e s ( e .g ., HM Os in su ra nc e c omp a nie s, nu rs ing ho me s, re fe rr a ls t o outside social worke rs when ne eded e tc.)]. Others dea l with complex issues involving re la tio ns hip s ( e .g ., fa mil y f ri e nd s, a sso c ia te s, a nd e mpl oy e rs ). F ro m he r v a nta g e po int

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68 “ the c lie nt d ic ta te s th e c ou rs e of the ra py a nd if so me thi ng e lse is b e ing uh pr oje c te d o nto them, that would be in my opinion bad, prac tice.” Th e re wa s a lon g pa us e a ft e r I a sk e d A my “ Wha t a re g oo d th e ra py pr a c tic e s. ” So I switched my tack a nd asked he r wha t good therapy wo uld be H e r r e sp on se wa s in te rm s o f e ff e c ts o n th e pa tie nt r a the r t ha n o n w ha t a g oo d th e ra pis t does (i.e., tec hniques). I g uid e d h e r t o th e ra py pr a c tic e s b y dir e c tly a sk ing wh a t a the ra pis t should not do a s I tur ne d to the ba d th e ra pis t se c tio n o f t he int e rv ie w. She a g a in t ur ne d th e a ns we r t o coming from the c lient (she later would ref er to them a s patients) and ma de g ood distinctions based on basically passive ac tions by the thera pist to finding out wher e the c lie nt i s a nd ba d p ra c tic e s a s f a ili ng to w or k f ro m th e c lie nt d ic ta te s. I ro nic a lly p a ssi vit y of the the ra pis t is se e n a s “ g oo d, ” c on tr a ste d w ith the pe ri l of ba d a c tio ns wh e n a c tua lly doing some thing with the pa tient. Amy : We’re g oing to labe l it “good,” y eah. U mm that would be wher e someone is able to f unction either . e ither more e ffe ctively or happily in their prese nt day beca use, they ’ve be en able to resolve, iss ue s f ro m th e pa st t ha t ha ve be e n b loc kin g the m. Mik e : Ok a y So mos tly it’ s ta kin g c a re of pr ob le ms a nd sy mpt oms tha t a p e r s o n h a s n o w ? O k a y W h a t i s b a d c o u n s e l i n g o r b a d t h e r a p y ? Wha t a re pr a c tic e s th a t sh ou ldn ’t be do ne Wh a t sh ou ldn ’t a person who is a counselor or thera pist do? Amy : Alway s beg in where the client is. Not wher e the c lient isn’t. Either uh that would be f orcing solution or interventions that 1) the client doesn’t ne ed, or the client doesn’t wa nt, or the timing is not proper for the c lient. Mike: So, in other words, y ou’re kinda telling me that a g ood prac tice would be to listen very car efully to the . Am y : c lie nt. Mik e : c lie nt?

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69 Am y : Ye s T h e c l i en t d i ct at es t h e c o u rs e o f t h er ap y an d i f s o m et h i n g, else is being uh projec ted onto them, that would be in my opinion bad, pra ctice. Mike: Okay what’s, totally unacc eptable? W hat’s the line? The pe rson that’s g one over the line? Am y : Yo u me a n a t it ’s ve ry wo rs t? M i k e : In c o u n s e l i n g a n d t h e r a p y, w h a t w o u l d yo u s a y? Amy : Where is the . . Mike: “You c an’t do that(?),” or “You shouldn’t do that( ? ).” Well . “You can’t do tha t. Amy : Well, either telling the client what his problem is bef ore he ’s bee n able to fig ure tha t out for himself—if it’s eve n true. Mik e : Um hmm Amy : Or imposing a n intervention that’s immoral or une thical or, not something tha t the client is willing to rea lly g o along with. Mike: What would one of those interve ntions be? Amy : Umm. perha ps sugg esting sex t hera py for um a pr oblem which the thera pist is l ike direc tly involved. I mean, that is the hig h end. I mmo ra l a nd un e thi c a l. Mike: So basically sex wit h the client or Amy : Right . for his own g ood. The use of pauses, turn pa ssing, a nd insistence on extreme c larity in the questions illust rate Amy ’s discomfort with the a rea of g ood and bad pr actice s. When I asked direc tly what the line be tween g ood and bad pr actice would be, she a nswere d first by re a sse rt ing he r i ns ist e nc e tha t not directing the client is being g ood (eve n when it prove s to b e in t he ri g ht d ir e c tio n) a nd the n b y de fi nin g ba d a s f or c ing int e rv e nti on s o n th e c lie nt,

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70 immoral or unethica l interventions, and at last she g ave ha ving se x with the client as one of the ba d th e ra py pr a c tic e s ( int e rv e nti on s) The L CSW Wil l, spoke of ther apy as a pr ocess that g ets one pa st obstacles fr om the past which a re impac ting the c lient and pre venting him/her from be coming fully alive. Mik e : Us ua lly the fi rs t th ing tha t I a sk is k ind of g e ne ra l: “ Wha t is thera py ? ” and “ What do you c o n s i d e r t h e r a p y t o b e ?” Will: Uh h. Th e ra py is a pr oc e ss b y wh ic h p e op le e xami ne uh pa st e ve nts in t he ir liv e s th a t ma y be imp a c tin g the ir liv e s n ow T he ir ability to function, their beha viors uh their thoug ht proce sses and their moods, uh their emotional world a nd uh to where they can g et some clar ity move past some thing s, move past these obstac les and be more fully alive. Wil l was the most independe nt of the L CSW s. His prac tice ofte n involved thirdpa rt y re fe rr a ls a nd on e of his g ro up s in c lud e d a c lin ic a l ps y c ho log ist s. F or the mos t pa rt Wil l was an “ independe nt contrac tor” a nd provided c ounseling and ther apy in a ver y simil ar ma nner to that re veale d by my clinical psy cholog ist int ervie wee s. When asked a bout substandard tre atment pra ctices, Will key ed on sug g estibilit y He state d that he does not do hy pnosis or drea m therapy but had done some g uided ima g e ry (o ne of the te c hn iqu e s th a t r isk s in c re a sin g c lie nt s ug g e sti bil ity ) b ut p re fe rr e d to do conver sation therapy to chang e cog nitive makeup. Will: Th e su g g e sti bil ity h ow y ou le a d th e qu e sti on ing I me a n th a t’ s a big thing in child, child abuse c ases a s well, y ou know. Who’s doing the interviewing That’s why they have to tape ever y thing now, bec ause tha t the questions are leading I f y ou’re talking about, y ou know, all this hy pnothera py and ag ain, what a re y ou d e a l i n g w i t h t o s t a r t o f f w i t h y o u k n o w w h a t i s t h e ( ? ) i t i c ? If y ou ’v e g ot a the ra pis t, a ps y c hi> : y ou kn ow e ve n a ps y c hia tr ist in thi s. . Wh o is > ha s a c e rt a in f ra me wo rk is loo kin g fo r c e rt a in things. uh it’s, y ou know, y ou can, y ou can g o find any thing. And if y ou ru n u p a g a ins t, y ou kn ow . ? Some ty pe s o f p e rs on a lit y disorders a re the re e very wher e.

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71 Wil l also expressed conc ern a bout the mental hea lth of some of the pe ople who we re be ing g ra du a te d f ro m so c ia l w or k u niv e rs iti e s. Wil l: I mean, I looked ar ound my class at [university ] and I said ‘50% of these pe ople oug htn’t to be prac ticing soc ial work.’ F ive y ear s. . An d I do n’ t kn ow if tha t’ s tr ue or no t. b ut t he re we re so me pe op le in there w ho, uh had to be we eded out. Ve ry needy ty pe of pe ople. I ’ve se en it happen a t [ differ ent university ] where they they ’ve ha d to> wh e re on the ir int e rn sh ips p e op le wo uld sta nd up a nd sa y th is person is not appropr iate to do this work. Mik e : Um hm. Wil l: You know. Straig ht “A” stude nt and eve ry thing, but she’ s, she’s cra zy as a loon. Wil l at first brushed a side the question of the line be tween g ood and bad pr actice as being subjective be fore I assure d him that I understood the subjec tivity of the que stion, but that was wha t I wanted— his subjective thoug hts on the topic. He then spoke of failure to achieve positive results, therapists with ag endas othe r than the me ntal health of the client, and c onfidentiality befor e re turning to not relea sing the patient when the t h er ap y i s n o t wo rk i n g. Mike: I want to ask one question. What is t he line betwe en g ood prac tice and bad pr actice ? Who are they How do we deter mine, bad thera pists and good the rapists? Should som ething be done a bout the ba d o ne s. Wil l: You know eve n that is a subjective thing You know it’s not like a lit mus te st. Mike: I know it’s subjective, a nd y ou’re the one. Wil l: Huh? Mike: I know it’s subjective a nd I ’m asking y ou. Will: Uh uh y e a h, y e a h. I wo uld thi nk tha t if (s no rt la ug h) the ir patients g et sicker (laug hs).

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72 Mik e : I f t he ir pa tie nts g e t si c ke r, if the y do ha rm — pr im um no n n oc e re ? Wil l: They . y eah. I n uh man uh Mik e : Wha t’ s a ba d th e ra pis t? Hav e y ou me t a ny ba d th e ra pis ts? Wil l: Oh y eah. T hey ’re people whose uh, Their a g endas a re more i m p o r t a n t t h a n t h e i r p a t i e n t s o r t h a t i t ’ s i t ’ s u h c o n f i d e n t i a l i t y > M i k e : W e d i d n ’ t g e t t o t a l k a b o u t c o n f i d e n t i a l i t y. Wil l: > and tha t stuff. Uh. Well I ’m more inter ested in the c linical kind of thi ng s th a n th e . y ou kn ow I thi nk tha t th e c on fi de nti a lit y thing, it’s it’s ver y important of cour se. B ut it’s like. . Now it’s bally to the hip of things. I t’s bally hooed wa y bey ond uh . y ou kn ow I me a n it ’s it’ s it ’s it’ s. . T ha t’ s so me ho w, tha t’ s g ott e n to be a poke I t’s like things in hospitals. A lot of the pape r work, re g s, a nd the thi ng s th a t y ou ha ve to d o, a re a ll d e sig ne d b y pe op le who don’t do that work. [Wil l then talked about a dminist ration and unnece ssary reg ulations before g etting ba ck to bad ther apists] . Ye a h. Ca us e a lot of pe op le I me a n, y ou g e t pe op le in h e re c ome int o th e ra py a nd the re ’s not g o i n g t o b e i m p r o v e m e n t Y o u k n o w ? I mean, a nd y ou see tha t all the time too. Mik e : An d s o, y ou wo uld wa nt t o g e t r id o f t he m or jus t ke e p th e m? Wil l: Yea h, just y eah, “ Well thi s is not working.” The two other L CSW s, Be tty and L arr y both relate d the object of thera py to be fr e e do m f ro m so me thi ng tha t th e c lie nt i s stuck in rathe r than healed from or got through an obstac le. For them, the thera pist helps to move the client out of the plac e whe re he /she is stuck. The foc us of B etty ’s re sponses did not appea r to come f rom a pa rticular A merica n perspe ctive. This L CSW included an inter cultural standpoint in understanding and trea tment of clients. She talked of thera py as an e x perie nce of g rowth that client a nd thera pist are both g oing thr oug h. She spoke of the the rapist in the third person a s if the the ra py is “ ou t th e re so me pla c e ” to b e dis c ov e re d th ro ug h th e int e ra c tio n o f t he the ra pis t

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73 and the c lient. This Oriental conc ept of “ rele asing ” the se lf into mental health involved a n in te ra c tio n o f t wo se lve s— tha t of the the ra pis t a s w e ll a s o f t he c lie nt. Mike: What do y ou think therapy is? What’s it mean to you ? Be tty : I g uess. . Ther apy for me pe rsonally or for my clients or both? Mike: What does it mean to you Be tty : Thera py is . its j ust an opportunity wher e two or more people g et tog e the r a nd umm a nd g ro wt h is g oin g to h a pp e n s ome bo dy is g oing to lea rn insightf ul things about themselve s. You know, stuff a bo ut t he mse lve s a nd umm is g oin g to l e a rn a bo ut t hin g s, ho w i t rela tes to them and how it makes them f eel a nd how it makes them be and be have in the w orld and wha t chang es they want to make a nd the ra py he lps the m br ing tho se le e ri ne ss t o th e fo re fr on t to he lp them g row . fr om whateve r aw are ness they are lear ning. So that to m e is w ha t th e ra py is. Mike: And so a ther apist would be . ? Be tty : L ike a c hang e ag ent Mik e : A c ha ng e a g e nt? Be tty : Yea h somebody who just helps someone move for war d out of wh a te ve r’ s h a pp e nin g wi th t he m a nd mov e ou t of tha t be c a us e they ’re stuck or . . B e tty jum pe d r ig ht f ro m my qu e sti on of wh a t a g oo d th e ra pis t w ou ld b e to the ra pis t sk ill s ( c omm un ic a tio ns a nd lis te nin g ) a nd the ra pis t mo ra lit y a nd e thi c s ( ho ne st and open) When I asked w hat a ba d thera pist would be, she answe red, “ a ther apist who, for their own g rowth and de velopment uses the pa tient for that.” A fter r eassur ing he r of confide ntiality (that I would make sure that her ide ntity as interview ee w ould be known by no one but me), I asked he r if she ha d know such a thera pist. S he re lated the fo llo wi ng w hic h a mpl if ie d h e r p os iti on on ba d th e ra pis ts:

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74 Be tty : Okay well not any one loca lly but when I lived in [ state] there wa s one per son who um dated their pa tient and the patient ha d money and influenc e and a ll other kinds of other thing s. And I think it was just purely for their own g etting out ther e and me eting people that t h e y c o u l d a l s o t r e a t a n d w h a t e v e r a n d u m b u t s o I w o u l d s a y a bad ther apist is someone who date s their patients or who sle eps with their patients or who um who ta lks about their patients, bre aks confide ntiality um without any body y ou know, other tha n a mentor or something You know? Mike: Right Be tty : But ther e sometimes nee ds to be some help with a c onsultant or whateve r. So a bad the rapist would be one who doesn’t take car e of the mse lve s a nd wh o u m a nd wh o is no t in g oo d f or m f or the ir patients, who is not healthy and whose not modeling be havior that is, that is . M i k e : W h a t d o yo u m e a n b y h e a l t h y? Be tty : Umm Somebody who’s not drunk a t night and hung over in the morning and ca n bare ly focus on the pa tient the next day S o m eo n e w h o d o es n ’t ex er ci s e a n d s l ee p we l l s o t h ey ’r e gr o ggy and slee py and not thinking ve ry well. um, You know? Someone wh o ju st i n g e ne ra l do e sn ’t ta ke g oo d c a re of the mse lve s u m a nd so they can’ t be fully prese nt to their patient The L CSW L arr y stressed the importa nce of a re ligious standpoint. He de scribed thera py in terms being a g uide in his relationship with clients. Mike: Okay The fir st thing is what is thera py for you ? What does t h e r a p y mean ? L arr y : Uhmm. Boy I g uess I ’m taking normal people that have to be . happen to be stuck in one of life ’s transitions and sort of pr oviding a saf e plac e for them to work throug h that and try to ge t them to a better pla ce. Mike: Right. Right . ther e’s no right (laug hs) answe r for me. I t’s y our answe r andL arr y : I could talk for a n hour but an hour is a ll y ou g ot, so. . Mike: Yea h. That’s fine

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75 L arr y : I g uess coming from my perspe ctive ther e’s a lot of attachme nt the re in, ba sic a lly s ome on e wh o c a n h e lp a pe rs on be c ome an ch o re d i n t h ei r . i n t h at t h ey ar e a p er s o n o f v al u e a n d o ft en go back a nd explore previous thing s or pre vious events wher e they have not f elt that. So it’s . transfere nce is proba bly a key thing i n m y a p p r o a c h t o t h e r a p y. L a rr y no te d th a t he too k th e qu e sti on s o n “ wh a t is the ra py ” a nd “ wh a t ma ke s a g ood (or ba d) thera pist” for g rante d. After seeing pauses, I decide d to chang e the or der of the qu e sti on a nd a sk e d a bo ut b a d th e ra pis ts f ir st. L a rr y the n a ns we re d th e qu e sti on a s to what a g ood thera pist does—basically to play a supportive r ole. He be g ins his sessions with an eig ht pag e introductory form that primar ily provides questions to reve al expectations of the client a nd to let the client know the psy cholog ical appr oach he takes as a the rapist. He r elated g ood prac tices to be those that pr ovide unconditional, positive reg ard to a ffirm the va lues of the c lient. His practice provides a se cure place to expl ore t h e ga p b et we en p s y ch o l o gi ca l an d s p i ri t u al re al m s He d i d t h i s p ri m ar i l y t h ro u gh “discussion.” Mike: Would i t be ea sier to say what make s a bad thera pist, an un a c c e pta ble the ra pis t? L arr y : (I nhales) I ’m probably influence d a lot, by Carl Rog ers on the whole, issues of unc onditional, posit ive re g ard. A thera pist has to. . A per son wants to g et from whe re the y are —to some other state other tha n wher e they are rig ht now, and that involves inf lue nc e a nd y e t a re a liza tio n th a t I do n’ t kn ow the ir wo rl d completely So a g ood thera pist is s omebody that aff irms the value of a pe rson, so that that’s a se ttled matter, and the y can e x plore other thing s that might be a littl e more threa tening to them in any oth e r c on te xt. We discussed authoritar ian re lationships often reque sted by clients and then I returne d the conve rsation to the topic of ba d thera pists. I n the following section L arr y talks of a pa rticular the rapist who wa s involved sexually with a client.

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76 Mik e : Ok a y L e t' s g o to wh a t' s a ba d th e ra pis t, w ha t ma ke s. . T his kind of emotional thing. H ave y ou known people tha t y ou considere d to be bad ther apists, and what wa s there a bout them that made them a bad ther apist? And if not, what would make a per son, y ou wo uld sa y a ba d th e ra pis t? L arr y : Most of what I g et is self-r eports of c lients' e x perie nces w ithout the . without a thera pist. Yeah, c erta inly y ou g et into the extreme. I have inde ed conf err ed in a ther apist that entere d into a sexual re la tio ns hip wi th a c lie nt. Mike: And y ou said . ? L arr y : I inherited that c lient, so something at that e x treme, uhhm. Of ten it's more in the are a of, pr obably the use a nd abuse of influence having an ag enda f or how they need tha t person to . what direc tion they neede d that person to g o in. So. Ahh, they ve us ua lly be e n in a re a s p e rt a ini ng to p ow e r a nd a re a s p e rt a ini ng to transfe renc e. He the n s po ke of a bu se of inf lue nc e a nd the n u se d h is e a rl y e xpe ri e nc e a s a thera pist to poi nt out the trap some ther apist may fall into (letting the ir own emotional needs le ad them into pressuring the client to outcomes) to those w hich may be more for the thera pist’s own benef it than that of the client. He then spoke dispar ag ingly of thera pists who abandon the c lient when help is still needed. Overview of H ow L CSWs Defin e Therapy P ract ices and Th erapists Whil e I decide d to ask about “the line” betwe en g ood and bad the rapy prac tices at a n e a rl y po int in a ll t he the ra py int e rv ie ws I a lso re tur ne d to “ the lin e ” a t th e e nd of a ll my interviews. I n many case s, psy cholog ists and psy chiatrists as we ll as the social worke rs adde d to their statements. With t he exception of socia l worker Wil l, the thera pists were a ll asked about g ood and bad the rapists very ear ly in the interview. The flow of Will’s interview pre cluded my asking until near the e nd. Whether it was an element of the proc ess of the inter view or some othe r fa ctor (i.e ., we ha d talked about

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77 sexual abuse of c hildren bef ore this topic was a sked about), L CSW Wil l was the only one of the c lin ic a l so c ia l w or ke rs wh o d id n ot m e nti on tha t th e ra pis ts w ho ha ve se x with clients, prese nt or forme r, ar e bad the rapists. Ea c h o f t he the ra pis ts h a d s e ve ra l pe rs on s w ho we re re so ur c e s w ho m he /sh e c ou ld call upon for support and to help him/her maintain g ood trea tment prac tices. Amy had the medical staf f at the hospital and se vera l social worke rs that she c alled upon for specia liz ed ser vice f or patients. L arr y met wee kly with another soc ial worke r, a psy cholog ist, and a nutritionist. He also spoke of c ontacts with cler ics who we re one of his resourc es for new c lients and in at least one instanc e had pr ovided counse ling a ssi sta nc e Wil l sh a re d a n o ff ic e wi th a ps y c ho log ist (a lte rn a te da y oc c up a nc y ) i n a c lin ic which included othe r clinica l social worke rs and psy cholog ists. He also conduc ted a mental hea lth gr oup with a psy cholog ist at another loca tion. Betty was supporte d by o t h er s t u d en t s an d i n s t ru ct o rs at t h e c l i n i c w h er e s h e w o rk ed an d wh er e s h e w as get t i n g a deg ree in acupunc ture. She a lso had contac t with massag e ther apists and other a lternative health spec ialists (mental as well as phy sical). Whil e my literature revie w had be en rife with expos tulations and defe nses on what tra its a bad thera pist has, and often the se we re c ontrasted with g ood thera pists, I was surprised to discove r that the intervie wed ther apists did not have such for mulated opinions. After I discovere d this in an early interview, I rephr ased my question and aske d about g ood practices as opposed to bad one s. At that point I left open the definition of “pra ctices” (i.e., whe ther I was a sking a bout how office s were run or wha t techniques would be labe led bad or g ood). I was intere sted in both, but I wanted to f ind out which ones ea ch ther apist would pref ere nce in their initial answer. F inally when a sking a bout

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78 prac tices, I included that I was intere sted in finding out wha t was the line betwee n pr a c tic e s th a t w e re la be le d g oo d o r b a d. Ea c h o f t he c ha ng e s I ma de in p re se nti ng the se topics broug ht more immediate re sponses and a ppear ed to re ach a rea s which had more sa lie nc y fo r t he int e rv ie we e s. L CSW A my did lis t so me of he r r ole s a s a re so ur c e c a se ma na g e r, bu t on ly B e tty spoke of g ood thera pists as those who had def inable skills (which she e numera ted) whe n sh e ta lke d o f t he ne c e ssi ty of ma int a ini ng pr of e ssi on a lis m [my te rm ]. A my str on g ly str e sse d th e imp or ta nc e of be ing a wa re of a nd fo llo wi ng the dic ta te s o f t he c lie nt i n deciding on interventions; L arr y spoke of pr oviding a supportive role; a nd Wil l said that it is i mportant for the thera pist to help in sol ving the client’s proble ms and stopping the thera py sessions when they are no longe r produc ing positive re sults. Whe n ta lki ng a bo ut b a d th e ra pis ts, a ll s po ke of the fa ult of g ivi ng pr e c e de nc e to the thera pists own ag endas a nd/or nee ds over those of the clients. B etty and Will s poke of the importanc e of ma intaining c onfidentiality Amy ’s def inition of bad therapy p r a c t i c e w a s t h a t i t i s t h e o p p o s i t e o f t h e d e f i n i t i o n o f g o o d t h e r a p y— not following the dic ta te s o f t he c lie nt/ pa tie nt— the ra py pr oc e sse s mu st involve and spring from the c lient. For L arr y the par amount differ ence from stateme nts of the others wa s in emphasizing the i m p o r t a n c e o f c o n t i n u i n g t h e t h e r a p y s u p p o r t a n d n o t a b a n d o n i n g t h e c l i e n t p r e m a t u r e l y. Whil e L a rr y a dv ise d c a uti on in n ot l e tti ng the pa tie nt g o to o s oo n, Will a dv ise d c a uti on in not letting the pa tient go soon e noug h. Th e so c ia l w or ke rs wh o h a d b e e n in te rv ie we d w e re e sse nti a lly tr a ine d to a ssi st i n the pra ctical c oncer ns of their c lient/patients. To become L icense d Clini cal Social Workers they also had be en re quired to pass a national examination. Three of the

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79 L CSW s were occupy ing pr imary thera pist roles and the other was pe rfor ming r oles and ta sk s w ith in a te a c hin g ho sp ita l. T he se ta sk s in vo lve d s up po rt ing do c tor s c ha rg e d w ith ph y sic a l pr ob le ms a nd su pp or tin g the ps y c hia tr ist s w ho we re of te n r e sid e nts a ssi g ne d to the hospital. One a spect of he r support took the for m of aler ting medic al per sonnel to the mental hea lth needs of the pa tient for coping with the world external to the hospital environment a s well as within it. Al l of the L CSWs h a d s up po rt pe op le to a ssi st i n th e ir pr a c tic e a s n e e de d. Th os e in private pra ctices pe rfor med func tions described similarly to those of other pr imary thera pists. They acte d as the primar y mental hea lth resourc e for their clients on a one -onon e ba sis a nd le d me nta l he a lth g ro up se ssi on s. Ea c h o f t he ir of fi c e s w a s in a c lin ic which conta ined other the rapists and a vailable support pe rsonnel. Two of the L CSW s oriented to ther apy rela ted that clients we re mired in situations and conc eptual binds that wer e af fec ting his/her me ntal health. Another was c oncer ned with blockage s re str a ini ng the c lie nt f ro m me nta l he a lth T he fo ur th w a s o ri e nte d to trea ting menta l illness as an inj ur y and her self as a component of the healing proce ss. The L CSW s in private pra ctices a ll used brief the rapy consisting of only a fe w thera py sessions. Each ha d trea ted clients in g roup thera py sessions as well as individually Along with Wi ll, Amy and B etty noted that cha rac ter fla ws wer e additional barr iers to g ood prac tice. All had, in at lea st one instance in their car eer s, experience d the a c tio ns of a lic e ns e d c lin ic a l so c ia l w or ke r t ha t th e y la be le d “ c ra zy .” I n e a c h o f t he se c a se s, the y we re a pp a lle d th a t su c h a pe rs on c ou ld b e lic e ns e d. Sin c e thi s r e se a rc h is conce rned w ith the labeling of pra ctices a s deviant or nor mative and lea ves questions of

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80 char acte r for others to pursue, the interviewe r did not probe f or deta ils or seek other instances of char acte r flaw s, which ar e not direc tly proscr ibed by profe ssional ethics or the law. The L CSW s corr elated ba d thera py with doing ha rm to the client (i.e., primum no n n oc e re ). F or Am y se xua l a bu se of pa tie nts by the the ra pis t, c ult iva tin g e xtre me de pe nd e nc y on the the ra pis t, a nd ma nip ula tio n ( e ve n w he n it re su lts in a g oo d o utc ome for the pa tient) wer e the thing s that harm patients. L arr y discussed har m that came f rom counter -transf ere nce. Will and Be tty more dire ctly rela ted har m to not being se nsitive (“ pr e se nt” ) f or the c lie nt/ pa tie nt. Al l of the so c ia l w or ke r i nte rv ie we e s a dv oc a te d s ome kind of constra int by licensing boards a lthough the f orm that this might take va ried, g r e a t l y. To g et to actua l therapy techniques, I had noted that my literature revie w had broug ht up the prac tices of hy pnosis, drug thera py and g uided imag ery and, in turn, aske d wh a t di d e a c h th ink a bo ut t ho se pr a c tic e s. Will h a d u se d g uid e d im a g e ry a t so me tim e s in his pr a c tic e b ut h e pr e fe rr e d to us e ta lk. He str on g ly c a uti on e d th a t us e of the se te c hn iqu e s r a ise the iss ue of su g g e sti bil ity a nd tha t us e of the m op e ns the the ra pis t to acc usations of manag ing the client ra ther than he lping them solve the ir problems. None of the other s had used a ny of these te chniques. B etty and Amy also wer e conc erne d about sug g estibilit y in relation to these tec hniques but acc epted that they wer e used by others. L arr y ’s theore tical per spective pr eclude d use of hy pnosis or g uided imag ery Be tty was pa rt ic ula rl y c on c e rn e d a bo ut t he ov e rpr e sc ri pti on of ps y c ho tr op ic dr ug s b ut l ike the re st sa id t ha t th e y we re us e fu l in so me ins ta nc e s.

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81 Interviews w ith Psyc hologis ts and an Edu cational Counselor T h e c l i n i ca l p s y ch o l o gi s t s an d t h e e d u ca t i o n al co u n s el o r s p o k e o f u s i n g a c og nit ive -b e ha vio ra l pe rs pe c tiv e on the ra py A ll, ho we ve r, we re e c le c tic in t he ir selec tion of particular approa ches a nd g oals. These wer e tailore d to the context of the thera py sessions and the conte nt of the social a n phy sical environme nt of a pa rticular c lie nt. Rick, a psy cholog ist, got seve ral of his c lients from ref err als by cler g y He differ entiated be tween a n ideal ty pe of the rapy and the wa y thera py is practice d. Neve rtheless, his theore tical per spective w as ver y simil ar to the othe r psy cholog ists but focuse d more on fitting client selec tion accor ding to his re ligious fr amewor k. He did not believe tha t there w as a c onflict betwe en his relig ious beliefs and his theor etical tra ining but did give e x amples of times whe n his relig ious beliefs had a ffe cted c lient selection. At fi rs t, h e a pp e a re d ta ke n a ba c k b y my pr ob e a bo ut t he ra py H e c ho se to r e fr a me my qu e sti on “ Wha t is the ra py ? ” int o “ Wha t th e ra py sh ou ld b e ? ” He a ns we re d th a t it sh ou ld be a w ay of produc ing w anted a nd healthy chang es in life. Ric k: I n e sse nc e th e ra py I be lie ve n ot t o g e t to o Cl int on ia n, bu t I g ue ss pa rt of the re a so n I ’m ha vin g tr ou ble a ns we ri ng y ou r q ue sti on is i t depends on w hat y ou mean by ‘is.’ So I ’m g oing to a nswer instea d, “What thera py should be.” The rapy for me should be a, mode by which a pr ofessional a ssists, s omeone in, produc ing w anted a nd h e a lt h c h a n g e s in li f e [?]. When I asked how he (a thera pist) does that, he discussed the oreticia ns from the cog nitive behaviora l perspec tive and then a theore tician from the solution oriented approa ch. I n the thera peutic discipline blank on the de mogr aphic da ta form he had

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82 written “pr edominantly cog nitive-beha vioral, informe d by other a pproac hes, including solution oriented.” Hy pnosis was a tec hnique that Rick had used to he lp a client do thing s that the client wante d to do but had resistanc e to other the rapy techniques. Rick r emar ked that he ha d s ome tr a ini ng in h y pn os is a nd the c lie nt h a d s ug g e ste d tr y ing it. Ric k d id n ot f ind it to be ef fec tive. He sa id that with more training he would conside r using it in the future fo r c ha ng ing e xpe c ta tio ns b ut n ot f or c ha ng ing pe rs on a lit ie s. Rick: I t’s that ‘hope’ conce pt. “I can’ t stop smoki ng I can’ t stop thi s,” or “I can’ t ge t along with my wife.” “Ye s y ou can! ” [laug h] You know? Mike: Yea h Rick: And if that ends up be ing a tool that somehow, [raps on table] the ri tua l a nd a ll t ha t of it, uh te nd s to be mor e c on vin c ing tha n my jus t say ing, “ Well if y ou try this technique . .” The n it’s something us e d f or po sit ive va lue a nd a g a in a nd se rv ic e —f ine !, I t’ s a va lid thera py Uh there ’s a c liche for that. But [laug hs]. Uh, in t hat context, I could see using it. My belief in hy pnosis as being . a thing Uh it was some ty pe of, y ou know, quasi-mag ical thing that rea lly has a lot of e ffe ct on its own. I t’s limit ed. B ut I do know tha t pe op le u h a re c on vin c e d a nd so ld o n id e a s o f d if fe re nt w a y s, and if hy pnosis can be use d in a way of, of incr easing their, expectation of cha ng e, buy ing into that sug g estibilit y sobeit. . I don’t use it. I g uess what I ’m try ing to maintain he re a nd make clea r her e is that I don’t have an absolute pr ohibition aga inst the idea, if I thought it would be he lpful to do. I just haven’t found a c a se wh e re it is Ric k d id n ot u se g uid e d im a g e ry a bo ut m e mor ie s b ut h e did us e ima g e ry in re la xati on te c hn iqu e s, “ ima g ini ng the mse lve s. ” He did no t us e ph a rm a c olo g y be c a us e it wa s n ot a va ila ble to h im. He did se e it a s a too l he lpf ul f or the ra py d e pe nd ing ho w i t is used, but did not go into deta il as to when it is mis used.

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83 Rick was ver y succinc t in his st atement a bout when a the rapist has done bad prac tice: “You’ re g oing too f ar, w hen, y ou lose trac k of who the the rapy is suppose to be about. I t’s not about y ou, it’s about them.” Whe n I a sk e d Ri c k w ha t ma ke s f or a g oo d th e ra pis t, h e fi rs t r e sp on de d w ith p er s o n al t ra i t s t h at a t h er ap i s t s h o u l d h av e a n d t h en wo rk i n g with the clients instead of try ing to fix them and fina lly respe ct for the ir values. Rick wa s the thera pist who rejec ted potential clients on the basis of his own va lues. Ther efor e par t of his approa ch involved his a bil ity to s ho w t he c lie nt t ha t he sh a re s th e ir va lue s. Rick . [ex hale]. Well certain obvious things—intellig ence uh uh ins ig ht, un de rs ta nd ing s tud y —a ll t ha t ki nd of g oo d s tuf f. Uh b ut I think the basic, uh, Respec t for y our clients as a s a par tner in the proce ss. Uh, y ou’re not, fixing t h e m If yo u v i e w i t t h a t w a y, y ou’re g oing to be far too uh ag g ressive, a nd y ou can e ither . ca n push them in directions that they they don’t want to g o. uh You’re kin d o f h e lpi ng the m f ix the mse lve s. so a kin d o f r e sp e c t f or the m, and uh, which inc ludes uh, a re spect for their value s. Kind of g oes back to the que stion about, How do y ou build the trust. uh y ou know, wher e possible, kind of showing y ou know that y ou share their value s. uh Mike: y eah Ric k:: Just p a rt of ho w I e nd up g e tti ng a lot of re fe rr a ls. B a d th e ra pis ts a re de fi ne d a s o ne s w ho ha ve the ir ow n a g e nd a s a nd “ wa nts e ve ry bo dy to f it i nto the ir mol d. ” He tho ug ht t ha t e ve ry on e ha s h is/ he r o wn wo rl d outlook and philosophy but therapists should make theirs “ up front,” “ so that they can know whethe r they (clients) ma tch y ou and find somebody else if they don’t.” Rick’s relig ious outlook and ideology wer e ver y important for him. Rick: I don’t prete nd to be unbiased. uh I ’m in favor of, fa ith and values and strong marria g es and tha t kind of stuff and if y ou want s o m eb o d y wh o ’s go n n a, t el l y o u h o w t o get o u t o f y o u r m ar ri age

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84 without any g uilt.> I can r ecommend y ou to a fe w other the rapists. You don’t wa nt to be working with me. Be ing “ up front” a nd selec ting c lients with sim ilar value s were the way Rick avoided be ing a bad ther apist and having his personal a g enda a ffe ct his clients. “Ag enda” for Rick ha d three components: philosophical (melding profe ssional and re ligious ethics) ; financ ial (e.g ., keeping somebody in therapy when they rea lly don’t nee d to be); and emotional (e.g ., inappropria te re lationships). The interview flowed into the a uthority that a ther apists repre sent and the ne ed to listen to how the clients talk about their a nd pr ob le ms. Th e se a re e xami ne d f or log ic a l e rr or s a nd fa lla c ie s th a t th e c lie nt i s te lli ng him or her self and, a s a thera pist, Ri ck would foc us on solutions for the c lient. Rick’s prac tice wa s slow at the moment. He did not ac cept c lients from HMOs a nd c lie nts we re re sp on sib le fo r d e a lin g wi th i ns ur a nc e c omp a nie s. He sa id h e wo uld work with clients with insuranc e, but re quired them to pay up-fr ont and collec t the insurance remune ration themselves. Since he did not collect f ees f rom third parties, he did no t f e e l th a t he ne e de d to sp e nd muc h ti me on dia g no sis H e wo uld g o s tr a ig ht t o problem solution. I f a dia g nosis was nee ded by the client for insurance purposes, Rick would consult the DSM I V. When I asked w hat was the line betwee n g ood and bad thera py He sa id, “g ood thera py is about them, bad thera py is about y ou.” Kar en, Ph.D. in educa tional counseling define d thera py in term of the pr ivilege d re sp on sib ili ty of he lpi ng ba la nc e the c lie nts ’ f e e lin g a nd “ he a d” a sp e c ts. She re fe rr e d to “solution focused the rapy ,” but indicated it wa s an insufficie nt label for the ty pe ther apy she did. I n addition to focusing on problems that the client wa s prese ntly having she added tha t her wor k was e clec tic and involved helping people g et balanc ed in their lives

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85 by working on “the feeling side of them,” not “ just in t heir hea d a ll t he tim e .” Ka re n a lso descr ibed thera py as a pr ivilege d position wit h responsibilities. Ka re n: Wel l it ’s a ve ry pr ivi le g e d p os iti on I ha ve in t e rm s o f . in t e rm s of people trusting me w ith their stories and with their issues and the ir pr ob le ms a nd c on c e rn s a nd he lpi ng the m be lie ve tha t th e re is a wa y to live a better life, be true r to themselves, live in—I ’m tr y ing —h a rm on y a nd c omm un ity be tte r, be a t mo re a t pe a c e wi th the mse lve s, ma ke c ha ng e s th a t th e y wa nt i n th e ir liv e s. Ethics was the ke y to good tr eatment pr actice s for e ducational c ounselor Ka ren, a Ph.D. in educational c ounseling She also mentioned re specting the conf identiality of the client to the extent lega lly possible. Kare n talked about e thics and laws throug hout the int e rv ie w a nd so me tim e s it se e me d th a t sh e wa s w a iti ng fo r m e to e xpre ss s ome thi ng to g ive her a cue as to what he r answe r should be. Approa ch to thera py and tec hniques wer e not so important to Kare n as living up to professional e thics. She felt that diffe rent a pproac hes which mig ht be inappropr iate or ine ff e c tiv e fo r a pa rt ic ula r t he ra pis t mi g ht w or k f or a no the r. Th is w a s th e mom e nt I chose to a sk about the Ramona case (amplified in Chapter 9). I conclude d a short sy nopsis of the ca se by noting some of the pra ctices tha t were discussed in the ca se and noted: “The y used ce rtain pra ctices—hy pnosis, Sodi um Pentothal, directed imag ery and uh a lot of thing s that had to do with sugg estibilit y Do y ou use any of those in y our prac tice? ” Kar en: (L aug hing) Right, rig ht. No I don’t do hy pnothera py and dire cted ima g e ry I ’m no t su re wh a t y ou me a n b y the te rm L e t me pu t it thi s w a y is y ou r q ue sti on wh a t do I do a bo ut r e pr e sse d me mor ie s? Mike: Yea h that, should do.

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86 K a r e n : Y e ( l a u g h s ) a h u h I typ ically ever y thing’ s individual. I mean that the re ’s no t on e thi ng I do in m y lif e p ro ba bly th a t I do in t he sa me way ever y time—not even how I brush my teeth. So, I do believe tha t pe op le c a n r e pr e ss m e mor ie s. I thi nk it’ s a ph e no me no n, I jus t acc ept it as such. Do I work, to pull those out of people? I don’t. I think they are .. Mike: You don’t probe ? Ka re n: I ma y a sk the m so me qu e sti on s a nd I ’l l te st, I ’l l w a tc h r e a c tio ns I ’ll listen to words, I ’ll, y ou know, watc h, y ou know. Mike: But y ou don’t open it up? Kar en: L et’s see do I open it up? I f it’s appropr iate. Am I a sleuth about them? No. No, ther e’s a rea son that they ’re sort of latent a nd I thi nk it can be ha rm fu l. I me a n, if it’ s rel e va nt I wo rk wi th i t, b ut. . After stating tha t she did not use any of those tec hniques, she assumed tha t I was asking about how she a pproac hed re presse d memories. She believe d that people c an re pr e ss m e mor ie s a nd be lie ve d th a t r e pr e sse d me mor ie s c a n b e ha rm fu l. K a re n w ou ld ask some questions about the memor ies if the client br oug ht them up, but would not probe f or them. She showed some uncer tainty about the re levanc e of the se memories f or diag nosis and/or trea tment by ending her state ment on their re levanc e with a subjunctive “if” and the ope n-ende d qualifier “ but. . .” Of a ll the therapists I interviewe d, Kar en wa s most guar ded in her answe rs. As the interview went on, she w ould volunteer infor mation. I n the ea rly stag e of the interview she would use stalling ta ctics such a s repe ating the question as if she ha d not hear d it, laughte r, and long pauses a s if passing her turn to spe ak, eve n to respond to the question. One e x ample is that she took a c ompara tively extremely long time to sele ct five

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87 car ds from the c oncept c ards. She r eac ted to the ca rds as if they wer e a te st. Finally she i n d i c a t e d h e r q u a n d a r y: Kar en: I know what I am g oing to do, just dec ided what I am g oing to do with these. [A few w ords wer e ac cidently era sed fr om the tape] . pr oc e ss i t a nd on e of the thi ng s th a t g e t so rt e d a re pe op le wi th t e sts like these a re quic k to make judg ments or they think about the po ssi bil iti e s f or e ve r. (K a re n la ug hs ) I kn ow I kn ow b ut I m ju st thinking. . You’ ve g ot someone who' s g onna try to think li ke, Wel l if I pu t th e se th e n w ha t w ill tha t mean ." Ra ther than Oh this, thi s, this, thi s.” She was a lso judicious in defining a g ood thera pist. The following is an example: Mik e : Ok a y w ha t ma ke s f or a g oo d th e ra pis t? Kar en: Well, lot s of things. ( laug h) Mike: What's number one? Kar en: Yea h, what' s number one? Mike: What is t he one thing y ou would say if that person doe sn' t do that thi ng th e n th e y re no t a g oo d th e ra pis t. Ka re n: To be e thi c a l. Mik e : To be e thi c a l? Kar en: Yea h, cause I think. . Take ten the rapists with the same c lient. We can a pproac h things ten diff ere nt way s and then we can a ll be g ood or we can a ll be horrible. ( laug h). For Kar en, following the dictates of the law a nd the ethics of the profe ssion de te rm ine if the the ra pis t is g oo d o r b a d. She ind ic a te d th a t sh e ho pe d th a t th e le g a lit y and prof essional ethics would be the same in a particula r ca se, but the final de terminant of the line be tween g ood and bad pr actice was “ the law! ” The other psy cholog ists, Gail and Z oe, spoke f rom an e ducational pe rspec tive. This was discer nible by the text of their discussions as well as from the f act that Ga il was

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88 involved with children with problems ofte n reg arding intellectual bar riers a nd that Z oe was primar ily involved with students at a university Throug hout their interviews, the y wo uld de mon str a te fa c ili ty in t he tr a ns mis sio n o f k no wl e dg e —w ha t th e y kn e w a bo ut a subject. This perspe ctive is associa ted with the educ ational sy stem more so than with one of the oth e r i ns tit uti on s. Gail said. “I don’t rea lly fee l like I have a cer tain orientation towar d thera py .” During other e lements of the inter view, I would pose a que stion and she would g ive rema rkably detailed a nd inclusive answe rs that wer e obviously not memorized but internalized—illustrating a firm under standing of the topics. He r answe r for this question a pp e a re d to be le ss f or me d a nd mor e in t he pr oc e ss o f b e ing tho ug ht o ut a s sh e sp ok e it. This is notable in the unchar acte ristically uneven f low of the a nswer illustrated by the se c on d p a rt of thi s e xch a ng e : Mike: I n, y our words, w hat is therapy ? What do therapists do? Gail: I think therapists work with people to c onsider situations that are cre ating some sort of stress or unhappiness and e x plore options for making chang es, so that they can f eel be tter. M i k e : W h e r e d o yo u f i t i n t h e r a p y? Gail: I rea lly it’s hard, I ’m kinda ec lectic. I g uess that more uhm . Som e tim e s . D e pe nd ing on the pr ob le m, y ou kn ow . th is depends on the problem, so like y our, y our ty pical beha vioral kinds of thing s . or y our anxiety kinds of things. I ’m more c og nitive b e h a v i o r a l If i t ’ s a r e l a t i o n s h i p i s s u e — I’ m m o r e i n t e r p e r s o n a l If it’ s mo re of so me thi ng lik e u hm y ou r r e c ur re nt p ro ble ma tic pa tte rn s, lik e y ou kn ow s ome on e wh o’ s g ot m or e of a pe rs on a lit y dis or de r ( wh ic h I re a lly do n’ t se e muc h h e re no w, bu t I us e to)—uhm I might do more of a mixi ve, interpe rsonal and insig ht oriented kind of w ork.

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89 Fr om answer s to this and other questions, it became appar ent that for G ail thera py is p ri ma ri ly wh a t a the ra pis t does A thera pist works with people and e x plores options for making chang es so that they can f eel be tter. She had not put an a nswer in the bla nk of the demog raphic form which w as for Theore tical Perspec tive, but she descr ibed her self as ecle ctic in her approa ch to thera py during the interview Good trea tment prac tices for Gail wer e those whic h provide interve ntions. For her, inter ventions are “sug g estions” that ar e made for the c lients and with their input. Gail: Trea tment prac tices would mea n: what kinda interve ntions are y ou r g on na pu t in pla c e w ha t ki nd of su g g e sti on s a re y ou g oin g to make to par ents, or thing s that y ou are g oing to sug g est to kids or what sorts of options are available to them for g etting the needs met. Be cause we a re a multidi sciplinary setting, I rea lly think that tr e a tme nt p ra c tic e s is ha vin g a wi de ra ng e of thi ng s th a t pa tie nts have a cce ss to. Mike: What ty pes of inter ventions do y ou do or do y ou sug g est or. . What do y ou do? Gail: Well, a lot of tim es we ’re g oing to wor k on things that improve communication, or thing s that will im prove e x pecta tions, behavior an d d i s ci p l i n e a t h o m e, an d we ’r e k i n d o f j u s t m ak i n g s o m e t h i n gs clea r that have n’t bee n, and helping kids to understand wha t’s g oing on tha t’s cre ating behavior problems and wha t kinds of incentives a nd conseque nces a re a vailable whe n they make differ ent kinds of choice s. A lot of times parents a re c oming be c a us e the y ’r e ha vin g a dif fi c ult tim e ma na g ing the ir tempera ment and their c hild. So, knowing about the tre atments we have like thing s that they can g et from c ensoring litter treatment and all possible help with medica tion. W e also talk a bout the options they have a nd their fe eling s about pushing, or not. Rather than spe ak of spe cific tre atment pra ctices or techniques, G ail rela ted them to t he un sp e c if ie d w a y s u se d f or c la ri fy ing c a us e s, inc e nti ve s a nd c on se qu e nc e s a va ila ble fo r c ho ic e a bo ut c lie nts ’ p ro ble ms a nd tha t a re us e d to wo rk on imp ro vin g the c lie nts abilities in communication, ex pecta tions, and behavior. While she did not provide a ny

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90 information on g uided imag ery or hy pnosis, she was ver y much in favor of her clinic’s biomedical conne ction and its multi -fa cete d approa ch to the pra ctice of thera py She we nt i nto de ta il i n d e sc ri bin g tha t: Gail: This is a, y ou know, biochemica lly medical f acility and I ’m very much in support of it. I do think, that it’s uh, probably overpresc ribed a t times, and I think Mike: Her e, or . just in g ener al Gail: umhm, I don’t think here. I think that in gene ral. I think it has be e n c a re le ssl y pr e sc ri be d o r I sh ou ld m a y be e ve n s a y c a re le ssl y monitored. I fee l like, by the time a patient he re, ha s been pr e sc ri be d me dic a tio n, we ’v e do ne a pr e tty e xha us tiv e a sse ssm e nt, and uh, we ’re g etting inf ormation from fa milies and pare nts and ou r i nte ns ive zon e a nd ob se rv a tio ns a nd se e ing the m mu lti ple times and so I fee l pretty confide nt. I also think when we presc ribe medication, we do follow-up asse ssment, we g et teac her f eedba ck, we g e t pa re nt f e e db a c k, a nd we ha ve pa re nts ke e p jo ur na ls. a nd so on, I think when, when w e’r e doing it, it’s a. I think sometim es pe op le us e it a s a wa y to t re a t, f or ins ta nc e b e ha vio ra l pr ob le ms, a nd wh ile a lot of kid s have behavior al problems, medica tion is not g onna addr ess them. Uhm, y ou need a multidi sciplinary approa ch and, for a lot of the kids that have the disruptive beha viors, they need . the y need the ir own strate g ies, they need me dication, they need to lea rn ar ousal technique s (which is a big piece that I ’ve le a rn e d f ro m ou r o c c up a tio na l th e ra pis t th a t th e y pr ov ide the kid s) just learning how to modulate y our own a rousal leve l . for differ ent situations, to rev y ourself up or rev y ourself dow n. Ga il: So, I t’ s v e ry interesting [t he study of ar ousal technique s]. I mean, and a lot of the kids we work w ith have a le arning disability have at t en t i o n d i ff i cu l t i es t h at ar e s ec o n d ar y t o h av i n g learning disabiliti es bec ause w hen y ou’re working when y ou’re in an ar ea wher e y ou’re alre ady . stressed, a nd y ou have to wor k extra hard to keep up with eve ry one else y our stamina is g onna be le ss at the end of the day than the other kids that didn’t have to work a s hard, and that’s g onna cr eate attention problems. And so if y ou can, y ou know, boost y our sy stem by having medication, it’s g onna make the le a rn ing e a sie r. An d I ’m ve ry muc h in su pp or t of tha t. B ut I do thi nk s ome tim e s, tha t a fi ft e e n mi nu te int e rv ie w m ig ht b e a ll that a, phy sician nee ds to give someone med ica tion.

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91 Whil e Ga il f a vo re d me dic a l in te rv e nti on s f or str e ss, sh e did no t be lie ve tha t it is the cur e-a ll for beha vioral problems. She tied the use of medica tion into enabling the s o ci al i n t er v en t i o n s t o d o t h ei r j o b s He r i d ea o f t re at m en t wa s i n d ee d ec l ec t i c— t es t i n g, interviewing and obser vation to determine if me dication might he lp; then medication (ca ref ully presc ribed a nd closely monitored); then the less “ stressed” client is able to take advanta g e of the social tec hniques (occ upational thera py psy cholog ical testing cog nitive psy cholog y et al.); a nd finally a lot of fe edbac k during these pha ses of tre atment. I nte re sti ng ly th e do c tor wh o o wn e d a nd wo rk e d in the c lin ic wa s a pe dia tr ic ia n a nd no t a psy chiatrist. Ba d thera py prac tice wa s not working with the client and the ove r-pr escr iption of drug s. g ood thera py prac tice wa s a tea ching enter prise—helping clients understa nd what’s g oing on tha t’s cre ating behavior problems, re vealing incentives a nd conseque nces that are available for diff ere nt kinds of choices, ma nag ing te mpera ment, and discussing the op tio ns tha t th e y ha ve I t a lso inv olv e d r e sp e c tin g the c on fi de nti a lit y of the c lie nt. Ga il w ou ld n ot v olu nte e r a ny inf or ma tio n u nle ss I dir e c tly a sk e d f or it. She wo uld the n g ive e xha us tiv e a ns we rs w hic h s ome tim e s in c lud e d e xamp le s. I n c on tr a st t o Kar en’s r eticenc e on the topic of what make s a thera pist a g ood thera pist, Gail responded imm e dia te ly tha t a g oo d th e ra pis t ha s k no wl e dg e on the su bje c t th a t w ill he lp p a tie nts manag e their pr oblems, has traits of wa rmth and empa thy and who is supportive a nd available Other e lements of a g ood thera pist that she stressed we re ma king sur e the t re at m en t i s ef fe ct i v e a n d wo rt h wh i l e, s t ay i n g aw ar e, wa t ch i n g wh at t h e c l i en t i s p ay i n g, do ing fo llo w u p w ith fa mil ie s a t th e ir ho me s, a nd ma int a ini ng dis c ipl ine a c c ou nta bil ity to

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92 patients. I n direc t answer to my question on a g ood thera pist she had first mentioned the fo llo wi ng : Gail: Whatever issues that c ome up in thera py alway s try ing to stay e mpa thi c a nd tun e d in wi th t he fa mil y in t he fa c e of e ve n th e ir ex t re m e a n ger I m ea n I t h i n k t h at p eo p l e. . I ce rt ai n l y co u l d n 't sp e a k to wh a t so me on e tha t' s ma y be so c iop a thi c or lik e tha t, b ut i n g ener al, I think that people. . Ang er a nd just stress. . I think y ou can do a lot to help them with manag ing tha t, even in ver y unpleasa nt situations based on how y ou are with them. I f y ou' re non-def ensive, if y ou' re w arm. I f y ou' re suppor tive even in the f ace o f h a v i n g t o d o s o m e t h i n g r e a l l y yu c k y. During the cour se of the inter view, Ga il related tha t bad thera pists were those w ho have se x ual re lations with clients or interns, who violate pa tient confidentiality and doctors who ove r-pr escr ibe. Z oe discussed the rapy in terms of helping clients to adequa tely function in day -toda y lif e O n th e de mog ra ph ic s f or m, Z oe ha d w ri tte n th a t sh e c a me fr om a cog nitive-beha vioral theore tical per spective but stre ssed throug hout the interview tha t she was a counseling psy cholog ist, not a cog nitive psy cholog ist. Zoe descr ibed thera py wi tho ut h a vin g to r e fl e c t be fo re ha nd T he ra py wa s h e lpi ng pe op le to b e c ome a ble to "li ve t hei r l iv es i n a m ore f ul ly fun cti on al m ann er." M i k e : F o r yo u w h a t i s t h e r a p y? Z oe : Ah f or me th e ra py is h e lpi ng pe op le to be c ome mor e a h a ble to live lives, live their lives in a more f ully functional manne r. Uh the ra py c a n b e a ny thi ng fr om h e lpi ng a pe rs on wh o, is, ve ry low in their func tioning and da y to day life. L ike unable to, wor k on a re g ula r b a sis or c a rr y ou t th e ir da y to d a y a c tiv iti e s o n a d a ily basis. To help them to bec ome . ade quately functional. Or to e nh a nc e the fu nc tio nin g of a n in div idu a l w ho is a lr e a dy pr e tty fu nc tio na l bu t, a h w ou ld l ike to e nh a nc e so me a sp e c t of the ir li ve s, their interpe rsonal re lationships their assertivene ss, something along those . something of that nature

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93 More than the other psy cholog ists, Zoe talked of the rapy as more inc lusive of life pr oc e ss. She a ve rr e d th a t e ve n p e op le wh o w e re le a din g ba sic a lly fu nc tio na l li ve s c ou ld g ain some help fr om a thera pist. I n a dd iti on to p ro ble m so lvi ng Z oe sa id c og nit ive ps y c ho log ist s u se sy ste ma tic desensitization, relaxation, coaching modeling ( all of which she used), a nd also cog nitive restruc turing and imag ery techniques. The only ty pes of g uided imag ery that she used was during rela x ation exercises (a sk the client to imag ine a c alming sc ene) and for de ve lop me nt o f s oc ia l sk ill s ( a re he a rs a l to ov e rc ome so c ia l de fi c its —“ ima g ina l r ole play ing” ). When I asked a bout sugg estibilit y she said, Z o e : I d o n ’ t h a v e a f i r m i d e a a b o u t i t b u t h yp n o t h e r a p y— I’ v e a l w a ys be e n a lit tle le e ry a bo ut. B e c a us e u h h y pn os is r e lie s o bv iou sly o n s o m e l e v e l o f s u g g e s t i b i l i t y. Z oe: One se ssion of any thing is not g oing to r eally . g oing, to . do any thing—‘ a;’ but ‘b’ I think, I ’m just not convinced that the . that there is uh resea rch suppor t, for a hy pnothera py ty pe of approa ch, with, a wide varie ty of problems. May be ther e’s rese arc h support for it being eff ective w ith some ty pes of pr oblems. May be it’s completely depende nt on the level of sug g estibilit y of the individual but, I ’m still [ exhale] wit h things that, c ircumvent c on sc iou s th ink ing a nd thi ng s th a t do n’ t bu ild sk ill s, tha t he lp t o make c hang e. . She had witnessed one session in which psy chiatrists had used Sodium Amy tal. She felt that interve ntion had “y ielded no more than I g ot in clinical interview, f rankly .” Z oe: I f y ou’re not clear on what the c lients wants and y ou’re y ou’re us ing su g g e sti bil ity to s ug g e st t hin g s th a t you think are r ight f or the client. I think that is, ethically inappropria te. B e less than e thical Mike: Even thoug h y our hea rt’s in the rig ht place? Z oe : Yo ur he a rt ma y be in t he ri g ht p la c e bu t y ou a re no t th e on e to de c ide wh a t . h ow to l ive the c lie nt’ s li fe a c c or din g to t he ir values. So, unless y ou know what they want uhm and a ssuming

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94 wh a t th e y wa nt i s h e a lth y e no ug h, fo r t he m. I me a n y ou ha ve to help a c lient evaluate sometimes the. . I f a w oman in an abusive re la tio ns hip c ome s to y ou a nd wa nts to b e a ble to b e tte r, tol e ra te being beate n, y ou have to e valuate w ith her, if that’s a g ood choice or not, for he r phy sical saf ety But . other than life a nd limb, threa tening stuff. . Se ve ra l ti me s w ith in t he int e rv ie w, Z oe e xpre sse d th e imp or ta nc e fo r t he ra pis ts t o sti c k w ith in t he ir le ve ls o f e xpe rt ise —n ot t o g o b e y on d w ha t th e y we re tr a ine d to do in thera py Thera pists shoul d not acc ept clients for trea tment in area s where they have not rec eived a ppropriate training and g otten some supervised e x perie nce. Her response to the probe on the line betwee n g ood or bad pr actice s was that g ood prac tice helps pe ople meet he althy g oals and ba d prac tice pre vents people f rom meeting th e m o r p u s h e s th e m i n to u n h e a lt h y g o a ls F o r Z o e g o o d th e r a p is ts in te r n a li ze profe ssional ethics, kee p their skills up to date, work within their ar eas of competenc e, and: Z oe: You have to let help clients to g ain func tionality in a way that’s consistent and consona nt with who they are as individuals. I don’t think it’s up to us to decide w hat the clients g oals are I think it’s up to us to help them formulate reach able g oals . and he althy g oa ls. Acc ording to Z oe, bad the rapist ar e those who do not do those thing s. She was the only thera pist who spoke direc tly of the possibility of cha ng ing ba d thera pist so that they would be able to do good pr actice She said that the state lice nsing boa rds provide an outlet for pr ofessionals whe n there ’s a pr ofessional in distress or “ impaired.” They provide a way “of ma king it stick that a pe rson, comes ba ck into the fold [laugh] when they need to be ; or how they need to be functioning to be able to e ffe ctively provide service s.”

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95 Ove r vie w of How P sy c hol og ist s a nd a C ouns e lor De fine The r apy P r ac ti c e s a nd Therapists All of the thera pists had expressed the nec essity of on-g oing tr aining One psy cholog ist (Z oe) ha d stressed the duty of the disciplines to insist on professional ethics a nd pr ov ide a ssi sta nc e fo r “ dis tr e sse d” or “ imp a ir e d, ” ps y c ho log ist s ( a nd by e xten sio n, a ll thera pists). J ack disc ussed the duty of the ther apists to eng ag e in selfref lection about the ir ro le s w ith the c lie nt a nd to m a ke su re tha t th e ir a g e nd a do no t a ff e c t th e tr e a tme nt. Th e c lin ic a l ps y c ho log ist s a ll u se d c og nit ive a nd so lut ion -b a se d tr e a tme nt i n th e ir own pra ctices. The particula r tec hniques of ther apy wer e unimportant to one (K are n), as long a s therapists abided by the ethics of the ir discipline. I n conjunction with doctorsupplied medical tre atment and whe n interac ting with other specia lists, another ps y c ho log ist (G a il) us e d a va ri e ty of un sp e c if ie d p sy c ho log ic a l te c hn iqu e s a nd te sts a s a part of he r work w ith clients. The g oal was to he lp them rec og nize and achie ve the clients’ own soc ial g oals reg arding interper sonal communication, under standing of societal e x pecta tions, and achie ving pr oficienc y in behaviora l interac tions. Another clinical psy cholog ist (Rick) was ope n to using a ny technique tha t provided a “ positive” value, g ain, and/or se rvice even if it meant “buy ing into their sug g estibilit y .” “Positive” was not direc tly define d, but since this psy cholog ist is s trong ly attache d to his religion, connec tions from the tenets of tha t relig ion were likely the basis of his use of the conce pt “positive.” The fourth (Z oe) w as the only clinical psy cholog ist who list ed ac tual techniques ( i.e., sy stematic dese nsitiz ation, rela x ation, coac hing, mode ling, c og nitive restruc turing and imag ery techniques f or re laxation).

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96 Only one of the thera pists, psy cholog ist Ri ck, had use d hy pnosis, but he had not achie ved the r esult he had hope d. He ha d not used it ag ain, but did leave ope n the possibili ty that he mig ht try it ag ain, af ter fur ther tra ining. Guide d imag ery was done by the c lin ic a l ps y c ho log ist s to fa c ili ta te c lie nt r e la xati on O ne the ra pis t sa id s he a lso us e d it as imag inal role play ing f or deve loping soc ial skills. There wa s a wide r ang e of re sp on se s a bo ut t he us e of ps y c ho ph a rm a c e uti c a ls. Ka re n la ug he d a nd sa id t ha t of c ou rs e she did not use them. Given her partialities for la w and e thics, use of drug s—and per haps even c onsideration of the use—wa s something r eser ved only for M.D.s. Rick thoug ht that presc ribing was a tool that can be use d for the “ thera py resistant” c lients. He said he did not have the option of pre scribing available for him and he was unc omfortable a bout psy cholog ists being a llowed to presc ribe. He was unre solved on whethe r they should be able to pre scribe e ven with more tra ining. F or Ga il the prescr iption of pharmac eutics wa s a fa miliar and nec essar y fac et of he r work on a team that includes a pediatric ian. She was c on c e rn e d w ith ov e rpr e sc ri bin g of dr ug s b y M. D. s in oth e r s e tti ng s. Whe n I a sk e d in particula r about pre scription of psy chophar mace utics, Z oe re lated a c ase she had obser ved inv olv ing a c lie nt w ho wa s d e e me d o ve rl y de fe ns ive Sh e fe lt t ha t th is i nte rv e nti on did not achieve more than she had bee n able to do during the clinical inter view. Neve rtheless, she unde rstood that this may have be en an isolate d incidence and re mained open to its use, so long a s it was within the therapist’s ar ea of expertise. All the clinical psy cholog ists st resse d that the thera pist should never ente r into a s ex u al re l at i o n s h i p wi t h t h ei r c l i en t an d Zo e e x t en d ed t h at t o b an n i n g any social rela tionship beside that of thera pist and client. All therapists except Rick mentioned and str e sse d th e c on fi de nti a lit y of the c lie nt. Ho we ve r, the y a lso re ve a le d th a t th e y wo uld

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97 brea ch the c onfidentiality if they considere d that harm would c ome to the client or othe rs by maintaining it. Where as Rick fe lt that spending time on diag nosing pr oblems detrac ted from tre atment, Gail wa s very much in favor of doing a number of psy cholog ical tests on c lie nts to d e te rm ine the ir dia g no sis ri g ht f ro m th e sta rt Whether pra ctices a re g ood or bad w as def ined by Kar en in terms of w hether they fit within the leg al and e thical codicils of a particula r discipline. Gail fe lt that the line betwee n g ood and bad pr actice s depende d on whether the client is or is not helped by the thera pist’s 1) working to teach, 2) reve aling choice s and mana g ement tec hniques, and 3) is e xplor ing op tio ns Sh e jud g e d a s in he re ntl y ba d th os e the ra py pr a c tic e s w hic h c a me from any other a g enda, or which we re not wor king f or the c lient. Rick’s perc eption was simil ar—ba d was a ny prac tice that foc used on a the rapist-de fined a g enda r ather than the thera py being about the client. F or Z oe g ood prac tices we re those tha t helped the c lient achie ve hea lthy g oals (e.g ., mental and e motional goa ls). Ba d prac tices do not help, or pu sh the c lie nt a wa y fr om h e a lth y g oa ls. Conceptions about g ood and bad the rapists varie d widely for the c linical psy cholog ists. I n brief: Ka ren stre ssed that a g ood thera pist abides by the law a nd the profe ssional ethics of her /his profession; Gail stressed ha ving tr aits of war mth and e mpa thy b e ing su pp or tiv e a nd a va ila ble ma int a ini ng dis c ipl ine a c c ou nta bil ity (p ro fe ssi on a lly e thi c a l) d oin g fo llo wup vis its a nd be ing kn ow le dg e a ble on su bje c ts which will help patients mana g e life’ s problems; Rick stressed per sonal traits that g ive rise to an e thic of working with the client instead of f ix ing the m (working from the client’s ag enda r ather than the ther apist’s), being up-fr ont about biases, and sha ring

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98 va lue s; a nd Z oe str e sse d in te rn a lizin g pr of e ssi on a l e thi c s, ke e pin g up wi th t he la te st skills, and working only within one’s ar eas of competenc e. Ba d thera pists, for Kar en, ar e those ther apists who do not abide by the law or the pr of e ssi on a l e thi c s f or mul a te d b y the na tio na l a sso c ia tio ns G a il f e lt t ha t ba d th e ra pis ts are those who have sexual relation with clients or interns, who violate pa tient confide ntiality and those who ove r-pr escr ibe drug s. Rick talked about bad the rapists as those who allow their pe rsonal ag enda to a ffe ct the client r ather than following the c lie nt’ s a g e nd a e ith e r p hil os op hic a lly f ina nc ia lly o r e mot ion a lly F or Z oe b a d th e ra pis ts are simply those who ar e not g ood thera pists. S he conside red a bad ther apist to be a “prof essional in distress” or “ an impaire d psy cholog ist” and fe lt that licensing sa nctions pr ov ide ins ur a nc e tha t ba d th e ra pis ts a re e xclu de d u nti l th e y c a n f un c tio n to “ e ff e c tiv e ly provide ser vice.” Kar en had f ocused on he r privileg ed re sponsibili ty [t aken in c ontext to mean “g rea ter a uthority ”] to help clients achieve balanc e betwe en mind and emotion. This was done by working within the professional e thics and laws whic h g overn K are n’s discipline, a nd thi s c ou ld b e do ne by vir tua lly a ny te c hn iqu e G a il f oc us e d o n w or kin g wi th p e op le afte r psy cholog ical testing Under the leade rship of a pe diatrician, she another psy cholog ist, and a social wor ker a pproac hed ther apy as par ts of a tea m. Rick focused on se le c tin g c lie nts H e ba se d th is o n w he the r h e wo uld be a ble to a ssi st t he c lie nt i n achie ving “ positive” value, g ain, and se rvice This was done throug h use of a ny “tea ching ” tec hnique that fe ll within R ick’s qualific ations. Whi le he wa s insist ent upon working toward the client’s ag enda, he was willing to use eve n sug g estibilit y of the c lient a s a too l f or a c hie vin g the c lie nt’ s a g e nd a Z oe fo c us e d o n h e lpi ng c lie nts to a de qu a te ly

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99 function in day -to-day life. Of the psy cholog ists, only Z oe itemized a number of techniques tha t she used to in thera py These inc luded sy stematic dese nsitiz ation, rela x ation, coac hing, mode ling, c og nitive restruc turing and imag ery techniques f or rela x ation. When diag nosing, none of the c linical psy cholog ists had used any of the te c hn iqu e s w hic h h a ve be e n f ou nd to i nv olv e ri sk fo r i nc re a se d c lie nt s ug g e sti bil ity (g uided imag ery hy pnosis and drug thera py ). Rick and Z oe had use d imag ery for rela x ation and stress r emoval (e .g ., “imag ine a plac e whe re y ou felt ver y rela x ed and a t e a se ” ) n ot f or ima g ini ng oth e r p a st e ve nts Z oe a lso us e d im a g e ry a s a too l f or ro le pla y ing (e .g ., “ ima g ine ho w y ou wo uld a pp ly fo r t his job ” or “ ima g ine ho w y ou c ou ld interac t with this person in a c onstructive manne r”) None of the psy cholog ists had prescr ibed medicine. Rick a nd Gail had r efe rre d clients to psy chiatrists when the y thought that psy chophar mace utical interve ntion might be nec essar y Gail per formed te sts designe d to determine w hether a patient mig ht require intervention by the thera py team medica l doctor. Z oe had w itnessed a dr ug intervention a nd fe lt t ha t th e re su lts of tha t pa rt ic ula r i nte rv e nti on we re no mor e tha n e qu iva le nt t o those ac hieved in a c linical interview. N one of the clinical psy cholog ists felt that there was a problem with psy chophar mace utical interve ntions ex cept f or over -pre scription of drug s and the possibility of incre asing client/patient sug g estibilit y Their objec tion was not to the use of drug thera py —they wer e more conce rned a bout the potential for misuse. None of the psy cholog ists had refe rre d a client to a hy pnotist. Only Rick had used hy pnosis but was unsatisfied with the re sult. W hile Z oe had se en a c lient who had g one to a hy pnothera pist, the report she g ot from the par ents was that it “didn’t wor k at all.”

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100 She said that she wa s not surprised bec ause she had re serva tions about any trea tment that involves only one session. He r re serva tions also ex tended to questioning the ef fica cy of a ll t re a tme nt p ra c tic e s th a t “ c ir c umv e nt c on sc iou s th ink ing a nd thi ng s th a t do n’ t bu ild skills.” All the psy cholog ists specified that a the rapist had g one over the line into bad pr a c tic e if he /sh e e ng a g e d in a se xua l r e la tio ns hip wi th a c lie nt. Z oe e xpa nd e d th is t o include other s who are under the thera pists authority (i.e., psy cholog ical students or interns). All except Rick mentioned violation of client/patient c onfidentiality as a ba d prac tice except in ca ses when disc losure is leg ally require d. Kar en par ticularly proscr ibed neg lecting to follow releva nt law or violating profe ssional ethics. Fa ilure to terminate the thera py when the pa tient is not being he lped and f ailure to c onduct follow-up studies wer e stipulated by Gail as ba d prac tices. Not being up-fr ont about biases and violating Christian values was c ited by Rick as bad. Z oe conside red ba d thera py to be a c ontinued us e of pr a c tic e s th a t do no t he lp, or tha t pu sh the c lie nt a wa y fr om h e a lth y g oa ls. Other tha n the g ener al proscr iptions t o ensure that thera pists’ own ag endas a re subservient to the c lients’, the psy cholog ists varied g rea tly in their conc eption of the line betwee n g ood and bad the rapists. L eg al eleme nts were of primar y importance for Ka ren. Pr of e ssi on a l e thi c s a nd re lig iou s v a lue s c on c e rn e d Ri c k. An e thi c of pr of e ssi on a lis m throug h educa ting a nd working with the client was stre ssed by Gail. I nterna liz ing profe ssional ethical standa rds and maintaining the latest skills were e mphasized by Z oe. Apply ing he r conc epts to individuals, Karen f elt that profe ssionally formulated ethics and r eleva nt laws provided the line be tween g ood versus ba d thera pists. According to Rick a thera pist who applies his/her own ag enda on the client would be ove r the line.

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101 Ga il r e la te d g oin g ov e r t he lin e to p a rt ic ula r a c ts ( i.e ., se xua l r e la tio ns wi th p a tie nts violating pa tient confidentiality or over -pre scribing drug s). Z oe ce ntere d on bad thera pists as those who wer e in “pr ofessional distress” or we re “ impaired psy cholog ists,” a nd wh o w e re no t e ff e c tiv e ly pr ov idi ng se rv ic e to t he ir c lie nts Interviews w ith Psyc hiatrists The psy chiatrists who we re inter viewed spoke from a me dical per spective w hen de fi nin g the ra py Y e t, t he y ba la nc e d th e ir re pli e s w ith a mor e ps y c ho log ic a l ( so c ia l) perspe ctive. The y also wer e for ensic psy chiatrists. The psy chiatrists viewe d the the ra pis t’ s jo b to be a n in te ra c tio n w ith the pa tie nt t ha t is de sig ne d to tr e a t a dis or de r t o b e c u re d P ec u l i ar l y t h ro u gh o u t t h e i n t er v i ew t h ey re fe rr ed t o t h e p at i en t as h av i n g a disorder ( a socia l control and medic al conc ept) but they did not speak of the phy sical side of mental he alth unless direc tly probed. Be n considere d thera py as ana logous to tre atment of a disorder. H is practice was in a teac hing hospital, de aling with a g eria tric population. L imitation of function and dementia we re the major disorder s he trea ted. B en did not rela te a pa rticular the orist or the or e tic a l pe rs pe c tiv e fo r t he su pp or tiv e the ra py he pr a c tic e d, sta tin g tha t “ I t’ s a fa ir ly g ener al conc ept.” When aske d “wha t is therapy ,” he sa id: Be n: I consider the rapy uhhhh . to be, uh ana logous to tre atment .. of a g ive n d iso rd e r. Th e re a re dif fe re nt t y pe s o f t he ra py Wh e n I fi rs t debuted on my inpatient unit, I used supportive ther apy Uh Where we a re uh nur turing on the unit, and provide suppor t that may be la c kin g oth e rw ise . f or a pa tie nt. Be n had sele cted the c ard “ Trea tment Practice s.” Afte r finding out Be n’s opinions on the DSM I V, I g ot to this car d, about half w ay throug h the interview He a sk e d if I c ou ld b e mor e sp e c if ic I re la te d th a t th e lit e ra tur e I ha d r e a d s ho we d th a t th is

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102 was a n are a that “w as in some kind of conte x t, but it's not important what the conte x t was tha t I sa w i t in T he fa c t th a t you s el ec t ed i t m ea n s i t h as s i gn i fi ca n ce fo r y o u an d t h at 's what I m after .” He indicated that he understood and sa id: B e n: Tr ue I n p ra c tic e We ll, the re a so n w hy I uh . . Th e re s a big sh if t in ps y c hia tr y ri g ht n ow —it s b e e n g oin g on fo r a lit tle wh ile now—it's a ctually a shift awa y from ther apy and towar ds a more uh psy chophar macolog ical tre atment appr oach, a nd so that' s what caug ht my ey e whe n I saw that c ard M i k e : R e a l l y? Be n: Yea h y eah a nd the uh of uh uh be ing a ble to delineate what' s g oing on at a more phy sical leve l with . > M i k e : ( i n a u d i b l e ) s c h i z o p h r e n i a ? B e n: We' ve ha d s ome uh re vo lut ion a ry c ha ng e s in tr e a tme nt m od a lit y for a number of our diag noses that we, be fore did not have any uh re al ef fe ct i v e m ea n s o f u h ad d re s s i n g, an d t h at u h I t h i n k t h at 's been a big pa rt of wha t's be en g oing on la tely Possibi lities of ge ne ther apy wer e in the new s when B en wa s interviewe d. I asked what he thoug ht about it. Ben sa id: Be n: We’re looking at fa miliar components of these disorders a nd it’s on e of the thi ng s w e a lw a y s a sk a bo ut. Do y ou ha ve a fa mil y history for this? Do y ou have othe r fa mily members that suff er from this? Uh, so in looking a t that even now . it’s a lway s g oing to be problema tic at an e thical level a nd we g et to the point we ar e try ing to a lter thing s that’s alwa y s g oing to be a conc ern. Be n: Yea h, my profe ssion’s alway s been a ccuse d of try ing to make ever y one the sa me and not allowing for individuality or a f ree dom of expression and uh, we ll, that would be a nig htmare if w e starte d mandating that ever y one have particula r g enes a nd we didn’t a llow fo r t he va ri a bil ity tha t uh a llo w u s to a da pt o ve ra ll. He the n d isc us se d s tig ma a sso c ia te d w ith me nta l il lne ss. He sa id a g oo d th e ra pis t is care ful with how a pa tient is diagnose d since both lay men and ther apists may perc eive

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103 and re act on the ba sis of that stigma. Af ter noting that, he g ave a n example of neg ative connotations associa ted by other c linicians to a person dia g nosed with border line persona lity disorder. H e noted f urther tha t the diag nosis is carrie d in future medic al re c or ds a nd tha t th e pa tie nt m a y int e rn a lize a nd a lso sti g ma tize him /he rs e lf in r e la tio n to the diag nosis. These neg ative possibiliti es ar e mitiga ted by a g ood thera pist by being ve ry c a uti ou s a bo ut a pp ly ing dia g no sis la be ls. He sa id t ha t th e pa tie nt s ho uld be pu t a bo ve a ll e lse e mph a sizi ng mon e y a s a possible neg ative ag enda. T his included avoiding some confr ontational sty les of ther apy which ca n overw helm a fr ag ile patient, doing more ha rm than g ood. I n answe r to the probe, “ How do y ou fee l about hy pnosis,” Be n said: Be n: I t’s interesting espec ially as a f orensic psy chiatrist, uh I ’ve se en hy pnosis done, and it’s intere sting. The re’ s alway s conce rn about possible of false memory and of uh sug g estibilit y but I can, I can see w here there may be some utility in it, because there ’s a ve ry strong defe nse—if y ou’re overw helmed with a pa rticular me mor y —to su pp re ss i t. I t’ s a ve ry pr imi tiv e de fe ns e me c ha nis m, but it’s, it’s pretty eff ective. A nd if that information is vital, for wh a te ve r r e a so n, be it u hh fo r y ou to u nd e rs ta nd y ou rs e lf mor e in order to gr ow as a person or be t hat important for leg al re asons or t o fi n d t h e t ru t h ab o u t s o m et h i n g t h at h ap p en ed t o ad d re s s wr o n gs tha t ha ve be e n d on e in t he pa st. I c a n s e e the uti lit y in t ha t, i t’ s ju st uh the information. I ’m not sure how r eliable it is in all situations I think there’s a g rea t deal of c ontamination that can take place w i t h r e t r i e v a b l e s u p p r e s s e d m e m o r y. When I asked a bout psy chotropic dr ug s, he said that he ha d seen inter views whe n patients wer e af fec ted and that the sa me issues (sug g estibilit y ) ar ise. When I then aske d about g uided imag ery his answer indicated that he understood the ter m in the context of dis tr a c tio n r a the r t ha n r e c a ll o f p a st m e mor ie s.

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104 Be n: Sugg estibilit y Yea h, y ou alway s have uh bia ses of the inter viewer a nd uh qu e sti on se le c tio n, a nd the re a re a lot of op po rt un iti e s to ste er a nswers a nd lead the pa tient in a particula r ar ea. Mik e : Ok a y Wh a t a bo ut g uid e d im a g e ry ? Wha t do y ou thi nk a bo ut t ha t? Be n: The g uided imag ery I think is actually uh. That’s more interesting to me. I think that could be ver y helpful, for uh for a patient. And uh, uh being able to distrac t y ourself f rom things tempor arily and, a nd uh u se tha t ty pe of ima g e ry I thi nk c ou ld b e ve ry be ne fi c ia l. The psy chiatrist, B en, said that g ood thera pists are e mpathetic, ca pable of e sta bli sh ing a g oo d r a pp or t w ith the pa tie nt a nd a re g oo d li ste ne rs g oo d th e ra pis ts p r o v i d e e n o u g h t i m e a n d o p p o r t u n i t y t o f i n d o u t w h a t i s b o t h e r i n g t h e p a t i e n t B a s i c a l l y, b e i n g a g o o d t h e r a p i s t i s b e i n g a p e r s o n w h o i s s u p p o r t i v e a n d n u r t u r i n g i n a g e n e r a l w a y. Mik e : Wha t' s r e qu ir e d to be a g oo d th e ra pis t? Be n: For the supportive ther apy I m talking a bout, it helps if y ou' re e m p a t h e t i c If y o u c a n e s t a b l i s h a g o o d r a p p o r t w i t h a p a t i e n t If y ou re a g oo d li ste ne r. Gi ve the m th e tim e a nd op po rt un ity to t e ll y o u . wh at 's b o t h er i n g t h em an d wh at d i ff i cu l t y t h ey 're h av i n g, and be a ble to meet and c ompensate f or some of those dif ficulties. M i k e : A h h a n d h o w i s t h a t d i f f e r e n t f r o m g e n e r a l ( l a u g h s ) t h e r a p y. Be n: I t's diff ere nt in that uh it's not as much introspec tion. You don't . ev al u at e t h ei r p at t er n o f b eh av i o r a n d t h e p at h as m u ch Yo u d o n 't loo k f or de fi c its tha t a re g oin g on wh e re y ou re tr y ing to c re a te awa rene ss in the patient of those def icits. I t's more of uh just being a g ood person, be ing suppor tive and being nurturing in more of a g ener al way Jac k p ri ma ri ly tr e a te d h os pit a lize d g e ri a tr ic pa tie nts bu t w a s a lso inv olv e d in ou tpa tie nt t re a tme nt ( “ 18 up to. . N o a g e lim it o n th e top ” ). Jac k d e sc ri be d h is theore tical per spective a s psy chody namic (“ I t’s a kind of a mini-branch of ps y c ho a na ly sis ” ). Jac k s a w t he us e of ps y c ho tr op ic dr ug s, g uid e d im a g e ry (t o a c c e ss memories), a nd hy pnosis as useful and sometimes e ssential tools of therapy He ha d used

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105 drug thera py and g uided imag ery to acc ess memories but stresse d the nee d for dilig ence in refr aining from implanting me mories while the pa tient is in such a sug g estible state. J ack: Uh, well, intervie wing is one of the tec hniques that I that I that we rely on in psy chiatry Now, that obviously has it’s own set of lim ita tio ns th a t g o w ith it t o h e lp w ith so me of tho se lim ita tio ns we ’v e do ne thi ng s li ke so diu m A my ta l—t ru th s e ru m in te rv ie ws Ye a h, a nd so diu m Pe nto tha l. T ha t a lso is s ome thi ng we ’v e do ne to help. M i k e : G u i d e d i m a g e r y? J ack: Uhm that is helpful to some deg ree I think it’s a > Ag ain it’s almost like a slippery slope. Ther e is some > Wheneve r there > I > The g uided imag ery is okay and I ’ve ha d a little experience with that. I think the place w here y ou start to g et into the slippery slo pe is w he n y ou sta rt a sk ing po int e d q ue sti on s, a bo ut m e mor ie s. Thing s that y ou> I f y ou know of wha t y ou’re looking f or, y ou have to be ca ref ul on how y ou look for it, beca use y ou can of ten steer the c ou rs e of wh e re y ou a re loo kin g N ot e ve n p ur po se fu lly b ut i f y ou understand w here y ou’re . what y ou’re looking f or. Mike: I understand tha t y ou’re much, much more sug g estible, under so diu m A m> J ack: Correc t. and so y ou may not even mea n to, but y ou may implant so me ide a s. I f y ou a sk a qu e sti on lik e ‘D o y ou re me mbe r X .’ Wel l if they didn’t ever have tha t memory but y ou’ve now kind of planted, that see d in their mind there a re some, sc enar ios where that may become implanted. M i k e : A n d u n d e r g u i d e d i m a g e r y yo u ’ r e a c t u a l l y s u g g e s t i n g t h a t t h e y c on sid e r t ha t a s a fa c t? Jac k: As a fa c t. Mik e : Wha t a bo ut h y pn os is? Jac k: I thi nk hy pn os is c a n b e us e d in te rm s o f g e > uh re c oll e c tio ns r e p r e s s e d m e m o r i e s H y p n o s i s i s a n e f f e c t i v e t e c h n i q u e t o o In my mind it’s si milar to the sodium Amy tal—the truth serum. I do n’ t se e tha t it do e s magical things to our br ains. Um and I don’t se e tha t it it c ha ng e s so me thi ng T he wa y I se e it, hy pn os is i s basica lly an aa aaa heig htened se nse of r elaxation and that it may

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106 often he lp to lower the, the c hecks tha t we have in place, tha t may be kee p some of the memor ies out of our c onscienc es. Uh, sa me ide a a s th e tr uth se ru m. I t’ s n ot r e a lly tr uth se ru m, i t ju st simply lowers y our inhibitions and lowers some of y our, h es i t at i o n s re co v er i n g s o m e o f t h o s e, t h o u gh t s o r go i n g t h ro u gh so me of tho se thi ng s. Ah I kin d o f v ie w h y pn os is a lon g the sa me lines, but it can be ve ry eff ective in some pe ople to help to lower the inh ibi tio ns e no ug h th a t th e y ma y be a ble to thi nk a bo ut c e rt a in thi ng s th a t, w he n th e y ’r e no t r e la xed th e me nta l a ng st, if y ou wi ll, is j us t to o mu c h. Th a t th e br a in s imp ly wo n’ t a llo w t ho se tho ug hts into consciousness. and so that’s w hy they don’t have any ind e pe nd e nt r e c oll e c tio n o f t he m. When we we re ta lking a bout using memory as a ta ctic for thera py J ack disc ussed some of the tec hniques that he uses. O ne of the things of inter est is the shift of ca se fr om fi rs t pe rs on sin g ula r, to f ir st p e rs on plu ra l, t o th e ind e te rm ina te “ y ou .” Af te r s ta rt ing in the ac tive “I ” he sw itched to the plura l “we” (psy chiatrists, including him). When he ta lke d a bo ut “ g e t in to t he sli pp e ry slo pe ,” he sw itc he d to “ y ou .” He re tur ne d to the fi rs t pe rs on sin g ula r t o e xpre ss h is o pin ion on hy pn os is. Of a ll the therapists, J ack w as quicke st to respond to my question about thera py He pa used only a sec ond and his delivery was quite flue nt, which indicates tha t he may ha ve c on sid e re d th e qu e sti on mor e re c e ntl y tha n th e oth e rs J ack: Uhh. The c oming tog ether of two people with the idea that one . that the exchang e of ide as and f eeling s and emotions would help, or improve, the e motional well-being of one of . or both. Ev e n th ou g h h is a ns we r w a s r e la tiv e ly fl uid I fo un d it int e re sti ng tha t a psy chiatrist would not include the phy sical ele ment within his definition. During the interview, he did speak of the dominance of the medica l aspec t of his treatment (e .g ., trea tment with drug s).

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107 When questioned about g ood and bad the rapists J ack ha d definite opinions and discussed them at leng th. The g ist is t hat bec oming e nmeshed with the pa tient keeps the thera pist from being objective in their tre atment. “No se x ual involvement” wa s a g iven, but the “no involvement” injunction had a broade r mea ning f or Jack. J ack: I think that, intentional or not, I think some of the bad thing s, or ha ng up s w hic h th e ra pis ts c a n e nc ou nte r, be e nc ou nte re d, is, becoming enmeshe d—with the patient is one. I f y ou lose y our ob je c tiv ity a s a the ra pis t, I thi nk y ou los e u h mo st o f y ou r a bil ity to assist y our patient to bec ome better When asked a bout good the rapy J ack sa id “it’s basica lly opposite of what we we’ re sa y ing. I think being a ble to leave out our bag g ag e. To g et a be tter under standing of what the pa tient needs, not wha t we nee d.” He restate d these in positive terms and then added a n element he thought wa s very important—self-knowle dg e. Jac k: I thi nk it’ s im po rt a nt f or a the ra pis t or ps y c hia tr ist to b e a ble to understand some of their own me aning s and motives and nee ds, be it through the rapy of their own, or just through some se lfre fl e c tio n, of ha vin g so me un de rs ta nd ing wh e n th e y hit iss ue s in the ra py wi th s ome of the ir pa tie nts tha t ma y be the y re a lize tha t, ‘ m a yb e I’ m o v e r r e a c t i n g h e r e ” o r “ m y r e a c t i o n i s n ’ t r e a l l y thera peutic.” T aking a look at it once y ou’ve steppe d out of that role a s therapist and be ing a ble to look at it—say “Wait a minute. Wha t’ s g oin g on he re ? Why a m I a c tin g lik e thi s, ” uh m w ou ld c e rt a inl y be e ff e c tiv e to h e lp, to r e du c e tha t. Overview of H ow Psychiatrists De fi ne Therapy Pr actic es and Th erapists The intervie wed psy chiatrists prac ticed for ensic psy chiatry as we ll as psy chophar mace utics and thera py I n eac h of these a rea s, the psy chiatric focus involved a differ ent per spective. I n roles as f orensic psy chiatrists, their duty was to provide the courts with information on the pa tient’s mental hea lth and abilities. I n doing this, they wer e conf ronted with stricture s of the leg al sy stem, techniques of psy chother apy and of

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108 me dic ine a nd the e thi c a l st a nd a rd s o f t he ir pr of e ssi on (w hic h s ome tim e s c on fl ic te d w ith the others) When acting as a me dical doctor providing psy chophar mace uticals, they wer e conc erne d with the sy stemic nee ds of the body when menta l sy mptoms i ndicated that a phy sical lac k or imbalanc e mig ht be pre sent. As thera pists, their conce ntration was on the ag enda of the patient and how they could help the pa tient achieve rea listi c g oals, or how they could help them discove r which g oals wer e unre alistic. Be n chose to use g uided imag ery in the context of distraction rather than for me mor y re tr ie va l. H e ha d o bs e rv e d o the r p sy c hia tr ist s in c or po ra tin g the us e of dr ug s a s a tool for memory retrie val during the trea tment phase. Jack, on the other hand, had use d ps y c ho tr op ic dr ug s a nd g uid e d im a g e ry to a c c e ss m e mor ie s. B oth he a nd B e n h a d a lso vie we d h y pn os is a nd fe lt t ha t it wa s a us e fu l to ol, e sp e c ia lly fo r f or e ns ic pu rs uit s. Th e se ps y c hia tr ist s e mph a size d th e imp or ta nc e fo r t he ra pis ts t o r e a lize tha t us e of the se techniques inc rea ses of pa tient sugg estibilit y They note the questionability of inf or ma tio n r e c ov e re d th ro ug h th e ir us e a nd the y str e ss t he ne c e ssi ty fo r d ili g e nc e in int e rp re tin g the fi nd ing s. Empathy rappor t, list ening skills, and self-knowledg e ar e the tra its that the psy chiatrist attributed to g ood thera pists. They indicated that ba d thera pists are those who allow their own a g endas to take prec edenc e over the clients’ ( e.g ., pursuit of financ ial g a in, a pp ly ing the ir ow n “ ba g g a g e ,” a nd a c t w ith ou t se ns iti vit y to t he ir pa tie nts ’ su g g e sti bil ity a nd fr a g ili ty ). Th e y a lso sp ok e of ba d th e ra pis ts a s th os e wh o b re a c h th e ir p a t i e n t s ’ c o n f i d e n t i a l i t y.

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109 CH APT ER 7 MEMORY, SUPP RESS I ON, AND REPR ESSI ON B e c a us e of the c on tr ov e rs y ov e r m e mor ie s a nd the ir ro le in t he ra py th e the ra pis ts wer e aske d to talk about memories, suppre ssion, and repr ession. The c ontroversy was tho ug ht t o p ro vid e fe rt ile g ro un d f or le a rn ing a bo ut t he c on str uc tio n o f d e via nc e in thera py L CSW Wil l had clients who a lleg ed they had discove red a memory of childhood abuse. A lthough he advised e x treme c aution and suspicion as to whe ther the a buse had actua lly occur red or whether they “will bring that up as uh something else,” his treatment wo uld mir ro r t ha t of ma ny of my int e rv ie we e s w ho we re le ss s ke pti c a l: Wil l: Well y ou’d be suppor tive of them. uhh with empathy Allow them to h a ve the ir fe e lin g s. Yo u k no w, the ra py is a sa fe pla c e fo r p e op le to expl ore stuff like that. . Will: Ma inl y a bo ut t he e mot ion a l im pa c t of it y ou kn ow “ I f y ou sta rt to fee l the trauma a g ain, if something . .” And se e wha t’s happening with them phy sically You know. I f they start g oing throug h, y ou know. M i k e : A c t i n g n e r v o u s l y? Wil l: All that kind of stuff, and uh y ou know, just kind of be there for them and help them to experienc e. I t’s like to unrepre ss the stuff a nd uh a g a in. Yo u g ott a be c a re fu lly wi th t his Y ou c a n’ t ju st have a . . I mean I g ot some people that they ’re so sugg estive that I mean a nd not clients of mine now but, they ’ll say if y ou su g g e st anything they ’ll run with it. They ’re border -line. He then g ave a n example of a psy chiatrist at a hospital he had wor ked out wh o w a s “ re a l bi g int o mu lti -p e rs on a lit ie s. ” He sa id t he pa tie nts : Wil l: They [t he clients] were just more than happy to act out for the do c tor “ a ny thi ng y ou wa nn a se e .” . A nd wh e n th e y sh ut i t

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110 down—when he left, all of a sudden all of the pe rsonalities went a w a y. Mik e : So y ou thi nk tha t th a t w a s th e the ra pis t? Will: Wel l, y ou kn ow h e wo uld dia g no se the m a nd the y wo uld ta ke it a nd ru n w ith it. Wil l: I t’s it’s personality disorders r unning a muck. So, y ou g otta be car eful with. . Ther e ar e no cookbooks, y ou know, for this thing And a lot of it is uh. . Ag ain, if stuff c omes out—to be there —they have a safe place to bring that stuff for war d. Wil l: I try to keep thing s: “This is my prac tice, y ou know, uh how y ou dealt . who c are s about a psy cholog ist.” I said, “I use this. I ’m n o t t h e g u y w h o g o e s i n t o a l l t h a t a r e a ” Y o u k n o w ? Wil l did not probe for me mories and his trea tment of memories ba sically involved pr ov idi ng a sa fe -h a ve n w he re the c lie nt c ou ld t a lk a bo ut anything even a memory that ma y or po ssi bly ma y no t ha ve be e n o f a n a c tua l oc c ur re nc e N e ve rt he le ss, his sta te me nts ind ic a te tha t me mor ie s o f c hil dh oo d s e xua l a bu se r e a l or no t, w e re no t pa rt of his tr e a tme nt p la ns L CSW L arr y on the other ha nd had a lot to say about memory suppression and repr ession. During discussion of these topics, I g ot the impression from his fre quent taking of dee p brea ths and numerous pa uses that he wa s working hard to “ g et it rig ht.” Th e fo llo wi ng a re tw o b ri e f e xamp le s: L arr y : I don’t use hy pnosis. I will do some (I g uess it would . might not be) a ccur ate to ca ll it repressed me mory work, or w hateve r, but I ’ll do some family of orig in workMik e : Yo u d o me mor y re tr ie va l? L arr y : (B rea th) I have neve r se t ou t to do tha t. L a rr y : I wi ll c on tin ua lly ta ke pe op le ba c k to un de rs ta nd ing tr y ing to understand w hy y ou know. What holds the problems of the

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111 prese nt in place a nd often, it is. . I ’ll do what they call—I don’t k n o w i f y o u ’v e h ea rd o f i t — R ed ec i s i o n T h er ap y Bu t I ’m d o i n g a lot of work in attac hment theory and ce rtain dec isions that were . cer tain g ener alizations m ade by the self, a bout the self, and a bout the other inter rela tionship, growing up. L arr y also talked a bout his belief in, and use of Attachment The ory which includes oper ating under the assumption that people store memor y episodically and se ma nti c a lly Wh e n I a sk e d if he tho ug ht t ha t pe op le sto re d me mor ie s somat ically he would take se vera l noticeably deep br eaths during his discussion. Ex amples ar e L arr y : I be lieve . that person, ( brea th) reta ins that memory as cle arly as if they ’d experienc ed it, that morning . . And ce rtainly in that c as e (and I ’ve just come to be lieve that to a lesse r deg ree we a re less and less re fined in our c apac ity to re pr e ss ) and so, I think I have some (bre ath) somatic memor ies . . L a rr y we nt o n to de sc ri be a n e ve nt i n h is c hil dh oo d w hic h h e re me mbe re d in terms of bodily fac tors (e.g ., tasting the blood today when he thinks about the fea rful incident in which a bloodied nose had re sulted). When I asked him if he ha d an opinion on a diffe renc e in the conc epts of suppre ssion and repr ession he re plied: L arr y : (Short intake, long er e x hale) Yea h, I would. I ’d proba bly see tha t a s o n s ome wh a t of a c on tin uu m a s o pp os e d to be ing a bs olu te ly dis c re te. I g uess I ’d also just say out of pick iness that attachme nt theorists would shun the word re g ression, as f ar a s therapy and I g uess in the roug h sense of taking somebody back. B ut, they do n’ tMike: You ca ll it a reconstruc tion, or . ? L arr y : They just see that as too F reudia n, that people be come f ix ated a t cer tain stag es and, I g uess they see life as a se ries of a ttachment rela tionships not being stag e orie nted, but probably much more of a continuum. Or F reud w ould speak of r eg ressing back to a fix ed stag e in which ther e wa s a par ticular life ta sk to perfor m. At ta c hme nt t he or ist s w ou ld m a ke a pr e tty str on g br e a k w ith tha t, bu t I ’m thi nk ing wi th w ha t y ou me a n w ith re g re ssi on is, (b re a th) is

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112 taking back to a time prior, that y ou think sti ll is i nfluenc ing the m and they think doesn’t have a ny thing to do wi th i t. Of the the ra pis ts I int e rv ie we d, L CSW L a rr y p sy c ho log ist Ric k, a nd ps y c hia tr ist J ack most closely fit the psy choana ly tic model. Neve rtheless, L arr y ’s discussion above illust rate s that he take s g rea t pains to distance himself fr om it. I include the leng thy section below w ithout my benig n words and inter jections of enc ourag ement (i.e ., “Um hmm ” a nd “ Rig ht” ) t ha t w e re de sig ne d to ind ic a te tha t I wa s h e a ri ng him a nd wi sh e d to continue his speaking turn. This tactic will also be use d throug hout the rest of this pape r in instances whe n these wor ds add nothing bey ond indication of attention and/or tur n p as s i n g. L a rr y : I thi nk ma y be —o n p ra c tic a l di ff e re nc e s in my a pp ro a c h, wh ic h is cente red he avily on Attachment The ory —things that mig ht not be reg arde d as a tra uma worth looking at bec omes signif icant. L et’s jus t sa y tha t a t a tim e tha t I wa s h umi lia te d a nd so rt of vo we d in my hear t, “I ’ll never open my self up to fe eling that way ag ain.” And so, I would be continuing to talk that out, that it m ight be a minor thing. I t didn’t involve phy sical har m to me. I t didn’t involve what, for many people mig ht have se emed too much of a los s o f i de nti ty b ut i t be c a me ho w I wa s g oin g to s hie ld m y se lf wh e n I fe e l fee ling. And I can r emember exactly wher e that happene d, so it’s not re pr e ss e d. (b re a th) B ut I ’v e fo c us e d o n it from a c og nitive point of view, and I ’m not focuse d in on the sort o f t h e i d e n t i t y m a i n t e n a n c e d e c i s i o n t h a t I had and so, later on I ma rr y so me on e wh o is a sk ing me thi ng s b e c a us e sh e wa nts to c a ll me out and know my hear t and know wha t’s g oing on, but I have, at a subc onscious level, purpose d that I am (bre ath) not g oin g to shsh-, y ou know, I ’m g oing to play my car d close to my vest. I ’m not going to do that and so, I think that some of the obstacle s that need to be remove d in marital thera py would not fit under the classic de finition of trau ma, and ther efor e g et over looked. B ut they are to a lesser deg ree how someone ha s g uarde d their hea rt from a pa inful outcome, and is stuck with a de cision that’s no longe r re levant in the pre sent. Mine is more fr om the standpoint of intentional limi tation of attention. Yea h, y ou’ve c rea ted a g rid by which y ou are g oing to inter pret e vents and y ou cut y ourself of f

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113 fr om b e ing a ble to a tte nd to o the r d a ta tha t, s a y thi s d oe s n ot f it that circ umstance. Whil e it is possibl e that an e lement of the H awthorne Effe ct (the subjec t’s response is influenced by awa rene ss that he/she is being studied) may have a bear ing on L arr y ’s exposit ion, the detail and pe rsonal leve l of his monologue indica te that this is an are a that he ha d previously considere d. He ha d come to his own conc lusions (and rationalizations? ) eve n befor e he be came awa re tha t this was a par t of my rese arc h. He was a ble to use psy choana ly tic techniques f or discover y [primarily ] and treatment [to a deg ree ] whil e at the sa me time reduc ing susc eptibility to neg ative labe ling by those who be lie ve tha t th e su g g e sti bil ity inh e re nt i n r e g re ssi on the ra py pr e c lud e s it s u se in t he se are as. Secondly a new vocabula ry has eme rg ed that links psy choana ly tic discovery te c hn iqu e s w ith be ha vio ra l tr e a tme nt p ro c e du re s. Be tty found that during massag e sessions and dur ing a cupunctur e people broug ht up re pr e sse d me mor ie s w hic h w e re de sc ri be d a s b od y me mor ie s ( me mor ie s im mut a bly a nd c omp le te ly e tc he d w ith in t he str uc tur e of the bo dy e ve n th ou g h th e y ha ve no t c ome to consciousness since the time they wer e alleg edly etche d there ): Be tty : “You know, the things that they hadn’t talke d with any body about.. Be tty : I ’ve he ard storie s from massag e ther apists with some people who have g otten massag es whe re tha t ty pe of stuff happens a nd then I ’ve a lso seen it happen w ith acupunctur e. We’ve hit acupunctur e points that have broug ht back f loods of emotion or memories or wh a t ha ve y ou T ho ug h I do n’ t th ink in a c up un c tur e it’ s a s if they ’re fee ling the e x act sa me fe eling s. But massag e . I ’ve he ard many people talk a bout—I ’ve ne ver w itnessed it, but I ’ve he ard many people talk a bout—, “Gosh as soon a s we touch, y ou know, this one point it ’s like [ex hale] ever y thing r eturne d, y ou know.” So I ’v e he a rd sto ri e s a bo ut t ha t f ro m ma ssa g e the ra pis ts i n p e op le wh o h a ve g ott e n ma ssa g e s. Th a t th e re is m e mor y in d if fe re nt p a rt s o f yo u r b o d y.

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114 Mike: And it’s complete, whole and . ? Be tty : Yes Of those I interviewe d, Be tty was the the rapist who had most often e ncounter ed people who a verr ed re presse d memories. Ne verthe less, she fe lt that the memories cited should be looked at with ca re. H er sty le of de aling with repre ssed memories wa s such tha t sh e did no t dw e ll o n th e me mor y b ut j us t le t th e c lie nt t a lk i t ou t. S he the n w ou ld mov e the m ou t of it, ba c k to the c op ing wi th t he ir pr e se nt c ir c ums ta nc e s. Be tty : I mean I think someone’s attitude towar ds life c olo rs the way that the y re me mbe r t hin g s. An d th a t it c olo rs the wa y tha t th e y re c a ll thi ng s a nd tha t th e y wo uld the n te ll y ou a bo ut t he m. . So so me bo dy ’s c ur re nt a tti tud e th e ir wa y of loo kin g a t li fe th e ir pe rs pe c tiv e u hm de fin ite ly c olo rs the me mor y D e fi nit e ly wi ll c olo r h ow the y wi ll r e c a ll i t a nd the n h ow the y re te ll i t. Be tty : You know, so, they ’re g onna experienc e their tra uma, whate ver t r a u m a i t i s d i f f e r e n t l y. A n d t h e n t h e y m a y r e l i v e i t T h e y, m a y, reexperience it at a later date, g iven the new er w ay s of fe eling and c o p i n g w i t h t h e e x p e r i e n c e S o u h m a s yo u g e t o l d e r yo u m a y, re -e xpe ri e nc e it a nd the n y ou re -i nte g ra te it i n a ne w w a y be c a us e yo u l o o k a t i t f r o m a d i f f e r e n t w a y. Mik e : So h ow wo uld y ou tr e a t th a t? Be tty : I move them forw ard. I move them forw ard. Mik e : Ho w w ou ld y ou do tha t? Be tty : They . they can ta lk about it and then they can, ta lk about how it relates to their r elationships now, that they re in. And the n they c a n ta lk a bo ut i t so me mor e a nd the n h ow it r e la te s to the ir work-life now. and then, but c on> but constantly bring them to the fr o n t t o t h e t o t h e c u rr en t t i m e, o f l i v i n g an d d ea l i n g wi t h wh at 's happening with their lives now. And see how that made the m fee l then and then se e how they fee l now and see if they re c onnecte d a nd se e . . B ut n ot a lw a y s g o th e re s ta y the re a nd bla me ever y thing then now . .on this. I move them out of that. I move the m.

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115 L CSW Amy had not had a patient who had disc overe d repr essed memor ies. The para meters of her f unction as a w ard ma nag er pr eclude d much exposure to patients who might ave r re cover ed memorie s. The only time she did speak of memory was in a neg ative wa y when c riticizi ng licensing exams which tend to pref ere nce me morization of fac ts over scr eening for sa nity and ac tual competenc y for doing thera py Am y : Ye s. B ut t he re s n ob od y to s a y wh e the r o r n ot y ou pe rs on a lly [as a social worke r] are a nut. And if y ou have a ny business dealing with people on a pr ofessional leve l. Right now it is, ‘what is y our g rade on this ex am. How we ll do y ou memorize fac ts and, how muc h mo ne y wi ll y ou se nd us a nd . p e ri od —th a t' s it Kar en, the e ducation counse lor, did deal with memories. When I noted that the Ramona ca se had involved pr actice s which had to do with sug g estibilit y in rec all (i.e., hy pn os is, Sod ium Pe nto tha l, a nd dir e c te d im a g e ry ) a nd a sk e d if sh e ha d u se d th e se techniques, she jumped direc tly to the question of what she does about re presse d memories. She said that thoug h she does not probe for memor ies she mig ht open them up if she fe lt it was appropria te. She def initely does believe that sometimes memories ca n be repr essed. The one time a c lient broug ht up the possibili ty of a r epre ssed memory Kar en informed he r that that would not be the f ocus of he r work. K are n felt that the limited nu mbe r o f s e ssi on s c ou ld b e a nd wa s, sp e nt o n mo re re le va nt m a tte rs Kar en: No, I don’t do Hy pnothera py and dire cted imag ery I ’m not sure what y ou mean by the term. L et me put it this way is y our qu e sti on wh a t do I do a bo ut r e pr e sse d me mor ie s? Mike: Yea h that, should do. K a r e n : Y e ( l a u g h s ) a h u h I typ ically ever y thing’ s individual. I mean that the re ’s no t on e thi ng I do in m y lif e p ro ba bly th a t I do in t he sa me way ever y time. Not even how I brush my teeth. So, I do believe tha t pe op le c a n r e pr e ss m e mor ie s. I thi nk it’ s a ph e no me no n, I jus t acc ept it as such. Do I work, to pull those out of people? I don’t.

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116 . L e t’ s se e do I op e n it up ? I f i t’ s a pp ro pr ia te A m I a sle uth about them? No. No, ther e’s a rea son that they ’re sort of latent a nd I thi nk it can be ha rm fu l. I me a n, if it’ s rel e va nt I wo rk wi th i t, but . > Mik e : Ho w w ou ld i t be re le va nt? Kar en: < and sinc e in all t h e y e a r s . . O h o h w a i t l e t m e j u s t f i n i s h In a ll t he y e a rs tha t I ’v e do ne the ra py I thi nk tha t on ly on e tim e did s o m e b o d y c o m e t o m e a n d s a y, “ I w a s l yi n g d o w n t h e o t h e r d a y, and the c eiling f an wa s on. And all of a sudde n I g ot this . ink lin g of a re me mbr a nc e of be ing a t my g ra nd fa the r’ s, a nd I jus t ha d th e fe e lin g tha t so me thi ng ha pp e ne d th e re A nd I do n’ t r e a lly kn ow wh a t it is b ut I wa nt t o f ind ou t.” An d s he wa s won dering about had she been se x ually abused by her g randf ather . and she rea lly wanted to g o for it, she re ally did, she wante d to uncover it. An d I wo rk e d w ith he r, fo r a s lo ng a s I fe lt c omf or ta ble a nd tol d he r t ha t that would not be the foc us of my work a nd that I wasn’t g oing to do hy pnothera py with her. And tha t it’s not in m y are a of expertise. But, I didn’t nece ssarily I mean she was ve ry functional in the prese nt and I just didn’t believe that there was a ny benef it for that pa rt ic ula r p e rs on to, y ou kn ow to be c ome a n a rc ha e olo g ist into her past about that. Now that might’ve had she pr esente d some other time (he r) life . . I wouldn’t say that I would never ever work with her on that, but for the r easons that she came in, I don’t think she came in just t o talk about the ce iling fa n, I mean. I don’t reme mber whe ther we worke d on other thing s first and then that came up or wha tever but it really . . I n rela tively brief psy chother apy y ou have to make choice s. I mean, we had a lim ite d ti me in s e ssi on s. We c ou ld w or k to g e the r a nd we jus t did n’ t th ink it w a s the mos t r e le va nt t hin g to h e r. An d it pr ov e d to be not the most releva nt. She kind of decide d “Oka y may be I do n’ t ha ve to l ive wi th t ha t.” I f i t c a me up a g a in s ome oth e r t ime a nd sh e wa nte d to e xplor e it, he c k. . I do n’ t pa rt ic ula rl y appre ciate the viewpoint of psy cholog ists and psy chiatrists and any body else say ing tha t they ’re alway s totally fabr icated. . I don’t believe that and I think that there ha ve bee n some harmf ul things wr itten in my profe ssion about the non-validity of re presse d me mor ie s. She was a war e of a differ ence betwee n suppression and r epre ssion. I then aske d about PTSD (post traumatic stress disorde r). Ka ren be lieved that PTSD can be a re sult of ha vin g be e n s e xua lly a bu se d o r h a vin g su ff e re d s ome oth e r e xtre me str e sso r( s) Sh e sa id

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117 the PTSD from war experience was the not the sa me as fr om childhood sex ual abuse She also said there wer e other stressors, such a s that involved in writing he r dissertation could lead to PTSD. Kar en: Nope. Sometimes people w ho have be en in sexually abusive re la tio ns hip s do develop post trauma tic stress disorder but I don’t know that I can ma ke a c onnection. . Ye ah. So y es, I think so me tim e s p e op le do de ve lop po st t ra uma tic str e ss d iso rd e r, a s a re su lt o f w ha te ve r t ra uma s th e y ’v e su ff e re d, a nd g ra nte d it wa s f ir st wr itt e n a bo ut i n te rm s o f p e op le in Wo rl d Wa r I I ; bu t, t he re a re lot s of other r easons that pe ople deve lop post traumatic stress disorder I think I did about my dissertation. (laug hs loudly ) y eah ( continues la ug hs ). Just doing one. Gail spoke ope nly and in depth in re sponse to probes on topics that she kne w, but would not speculate about less fa miliar ones. She would continually use tec hniques which pass he r turn to spea k or would direc tly say she did not know about that subject. Re pr e ssi on wa s o ne of the se top ic s. She do e s n ot p ro be fo r m e mor ie s, do e s n ot u se reg ression thera py techniques, nor does she use trea tment techniques that mig ht lead the patient to be sug g estible or conside r themselves to be a victim. She is very much in favor of re sponsible medication of pa tients and works with a pe diatrician ( the direc tor of her clinic) who pe rfor ms the functions of a psy chiatrist. She ha d p re vio us ly wo rk e d w ith a nu mbe r o f p a tie nts wh o h a d p os t tr a uma tic stress disorder (PTSD) from wa r experienc es. On one of the fe w occ asions that her thoughts a nd fee lings on a topic was not conc ise and c lear she linked statements a bout that PTSD to t he fa ct that she ha d worke d with children who ha d been se x ually and phy sically abused a nd also in a support g roup composed of women who ha d been sexually abused. She le ft moot the question of whethe r she be lieved that these wer e the same PTSD. Whil e intervie wing Gail, I noticed that she w ould answer any question I

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118 asked f ully and thoug htfully but she did not volunteer any information which wa s not actua lly asked a bout. There was one occa sion when she we nt ag ainst this practice —she voluntarily expressed her conce rn about third-pa rty providers ( i.e., HMOs, Medic are and insurance companies) —that they have pr oduced a g rea ter impac t on the instit ution of thera py than eve n the fa ll-out from the re presse d memory polemic. Ga il: HM Os a nd Me dic a re a nd I thi nk ins ur a nc e c omp a nie s, tr y to presc ribe wha t they think is m ental hea lth care and wha t should be a de qu a te fo r d if fe re nt k ind s o f p ro ble ms a nd ho w t o d e c ide if something is ef fec tive or not, or wha t they ’ll pay for, a nd it [ sic] cer tainly understands, c oming f rom a business aspe ct, that y ou try to make thing s rea lly quantifiable, but I think it’s had much more of an impac t on treatment than r eg ression. Ric k f e lt t ha t me mor ie s w e re imp or ta nt, bu t “ On e of the thi ng s I tr y to t e a c h my c lie nts is n ot t o b e a sla ve to t he ir pa sts .” He wo uld sa y to s ome c lie nts tha t it “ on ly eff ects y ou to the point that y ou’re still keeping it alive . which of c ourse is memory .” I asked him if he use d the Mental Status Ex am (MSE), a c og nitive function exam that inc lud e s te sti ng sh or ta nd lon g -t e rm me mor ie s. He ha d a dmi nis te re d it wh e n a c tin g a s a consultant for hospital long -term c are trea tment, to provide a “ baseline.” Howeve r, he said he did not use it with his own private clients. His clients we re e ither able to pay for the sessions or “ha d looked fa r enoug h ahea d to ge t insurance to pay .” Ric k: B y de fi nit ion tha t me a ns the y ’r e ty pic a lly fu nc tio nin g a t a le ve l, t o be able to hold down the bills and y adda y adda y adda. T hat a lr e a dy te lls me a lot a bo ut w ha t th e me nta l st a tus e xam w ou ld t e ll me [laughs]. . They ’re able to do y ou know the executive planning . . They ’re able to do short-te rm and long -term memory They ’re able to do, uh simple compre hension and lang uag e skills and all the . a lot of the stuff which is in the mental status exam. So, uhm that . the MSE is ge tting, ver y basic, c ore, c og nitive proce ssing f unctions that. . I t may be a lit tle bit slo pp ie r b ut t ha t I c a n a lmo st, a ssu me a s a ma tte r o f c ou rs e

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119 that ‘there walking in the door, is a priva te-pa id client. They ’re [The elements of memor y are ] i n place .’ Rick had not had a client ave rring repr essed memor ies althoug h he had hy pothesized about it. He ca ref ully phrase d his answer s to the probes on re pression. This was indicate d by his shifting per spective in the c itation below. He be g an by qu a lif y ing his be lie f i n r e pr e ssi on wi th t he pr e po sit ion “ if .” Th e n h e sa id t ha t he wo uld n o t b e d e a li n g w it h w h a te v e r w a s r e p r e s s e d [t h e me mo r a b le o b je c ti v e r e a li ty o f th e p a s t] Then he indicated that it was important to look for a memory which is itself a pa rt of the client in the pre sent moment, if only in that it is being kept alive [whether of ac tual happening s or not are of limited importance—important is that it is being ke pt alive]. He wo uld loo k n ot a t th e me mor y bu t a t the present re ality of its being see n as repressed Wherea s the literature favor ing r eg ression thera py indicates that re presse d memories ca n on ly be br ou g ht b a c k w ith the he lp o f a pr of e ssi on a l th a t th e c lie nt t ru sts a nd pr ov ide s a c omf or t zon e in w hic h th e me mor y is d isc ov e re d, Ric k f e lt t ha t th e me mor y wo uld c ome back on its own a nd would do so beca use of dis comfort in life. K ey to his looki ng at repr essed memor ies is that “They ’ve br oug ht it to y ou.” Rick I f cla ssic repr ession exis ts, uh and if it exi sts in a client that I was seeing by definition, I would not be dea ling with wha tever was repr essed be cause what’s uh, wha t’s at issue to me is what y ou have a live at the moment and that’ s that. You’re keeping alive and reme mbering at the moment y ou’re dealing with. . So by d e f i n i t i o n I wanna be g oing looking for that whic h is repre ssed. Th e re is, the re ’s a fe w i nh e re nt implications of that and a ppare nt assumptions uh that it ’s something that’s re ally important. You g et uncomforta ble enoug h, it’s going to come bac k on it’s own. Rick: Certainly and that’s pa rt of how it will come bac k on its own. tha t’ s> a s y ou c on fr on t th a t mi nd -s e t, a nd n ot g oin g Yo u g e t th is min dse t “ Oh w e ll y ou we re ob vio us ly a bu se d. ” Yo u g e t th is min dse t “ Wel l w ha t’ s lo g ic a l a bo ut t ha t mi nd -s e t, w hy is i t

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120 D isso c ia tive A m n e sia (fo rm e rly P syc h o g e n ic A m n e sia ). 1 A T he predom i nan t di s t ur bance i s one or mo r e e pi s od es of i nabi l i t y t o re cal l i mp ort ant per s onal i nf o rma t i o n, us ual l y of a t raum at i c o r s t res sf ul nat ure, t hat i s t o o ext ensi ve t o be exp l ai ned by ord i nary f o rge t f ulne ss. B T he d i st urbanc e d o es not oc cur excl usi vel y duri ng t he co urs e o f D i ss o ci at i ve Identi t y D i sord er, D isso c ia tive F u g u e P o sttra u m a tic S tre ss D iso rd e r, A c u te S tre ss D iso rd e r, o f S o m a tiza tio n D iso rd e r a n d is not due t o t he di r ect phy s i ol ogi cal ef f ect s of a s ubs t anc e . or a n eur ol ogi cal or ot her ge ner al medi cal co nd i t i o n . (H al es, Y ud o f sky and T al b o t t 19 9 4 ). imp or ta nt f or y ou y a dd a y a dd a y a dd a Wh y d on ’t we g e t r id o f i t y adda y adda y adda.” and in the proc ess, uh if it’s salient, salienc y and impressive, the y ’ll g o “Well, actually I g o to this m ind-set be c au se . .” and the n y ou’re off to the r ace s. But they ’ve br oug ht it to y ou. Z oe desc ribed he rself a s an empiricist. She did not believe tha t enoug h supportive data e x isted on reg ression thera py to use memories a s an interve ntion technique. Z oe : I ’m a n e mpi ri c ist B a sic a lly if the da ta isn ’t the re to s up po rt tha t a technique is e ffe ctive, then, I don’t think that’s something that we sh ou ld b e do ing a s a pr of e ssi on A nd a s f a r a s I kn ow th e re isn ’t a . there isn’t enoug h data in support of tha t being an ef fica cious intervention to support that being done. She went on to talk about re pression as a defe nse mec hanism that cannot be tested. F rom what is known about memor y and fr om her own c linical experience Z oe felt that people do not forg et being sexually abused. She f elt that rathe r than re pression that dissociation might be w hat is occur ring in case s where repr essed memor ies are 1 al l ege d W h er e r ep re s s i o n i n v o l v es n o t b ei n g ab l e t o re m em b er s o m et h i n g o r t h i n gs wh ic h h a pp e ne d, dis so c ia tio n f or Z oe inv olv e s n ot r e me mbe ri ng be c a us e the ind ivi du a l is overloa ded with things to re member a nd is episodic rathe r than c ontinuous. Her e xpla na tio n o f t his dis tin c tio n f oll ow s: Z oe: I g uess the other part> like these re g ression, thera pies are re pr e sse d me mor ie s, thi ng s. uh Re pr e sse d me mor ie s a re (w e jus t ta lke d a bo ut t his in c la ss t he oth e r n ig ht [Z oe te a c he s a t a university ]). Repression is a defe nse mec hanism . we c an neve r, say does or doe s not ex ist. I n rea lity it’s an untestable . it’s a n

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121 intang ible sort of thing And I ’m very uh, based, on w hat we know about memory These r epre ssed memories should not be, espec ially repr essed memor ies of sexual abuse. . Uhm. Although I ’ve w orked w ith a lot of sexually abused, c hildren—I have e x tensive experienc e with that—uhm, which may be eve n fu rt he r m y fe e lin g b ut n ot f ro m a n e mpi ri c a l st a nc e bu t ju st f ro m a clinical . obser vation stance Uhm, People, for the most part, do not forg et that they wer e sexually abused. I t’s, a huge pa rt of the ir l i v es I t h i n k y o u m i gh t s ee d i s s o ci at i o n o cc u rr i n g. I then aske d her a bout suppression. She said that in contrast to re pression that suppression is a consc ious choice to not think about something a nd is tang ible enoug h for considera tion. W hen I asked he r how she tr eate d memories or if she did, she said that she did no t lo ok fo r m e mor ie s. Z oe: I mean I ask a c lient for their pa st, but, y ou know, “ What was y our childhood like? ” or Y our re lationships with y our par ents or signific ant people in y our life but, uhm. . I ’m looking f or more, may be, pre sent day problems. And I look to see how the pa st may h av e i n fl u en ce d t h at E s p ec i al l y i n t er m s o f i n t er p er s o n al re l at i n g . but, uh, I don’t find the nee d to dig ter ribly much. [laugh] There ’s usually plenty rig ht there in fr ont of y ou. That y ou don’t h av e t o d i g. I probed w hether she had e ver ha d a client a verr ing r epre ssed memories a nd she c ite d a c a se sh e ha d s up e rv ise d w ith a n in te rn Wh e n I a sk e d h ow sh e ha nd le d th a t c a se she said: Z oe: Well. I think what happene d is the client, only came for a couple of se ssi on s, a nd so it w a s k ind of a moo t> We d idn ’t re a lly g e t to bring that to fruition to see wha t would come out. B ut, in part what I wanted the supervisee to do, was to deter mine, what context, that thi s memory came back to them, wha t, how did . w h e n d i d t h e y f i r s t b e c o m e a w a r e o f t h i s m e m o r y. She tho ug ht w ha t w a s h a pp e nin g in r e c ov e re d me mor y the ra py wa s th a t “ so me thera pists are seizing on any thing that r emotely rese mbles survivor status. And, I think they are convinc ing clients that they wer e sexually abused. When, in fa ct, I doubt it. I

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122 do ub t it .” Whe n I a sk e d w ha t sh ou ld b e do ne a bo ut t he ra pis ts w ho do thi s, sh e sa id laug hingly “Oh lordy [S igh, la ug h]. Hang them by their toe-na ils [ laug hing]” a nd then m o r e s e r i o u s l y: Z oe: I g uess the dea l is that, I think a lot of time those therapists are people who ha ve had . w ho are emotionally unhealthy themselves. And they are prac ticing in that state . . I hear d stories about someone w ho prac ticed in the town I used to live in. Uh, hated me n. And eve ry client she ha d who had a man in her life, the man turne d out to be the sea t of all evil and . e t ceter a. Uh A nd I thi nk it’ s k ind of the sa me thi ng wi th t he se uh pe op le who bring out these. These are either pe ople, I think, who believe that ever y thing that ha > bad tha t c ome s o ut o f a pe rs on c a me a bo ut b e c a us e of se xua l a bu se or be c a us e the y we re se xua lly abused the mselves and they see tha t in every body I don’t know what is happe ning but. . I n g ener al, this whole rec overe d me mor y thi ng a s much as I ’ve w orked w ith sex ually abused, children a nd adults, survivors, [clap]. I ’ll be dar ned if a ny of them ha ve a ny [la ug h] pr ob le m w ha tso e ve r, be ing c og niza nt o f t ha t. Z oe supported the finding of the litera ture re view that the topic of repr essed me mor y is ho tly contested. She c ited an occ asion when Elizabeth L oftus [first president of the Am e ri c a n Ps y c ho log ic a l So c ie ty ] wa s a sk e d to pr e se nt h e r r e se a rc h o n me mor y to a re g ion a l ps y c ho log ic a l c on fe re nc e T he Re pr e sse d M e mor y F ou nd a tio n “ c on ta c te d, us threw a big f at fit—that we w ere n’t balanc ing by prese nting the othe r side of the debate .” The c onfer ence org anizers had de cided that ther e wa s not a compar able leve l of rese arc h offe red by the founda tion. The esca lating na ture of e mails and other c ontacts made by an ind ivi du a l f ro m th a t f ou nd a tio n r e su lte d in the c on fe re nc e a c tua lly hir ing se c ur ity T his was the f irst and only time that particular reg ional confe renc e had f elt the nec essity of providing secur ity Psy c hia tr ist B e n in his pr ima ry ro le a s a g e ri a tr ic ps y c hia tr ist us ua lly de a lt w ith me mor ie s in a dif fe re nt c on te xt tha n th e so c ia l w or ke rs a nd ps y c ho log ist s. Som e of his

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123 c lie nts ’ p ro ble ms w e re tha t th e y did no t ha ve me mor ie s e xce pt f or old me mor ie s. Som e would conce ive of themselve s as living in the time of the memory rathe r than in the prese nt. Although he did not do a lot of therapy (dea ling more often with for ms of d e m e n t i a ) h e h a d e x p e r i e n c e a n d o p i n i o n s o n r e g r e s s i o n a n d m e m o r y. Be n: I don’t use it. I don’t use it much. You have to understand, too, that I don’t do a g rea t deal of the rapy g iven my role in wha t I do rig ht now. When I encounte r re g ression it is usually the patient spontaneously elec ts to reg ress, a nd it’s often debilitating for them and counte rproduc tive for them. a nd so I ’m usually try ing to g et the m ou t of re g re ssi on So it’ s a lmo st a g a ins t my na tur e to w a nt t o ind uc e it. Mike: So if someone, say s “I have this memory I need to talk a bout that jus t po pp e d u p. ” . I n o the r w or ds y ou do n’ t so lic it m e mor ie s? B e n: I inv e sti g a te a re a s th a t th e pa tie nt h a s c on c e rn a bo ut. An d if it’ s a pa st m e mor y tha t th e y ’v e re c e ntl y un c ov e re d, I ’d c e rt a inl y dis c us s it with them and look into i t. I wouldn’t purposef ully uh have the patient uh try to reg ress themselve s in order to re cover new me mor ie s. I asked Jack wha t he thoug ht about using me mory as a the rapy tactic. He thought that memory had pluses and minuses. J ack: Uhm. I t has it’s pluses and minuses. Memory is obviously g oing to be one of the cor nerstones I think, because it’s—Unless it’s documented some wher e—but, uhm I think that’s going to be a dif fi c ult thi ng a lot of tim e s. Although Jack said that r epre ssed memory sy ndrome wa s not in his area, memories of the past wer e important enoug h for his thera py for him to advoca te memory retrie val methods (see Chapter 5, ‘ Good’ ve rsus ‘B ad’ Tr eatment Pra ctices) He r elated his e xpe ri e nc e wi th a wo ma n w ho ha d r e tr ie ve d me mor ie s o f c hil dh oo d s e xua l a bu se while under the ca re of a counse lor. Mik e : Th e re pr e sse d me mor y sy nd ro me w ha t do y ou thi nk a bo ut t ha t?

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124 J a c k : U h m T h a t ’ s n o t m y a r e a o f s p e c i a l t y. Mik e : Ha ve y ou e ve r t re a te d, a pa tie nt w ho ha d me mor ie s th a t f e ll w ith in thi s. Jac k: I n, kin d o f a n a nc ill a ry fa sh ion O ne of the fo re ns ic c a se s th a t I revie wed wa s a patient that, I wasn’t in—involved in that aspe ct of the c a se b ut t ha t th e y we re de a lin g wi th s ome re pr e sse d me mor ie s, that actua lly had bee n rec overe d, and M i k e : W e r e t h e y r e c o v e r e d d u r i n g t h e r a p y? J ack: Yes. And tha t was the issue (la ug hingly ) ac tua lly T he be st o f m y re c oll e c tio n it wa s a pa tie nt t ha t ha d . a his tor y of a bu se a s a child. M i k e : A n u n r e c o r d e d h i s t o r y? Jac k: Un re c or de d h ist or y of a bu se a s a c hil d. a nd a s a n a du lt. be g a n to experience problems in rela tionships, and things like that which led them to pursue ther apy During the thera py (I don’t reme mber how long the y had bee n in therapy uhm and I can’ t I don’t reme mber the time line, but somewhere in there) it started out as dre ams, if I reme mber (br eath e x hale) that started c oming ba ck to her and she wa s w on de ri ng du ri ng the ra py wi th a the ra pis t w he the r t he se drea ms were drea ms or whether they wer e re collections of pr evious of experienc es, bec ause it wa s her, a s a y oung er . a s a child. Mik e : Was the the ra pis t do ing dr e a m a na ly sis ? J ack: No. er at least a ccor ding to he r, they hadn’t. The y wer e talking about their dre ams a little bit but not in any kind of forma l, uh drea m analy sis. Uhm and then, at some point during there she s>, the memory started be coming more intrusive imag es. I t started happening when she was a wake uhm and then eve ntually I think, the y sta rt e d f oc us ing in o n th os e N ot j us t th e dr e a ms b ut a c tua lly the memories of the intrusive thoug ht that were starting to interrupt her day And then eve ntually led to these uh re collections of wha t these re p> wha t she ca lled, and the ther apist had identified as re presse d memories. Mike: What kind of therapist was she ? J ack: All she told was she wa s a counse lor. She was . I know she wasn’t a n M.D. but she was some sor t of mental hea lth counselor.

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125 Mike: And so. How did y ou g et involved with her. J ack: We were viewing a ca se fr om, from leg al cha rg es that she ha d had, su bs e qu e ntl y I t’ s k ind of un re la te d to tha t bu t, a s p a rt of my evalua tion I will ask them about, previous psy chiatric history of counseling and thing s like uhm and that’s whe n she starte d opening up about all this. And so I just went into as much depth as s h e w a s c o m f o r t a b l e s o I > Mik e : Wha t do y ou me a n b y le g a l c ha rg e s? J ack: She had bee n char g ed with a c rime. I t was unre lated to any of the memories or a ny thing like that but, she ha d been a rre sted for a crime tha t she had a lleg edly committed. uhm and then her attorney ha d b ro ug ht h e r t o u s, to e va lua te he r f or c omp e te nc y to g o to tr ia l. Mik e : Ok a y A nd a s p a rt of thi s y ou c on ta c te d th e me nta l he a lth counselor? J ack: No, this is st rictly on her [the patient’s] repor ts and in her rec ollections of what ha ppened. Mike: And how. I don’t understa nd the conne c>, how y ou g ot these or whateve r, y ou know. “She ha d this mental health counselor and then uh uhmm then at some point, I g uess later y ou wer e> J ack: Right. I think it was just . a few y ear s, two, three, ma y be four y e a rs a ft e r t his wh ole th e iss ue of uh m w he n s he a nd the the ra pis t labeled the m as rec ollections, or re presse d memories that had be en rec ollected. uhm Somewher e af ter that wa s when the a lleg ed crime c ommitt ed, wa s committed. And that was whe n they sent her to us. I t was two sepa rate issues, but just because w hen she came in to me I try to do a thoroug h exam she was . that wa s one of the issues that ca me up. Mik e : An d u h d id y ou a sk he r a bo ut t his ? Di d y ou do a dis c ov e ry on thi s issue. Jac k: Som e I tr ie d to do so me Just ba se d o n, be c a us e of the fa c t th a t if she had the se re presse d memories, one of the issues that might come up would be post traumatic stress disorde r. And so that would cer tainly have r eleva nce to a ny kind of crime, pe rhaps, that sh e ma y ha ve c omm itt e d. So I did a sk he r a bo ut i t.

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126 J ack’ s experience with the patient orig inated af ter she ha d been in ther apy a fe w y ear s befor e. She had r ecove red the memories with an unknown the rapist at that time. His function was to find out whe ther the c lient had post traumatic stre ss disorder for the court. His examination came f rom a pa radig m in which he wa s not responsible for the pa tie nt’ s th e ra py b ut t o r e po rt ing he r m e nta l c on dit ion to t he c ou rt M .S. W. s o n M e m or y, Re pr e ssi on, and R e gr e ssi on Th e r apy The c linical social worke rs’ e x perie nces w ith averr ed re presse d memory and suppressed me mories ra ng ed fr om no contact ( Amy ) to multipl e conta cts. Of those w ho had conta ct with clients/patients who did aver these memorie s, eac h would provide the client/patient with a saf e plac e for talking a bout them but would at some point acknow ledg e that the e vent the memory evince d either did or mig ht have ha ppened, but that circ umstances of the pre sent should not be held hostag e to those memories. I nstead, the thera py of the socia l worker s dealt with the pra cticalities of menta l health within the prese nt mili eu. P h.D .s on M e m or y, Re pr e ssi on, and R e gr e ssi on Th e r apy Gail had sa id that she does not look for memor ies or re pression and doe s not specula te about wha t she would do with a patient who me ntions a repr essed memor y She does not use tec hniques which would be likely to discover r epre ssed memories. Kar en does not foc us on memories. On the one occa sion when re presse d memories we re broug ht up, she conc entra ted on pre sent problems ra ther than the repr ession. Although psy cholog ist Ri ck thinks that memories ar e important, to date no c lient had ave rre d repr essed memor ies to him. He hy pothesized that if or when a client broug ht repr ession up, he would look at wha t is repre ssed. At the same time he re veale d that

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127 the ra py in r e la tio n to the me mor y wo uld be a pp ro a c he d a s so me thi ng tha t th e c lie nt i s now making a proble m. He would look at its importance f or the c lient and would not have the client conf ront the alleg ed per petra tor. I nstead he would have the client confr ont the memory as a pr oblem that neede d to be taken c are of. Z oe said the que stion of whether there actua lly was re pression wa s something that could not be supported by data. I n the only case she had be en involved in, she wa s more conce rned w ith the context i n which the memor y first ca me bac k and probe why that me mor y tr ue or fa lse o c c ur re d to e ff e c t th e c lie nt a t th a t ti me Sh e fe lt t ha t so me thera pists are seizing on a ny thing r emotely rese mbling survivor status a nd are convincing clients that they wer e sexually abused a nd had for g otten. She g ave a n example of a thera pist she had known who wa s a misanthropist and re lated any thing ba d that was happening to the women under her c are to something a man (or me n) in the client’s life ha d d on e to t he c lie nt. M .D ./P h.D .s on M e m or y, Re pr e ssi on, and R e gr e ssi on Th e r apy Psy chiatrist B en wa s conce rned tha t reg ression is often de bilitating and counter productive f or his patients. I n fac t when it is broache d, it is because of spontaneous ele ction to reg ress a nd usually Be n tries to g et them out of re g ressing He do e s d isc us s a ny c on c e rn a pa tie nt h a s a bo ut a me mor y a nd wo uld loo k in to i t, b ut w ou ld no t tr y to g e t th e pa tie nt t o r e g re ss t o r e c ov e r n e w m e mor ie s. J ack did think memories we re a n important tool for thera py and in some ca ses he would advoca te memory retrie val. Howe ver, the only case he re lated wa s one in which another thera pist (a counse lor, persona lly unknown to him) had worke d with a patient and uncover ed memorie s of childhood abuse His function in this case wa s to find out

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128 whether the patient had dia g nosable post trauma tic stress disorder for a court. As suc h, h e w as n o t re s p o n s i b l e f o r t h e p at i en t ’s t h er ap y He wa s j u s t t ry i n g t o d o a t h o ro u gh exam on releva nce f or the c ourt and a sked her about it to see if it had any rele vance to her competenc y for tria l on the alleg ed cr ime.

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129 CH APT ER 8 AC CO UN TA B I L I TY AN D E TH I CS Amy had put Acc ountability and Ethics as one of her five c hoices for topics of discussion. W hen I asked he r about it, I was surpr ised that her r esponse wa s directe d at patient acc ountability and empowe rment ra ther than the rapist ac countability I questioned Mike: Whil e we re on a ccounta bility uhm, y ou talked about he lping or insisti ng upon the client bec oming a ccounta ble. Am y : Um hmm M i k e : W h a t i s t h e a c c o u n t a b i l i t y o f t h e t h e r a p i s t o r t h e c o u n s e l o r ? Amy : Not to foster de pendenc y . > Mike: Okay Am y : > fr om c lie nts Mike: Okay What about. So they have a n acc ountability to clients. What about to society or to pee rs or What kind of, y ou know, a c c o u n t a b i l i t y d o y o u h a v e t o t h e m ? Am y : T o ad h er e t o t h e h i gh es t s t an d ar d s n o t t o u h t o ab u s e t h e p at i en t 's rig hts or privileg es. A re source that that can be talked throug h. Mike: Okay I n terms of e thics, I ve looked a t NASW, I g uess that' s what it is, uh st atement on e thics and, incidenta lly what y ou' re doing no w i s, I thi nk in t he pr e a mbl e is y ou wi ll p ro vid e pu bli c in for mat io n" > Am y : Um hmm Mike: > and tha t sort of thing. So it' s appre ciated. Am y : Um hmm

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130 Mike: I was g lad to see tha t in all the therapy disciplines . . Am y : Um hmm Mik e : An d u h, e thi c a l st a nd a rd s— y ou ve g ive n o ne n ot t o s le e p w ith y our client or to uh in some wa y abuse se x with the client. Am y : Um hmm At this point I decide d to move on. I n addition to not fostering depende ncy on the thera pist, she had spoken of the injunction to not have a sexual relationship with any of the thera pist’s clients. Near the end of the interview Amy spoke of he r training and mentioned that, among others, it had cove red e thics, “but eve n those wer e pre tty much essay s.” Perhaps Amy ’s position withi n the medica l team (she ne eded a phy sician’s approva l for many of her interventions) a nd the ca se mana g er pe rspec tive of func tioning as aug menter of patient welf are sheltere d her f rom having to consider the ra pis t acc ountability and ethics. She w as the only one of a ll my interviewe es who interpr eted this card to re fer to patient acc ountability Fr om her re sponses, she re veale d that she had not considere d the ethics portion of the car d. Wit h L arr y the interview was a lmost half over be fore I asked him wha t the car d “ac countability ” involved. This appe are d to mark a tra nsition poi nt in the interview. Up to that point L arr y had bee n leaning toward me with his elbows on his knees. He took a deep br eath a nd sat fully back in the c omfortablelooking of fice chair and stay ed in that position for most of the rest of the inter view—as if on g uard. H e said that pa rt of the rea son that he par tnere d with other thera pists was "to ha ve somebody to bounce

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131 something of f of." He use d other membe rs of his offic e and e ven outside member s when he g ot into si tuations where “‘I ’m not sure how this is play ing out’ or ‘I ’m not sure wha t my role is in this.’” He a g ain mentioned bring ing in a lady in a chur ch ministerial position when c on fr on te d w ith the sit ua tio n o f t he wo ma n w ho wa nte d to re c ov e r m e mor ie s a bo ut a se xua l a bu se tha t ha pp e ne d in he r y ou th. Af te r f oll ow ing the dis c us sio n in to o the r a re a s, I no te d th a t he ha d ta lke d a bo ut a c c ou nta bil ity to c lie nts to “ g ive him [sic ] the be st the ra py tha t w or ks fo r h im. ” I the n a sk e d a bo ut a c c ou nta bil ity to p e e rs L a rr y : Wel l, i n my initial accountability to peer s is my partne rs and we meet eve ry other Wednesda y for an hour." He talke d about the ar rang ements that he ha d with his business partners for s ev er al m i n u t es an d d es cr i b ed t h e W ed n es d ay m ee t i n gs an d co n s u l t i n g: M i k e: W h at 's t h e n at u re o f y o u r p ar t n er s h i p m ee t i n g? L a rr y : I t us ua lly g oe s f ro m de ta ils of the fi na nc ia l a sp e c ts o f t he bu sin e ss and so for th to ge tting more into therapy issues. . Three thera pists will consult, for e x ample to do that, and in the of fice . . The re ason we set it up that way is in the off-we eks that often a ny two or three of us who ar e in the mental he alth field will meet and discuss therapy issues. Mik e : Uh hmm L a rr y : An d I br ou g ht t he m in jus t to c he c k b lin d s po ts f or me I re c e ntl y told a cer tain very complicated or conflict re solution i ssue that inv olv e d th re e g e ne ra tio ns I br ou g ht t he ra pis ts f ro m th e ou tsi de to re vie w m y wr itt e n w or k a nd to i nte rv ie w t he pa rt ie s b e c a us e I fe lt stuck. And so there s that kind of acc ountability of submitting y our work to somebody else to tell y ou if y ou' re missing something a nd hoping tha t they find something be cause (laug hs) y ou want to be unstuck more than y ou want to be de fende d. (laug hs).

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132 We were near ing the end of the hour allotted for the interview and I had re lated the g ist of the Ramona ca se and its ruling eff ecting acc ountability to third-parties whe n he me nti on e d th a t he ha d th e tw o e thi c s c la sse s ( on e in 1 99 5) a nd tha t th is c a se a nd top ic ha d p ro ba bly be e n d isc us se d b ut h e did no t di re c tly re me mbe r e ith e r. He did ha ve thi s to sa y re g a rd ing ha rm to c lie nts : L arr y : The idea being that thera pist is s ort of a c o-author in sha ping the client’s view of life and if tha t emerg ing vie w of life c an be pr oven to harm someone e lse, the thera pist becomes culpa ble in that proce ss. Whil e noting that the thera pist is i nvolved in shaping the client’s view of life, L a rr y sa id h e g ua rd e d a g a ins t th e po ssi bil ity of c ou nte rtr a ns fe re nc e (u nc on sc iou sly projec ting his own e motions, t houg hts, and wishes fr om his past onto the client’s persona lity “thus expressing unr esolved c onflicts and/or g ratify ing the psy chiatrist’s [sic] own per sonal nee ds” (Sche iber 1994, 218). When I noted that the standa rds of e thics for the diffe rent disciplines we re ve ry simil ar, he replied: L arr y : Yea h. But that' s ethics. Prac tice—ther e ar e ver y differ ent flavor s in prac tice. I n my field, the NCE, the N ational Counselor Exam, I thi nk is a dmi nis te re d to a ll t hr e e dis c ipl ine s w ith in L ine Sta tut e 491 that we' re unde r, and tha t seems to provide some c ommon threa d throug hout. Over all, L arr y ’s re marks showe d that acc ountability was a n are a that he ha d previously considere d. He talks of a “bala nce” that is to be struck betwe en ethics a nd the prac ticalities of doing thera py which appa rently hinge s on doing one ’s best and ref raining from doing harm. The way he bec omes ac countable to his clients is throug h a sy ste m of ba c kin g up his de c isi on s w ith a dv ic e fr om o the rs a nd the wa y he is

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133 acc ountability to his therapy and business par tners is throug h taking advice and off ering a dv ic e to h is t e a m me mbe rs Wit h Wil l, toward the e nd of my interview the subject of Ac countability and Ethics came up. Wil l relate d these topics to injunctions from the state lice nsing boa rd. W i l l : Yo u k n o w, y o u h av e a s t at e b o ar d -t h er e's a c er t ai n t h i n g. T h at 's le g isl a te d a nd uh the re > I wa s e mpo we re d b y the sta te a nd it' s a lso it' s e mpo we re d to uh be pu nit ive if ne c e ssa ry y ou kn ow to sanction. and uh . > Mike: Yea h. I m awar e of it. I n fac t . . Wil l: > and a ll that. But it reg ulates the ong oing uh, pr ofessional life of the profe ssion, if y ou will. You know. How much e duc> continuing e ducation y ou need.. U h, the ethics. The ethics ar e leg islated. and uh so, y ou know, it's it' s raises the le vel of acc ountability and, empowe rs the prof ession. The more y ou' ve g ot of that the more power ful y ou, y ou know, y ou are B e ing a c c ou nta ble to t he lic e ns ing bo a rd wa s a dv oc a te d b y Will, bu t he a lso returne d to the subject of the r esponsibility of a the rapist to end the ther apy sessions when there is no further improve ment and not lead the client into expensive future sessions. Wil l: You know people are ethical a nd up front that that would y ou k n o w t h a t : “ W e ’ v e d o n e a l l w e c a n d o ” o r “ I d o n ’ t s e e a n y . . Is thi s r e a lly wo rk ing fo r y ou ? ” I c a n g ive it t o y ou sim ple : “ I s it w o r k i n g f o r y o u ?” Of the soc ial worke rs, B etty appea red to ha ve conside red the se topics the most. Early in the interview she had desc ribed the ne ed for a g ood thera pist to be moral and ethical. Muc h later in the inter view she spoke of the wor ds that a ca rele ss therapist ca n us e w hic h a re a t th e wr on g tim e or wh ic h a re the wr on g thi ng to s a y to that patient. Be tty often re fer red to the r esponsibility of thera pists to avoid care lessness and

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134 ne g lig e nc e —to be the ir “ be st” po ssi ble (t ota lly “ pr e se nt” fo r t he pa tie nt) Sh e a lso c on tr a ste d th e re sp on sib ili ty of the c lin ic a l so c ia l w or ke r t o th a t of the oth e r m e nta l he a lth c ou ns e lor s to c on ne c t th e pa tie nts to s oc ia l se rv ic e s. Mike: I ve noticed tha t many of uh that, seve ral of the m which I was loo kin g thr ou g h th e DO H l ic e ns ing w ou ld b e lic e ns e d a s b oth if the y we re me nta l he a lth c ou ns e lor s. B e tty : Ye s. Mik e : I g ue ss f or the me nta l he a lth c ou ns e lor s c a us e th e y wa nte d to acc entuate the fac t that they wer e doing actua l individual therapy mor e tha n u h th e uh so c ia l, u hm s e rv ic e s > Be tty : Yea h. Yep, y eah. Mike: > ele ment of . . Be tty : Yep, c onnecting them with resourc es and y ou know, they re doing some of the c oncre te servic es as oppose d to some of the inter, i n t e r a c t i o n a l yo u k n o w t h e r a p y. Th e su bje c t of a c c ou nta bil ity a nd e thi c s d id n ot c ome up in m y int e rv ie w w ith Ka re n u nti l w e we re ta lki ng a bo ut c e rt if ic a tio n a nd lic e ns ing F or he r, the ra pis ts a re he ld acc ountable by "be ing a war e of the leg ality and the e thics of my profe ssion." When I a s k e d h e r i f i t f o r c e d h e r t o b e a w a r e s h e s a i d t h a t s h e w o u l d a n yw a y: Ka re n: B ut i ts a no the r r e min de r. I m ve ry a wa re tha t pe op le c a n c omp la in to t he lic e ns ing bo a rd or fi le su it a g a ins t ( vo ic e br e a ks ) m e So ho pe fu lly I d b e a n e thi c a l pr a c tit ion e r a ny wa y b ut b e ing he ld acc ountable by law and by license pr obably helps that, eve n more. When she was a sked wha t is the one thing tha t a thera pist must do to be a g ood t h e r a p i s t K a r e n h a d s a i d “ T o b e e t h i c a l . W e c a n a p p r o a c h t h i n g s t e n d i f f e r e n t w a ys and then we can a ll be g ood or we can a ll be horrible.” When she was a sked about the

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135 lin e be tw e e n g oo d a nd ba d p ra c tic e s n e a r t he e nd of the int e rv ie w, sh e sa id, “ Th e lin e is the leg ality and hopef ully the leg ality and the e thics are at the same place .” When I asked he r wha t would be the minimum that would be nece ssary for a trea tment to be above the line, she exclaimed, “The law!” The only ethical pr inciples which she ta lked about in particula r we re doing no harm to the c lient, the leg al duty to report a buse, and the leg al duty to warr ant (i.e., to re port specif ic intentions that are a specific dang er to a sp e c if ic pe rs on ). Se ve ra l pr ob e s f a ile d to fe rr e t ou t w ha t in pa rt ic ula r a the ra pis t sh ou ld be ac countable f or and w hat ethics in par ticular she r efe rre d to when she sa id “the law.” She said that in a par ticular situation that she thoug ht might involve an e thical or leg al question, it is her duty to talk with people whose job it is to interpret the law (i.e., colleag ues, super visors, and then the unive rsity attorney ). I tr ie d a dif fe re nt t a c k f or thi s to pic by a sk ing he r i f s he kn e w o f p e rs on s w ho did no t li ve up to t he sta nd a rd s o f g oo d p ra c tic e T he n s he e xpa nd e d h e r d e fi nit ion to t he se specific s: poor judgme nt in prescr ibing medic ations and cr ossing the bounda ries of friendship a nd thera py (i.e., sexual rela tionship). Her re marks on conf identiality stressed that the client holds the conf identiality and that the ther apist does not. She stressed that sh e us e s th e pr ote c tiv e me a su re of a lw a y s r e c or din g he r p ra c tic e a nd ne ve r w ri tin g a c a se note without remembe ring that they may be used in c ourt someday That her interest wa s in the leg al ar ena r ather than the ethica l is shown by the fa ct that she used the word “ law” thirty times and the word “ leg al” thre e during the interview Gail picked the acc ountability and ethics c ard to discuss ef fec tiveness of trea tment, assuring worth of tre atment eve n in terms of pay ments made, following -up the

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136 trea tment with home awar eness, pa rtnering with peer s to make re commendations, and he lpi ng the c lie nt t o a c hie ve ma ximum inp ut i n th e ir liv e s. Ga il: Whe n I pic ke d th a t c a rd I jus t th ou g ht a bo ut t ha t in the se ns e tha t I think of law. I went to an insura nce c onfer ence last wee k, and we just really tuned in to fee ling like y ou have to make sure that y ou' re trea tment is effe ctive and w orth while, and w atch wha t y our patient' s pay ing a nd, and aw are beca use we do trea tment. We'r e ve ry se ns iti ve to t ha t. E sp e c ia lly in m y a re a a lot of ps y c ho log ist s will do evaluations that don' t nece ssarily do a lot of following up with families at home (w ho are ) somewha t implementing tre atment rec ommendations. And so I think, discipli ne ac countability Even pa rt ne r w ith so me on e tha t w a nts y ou to m a ke re c omm e nd a tio ns helping maxi mum input i nto their lives, and, with this school even when we re not c ounseling So, I was just tuned into that since I ve be e n h e re T ha t' s o ne of the thi ng s I fe e l pr ou d a bo ut, a bo ut m y work he re, is that we have the ability to do that. Rick said that a ther apist is accounta ble to the client, who is the boss and consumer, e x cept in Tar as off kinds of situations (duty to protect). I asked him about relig ious ethics and prof essional ethics. He cited a c oncept, whic h he believe d from Ca tho lic tho ug ht, wh ic h c ov e re d th is f or him Rick: “The truth cannot c ontradict truth. Whatever source it’s coming from.” So, g ood scienc es, g ood ethics, g ood relig ion, goodany thing, e ventually leads the sa me place Rick: Misunderstood. I f there appea rs to be a c onflict, betwe en, twwo source s, of truth. -g ot something wr ong with one of them. You know? Mike: Yea h Rick: You know. Mike: y eah Rick: So, y ou either misunder stood, the theolog y or, y ou misunderstood, the ethica l principles. Uh and tha t’s—I don’t try to.

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137 Having said that, Rick mentioned that he wa s not a member of the Amer ican Psy cholog ical Associa tion “prec isely beca use of their ethics.” I asked a bout the Americ an Psy cholog ical Society which includes A PA members, but is more rese arc h—oriented. H e said he was not a me mber of a ny of them. His problem with the APA wa s th a t Rick: My problem, in short with the APA is, that, like far too many o t h e r p r o f e s s i o n a l o r g a n i z a t i o n s t h e y s t r a y way bey ond, their ar eas of compe tence And, g et into things whe re, the y should not be speaking And then, uh re g ardle ss of, abortion, re g ardle ss of the a bu se on a bo rt ion s, wh e the r y ou ’r e pr olif e or pr oc ho ic e th e APA shouldn’t have a position on t hat, y ou know. . And, y ou know, the APA wo uld be a lot mor e e ff e c tiv e if it c on c e ntr a te d o n w ha t it do e s, ins te a d o f t ry ing to m or ph int o s ome ty pe of po lit ic a l a c tiv ist org anization. Z oe no te d th a t th e e thi c a l st a nd a rd s o f t he ra pis ts a re sim ila r b ut n ot n e c e ssa ri ly in ag ree ment to the level of staunc hness to which she holds the injunction ag ainst entering into a social re lationship with a client “Until death y ou do part.” She had ethica l “conc erns with sug g estibilit y —to be “stra ight f orwa rd” w ith the client and re fra ining fr om u sin g su g g e sti bil ity to s ug g e st t hin g s th a t you thi nk a re ri g ht f or the c lie nt. She fe lt that the ethics of c onfidentiality should be seconda ry to protecting the client fr om selfha rm or ha rm to o the rs Sh e wa s a lso g la d th a t e ve ry tw o y e a rs fo ur ho ur s h a ve to b e in the e thi c s o r f or e ns ic a re a F ina lly ma ny tim e s sh e sp ok e of the e thi c s o f s ta y ing wi thi n y our re alm of expertise in thera py g ained throug h formal tra ining a nd y our super visor’s e xpe ri e nc e Z oe re la te d, “ I thi nk it’ s u lti ma te ly the tr a ini ng pr og ra ms . [ed uc a tor s] sh ou ld t a ke mor e re sp on sib ili ty fo r s c re e nin g ou t pe op le wh o a re ps y c ho log ic a lly un fi t to serve as thera pists or counselors.”

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138 I n his role as a fore nsic psy chiatrist, B en had e ncounter ed ther apists who ”have crosse d the line—taken a dvantag e of the ir thera peutic role in sex ual way s.” He acte d as a n e va lua tor a nd so me tim e s sa nc tio ns we re a dmi nis te re d, inc lud ing los s o f l ic e ns e to pr a c tic e a nd e ve n lo ss o f a ff ili a tio n w ith the loc a l me dic a l bo a rd in p sy c hia tr y Wh ile it wa s h is i mpr e ssi on tha t it wo uld e ff e c t li c e ns ur e in o the r s ta te s, e ve n th is p sy c hia tr ist who was pa rt of a tr aining prog ram for psy chiatry was not sure When I asked if he had eve r re ported a nother ther apist for bre ach of ethics, B en said that he ha d not. He said that in one instanc e he ha d considere d doing so in a confide ntiality matter, but had not. Be n: I think if y ou talk to any clinician, they know of pe ople that have do ne thi ng s th a t th e y sh ou ldn ’t a nd ha ve . a nd ha ve n’ t r e a lly be e n r e pr ima nd e d s uf fi c ie ntl y a nd the y ’r e sti ll e ng a g e d in tho se activities and y ou know it’s a sour taste in ever y one’s mouth. And at the same time y ou don’t want a n outside org anization y ou know imp os ing it’ s w ill on o n y ou Y ou wa nt t o k e e p y ou r a uto no my int a c t. When asked a bout acc ountability and ethics, Jack spoke of stepping over the line with some therapy prac tices. Jac k: Rig ht. Th e re s p ro ba bly no g re a t bl a c k li ne bu t ( sn or t la ug h) I in g e ne ra l . a g a in, ve ry ba d to ha ve a ny kin d o f r e la tio ns hip wi th patient, or pa tient's dire ct fa mily members a t any point. J ust give n the nature of wha t we do in psy chiatry it's just too. . I n a rela tionship t he idea would be for an equa l balance of powe r. And I see tha t if a patient ha s come to y ou in the doctor/patient rela tionship, be now or ten y ear s ag o, that balanc e of pow er ha s been tipped a nd it's not eve n. Pr of e ssi on a l e thi c a l g uid e lin e s p ro hib it a re la tio ns hip wi th a fo rm e r p a tie nt. Th is involves being available as a the rapist for the future a nd not providing c onflicting

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139 m es s age s ab o u t t h e t h er ap y o f t h e p as t Fr o m h i s p s y ch o an al y t i c p er s p ec t i v e, J ac k 's e mbr a c e me nt o f t he pr oh ibi tio n h a d a log ic a l e le me nt a s w e ll. J ack: By nature what we do is talk about how past re lationships and ex p er i en ce s t h at ar e a ff ec t i n g o u r c u rr en t s i t u at i o n An d s o I d o n 't se e it a s f a ir fo r u s to sa y ‘Y e s, wh a t ha pp e ne d to y ou a s a c hil d from y our par ents is affe cting how y ou act now, but wha t y ou and I we n t t h ro u gh t en y ea rs ago i s n 't af fe ct i n g y o u ri gh t n o w. T h at i t 's no t." . . [I t] sw a y s y ou r d e c isi on ma kin g So I do n' t se e tha t a s a fair e x clusion. So I g ener ally fee l there' s a lifetime . . J ack f elt that there are a number of pra ctices w hich a ther apist or a phy sician ca n do that are bad pra ctices. Exploiti ng the patient for phy sical or moneta ry g ain—cr eating depende ncy Another w as neg lect of issues whic h would help the patient. Althoug h he did not use the word “ ag enda,” he spoke of apply ing the thera pists own “bag g ag e” to the patient. He a lso was conc erne d about bre ach of confide ntiality but rec og nized that the new c limate that require d repor ting to HMOs a nd insurance had cr eate d a “tr icky ” issue. J ack: For example having a patient c ontinue in therapy when y ou fee l like y ou' re not re ally improving tha t patient. Jac k: I ha ve ru n in to p a tie nts a nd ph y sic ia ns p sy c hia tr ist s, tha t w ill continue patients in thera py even thoug h they are not rea lly doing thera py and it' s. . They ve almost kind of turned the tables and the y re —th e y ve c re a te d a de pe nd e nt s itu a tio n. So t he pa tie nt i s almost depende nt upon seeing the psy chiatrist. So they know that they will continue to come. Jac k: I thi nk ne g le c tin g a n a re a th a t, w ou ld h e lp t he pa tie nt u h b e c a us e of some of my bag g ag e. that I bring into the therapy room with me. F or e xamp le : on e of the iss ue s th a t a lw a y s se e ms t o c ome up wi th some of the r esidents that I train, is sexualit y issues. I f a pa tient c o m e s t o t h e m a n d i s h a v i n g s o m e i s s u e s w i t h t h e i r o w n s e x u a l i t y . the example that' s alway s, broug ht to mind i s somebody that has been ma rried f or a little while and is now thinking that may be they have some homosex ual tendenc ies. They come to ther apy thinking that they ll fix this. that they can just g et throug h this and g et rid of

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140 these c razy thoughts. Well, that shouldn't be the g oal of the the ra pis t. T he g oa l of the the ra pis t sh ou ld n ot b e to g e t r id t he se h o m o s ex u al t en d en ci es T h e t h er ap i s t n ee d s t o h av e a t h o ro u gh understanding of that patient. Tha t doesn' t mean that eve ry patient that comes to us is g oing to be come a homosex ual, but, it means that y ou need to talk to the pa tient and find out what it is that they actua lly . . Mik e : Whe re the y fi t? J ack: Ex actly Where they actua lly belong and whe re the y fee l like they belong I t's not wha t I think they need to do, it' s what they think. they need to do. So I think—be it through omission, voluntary omission, or from a lac k of knowledg e—I think bringing our own bag g ag e into the thera py room and then dire cting our trea tment. I think that y ou are allowing y our own pe rsonal belief s, to interfer e with what y ou' re try ing to do in ter ms of helping that patient. They do n' t li ve by ou r c od e N ob od y liv e s b y my c od e e xce pt f or my se lf and so it' s unfair. M.S.W.s on Accountabili ty and Eth ics The re sponses of the L CSW s to the subject of a ccounta bility and ethics w as int e re sti ng in i ts s c op e A my wa s c on c e rn e d w ith he lpi ng pa tie nts be c ome a c c ou nta ble fo r t he mse lve s. She did no t ha ve re a dy a ns we rs to p ro be s a bo ut t he ra pis t a c c ou nta bil ity and virtually ignor ed probe s on ethics of ther apy prac tice. This topic appe are d to provide a tra nsition poi nt in the interview with L arr y His chang e of posture and re sponses sug g ested that he felt that this was an a rea which re quired c aution in his responses. He int ro du c e d th e su bje c t of [wh a t I te rm ] pe e r r e vie w. Will p ro vid e d tw o d ir e c tio ns in h is response s. He wa s very much in favor of attention to the state boa rd and w as ada mant about the re sponsibili ty of the ther apist to put an end to thera py sessions when ther e is no fu rt he r i mpr ov e me nt. B e tty o n th e oth e r h a nd a pp e a re d to ha ve c on sid e re d th is t op ic in some depth. She re fer red to it in sever al place s during the interview befor e and a fter

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141 be ing pr ob e d a bo ut i t in g e ne ra l. S he inc lud e d r e fe rr a l of the c lie nt t o s ou rc e s o f h e lp ou tsi de the the ra py se ssi on s a s a re sp on sib ili ty of the the ra pis t. P h.D.s on Accountabil ity and E thics Ed uc a tio na l c ou ns e lor Ka re n h a d f it e thi c s a nd a c c ou nta bil ity wi thi n a le g a lis tic and ethica l frame work. To be a g ood thera pist, to determine whethe r thera py prac tices a re g oo d o r “ ba d, ” or to d e te rm ine wh e re the lin e is b e tw e e n g oo d o r b a d tr e a tme nt— a ll wer e dete rmined first by the law a nd then by the ethica l standards of the profe ssions. For Gail ef fec tiveness of tre atment, worth of tr eatment, pa rtnering to ensure be ing as ac countable a nd ethical a s possible, doing followups to ensure tre atment was e ffe ctive a n d e n d u r i n g a n d h e l p i n g p a t i e n t s a c h i e v e m a x i m u m i n p u t i n t h e i r l i v e s w e r e a l l w a ys that ethics and a ccounta bility wer e pra cticed. She did not re fer to acc ountability to the la w. She wa s c on c e rn e d w ith a c c ou nta bil ity to p a tie nts a nd to h e r c lin ic c ow or ke rs Rick talked about be ing a ccounta ble to the client and to those w ho might be harme d by the client. He was a lso acc ountable to his relig ious beliefs. He felt that the national org anization, the APA, had transc ended the ethical manda te of ther apy and wa s i n t ru d i n g i n m o ra l ar ea s wh er e i t d i d n o t b el o n g. Z oe spoke of the injunction ag ainst entering into a social re lationship with a client in p e rp e tui ty g ua rd ing a g a ins t c lie nt s ug g e sti bil ity b e ing str a ig ht f or wa rd wi th t he c lie nt, maintaining c lient confidentiality unless self-ha rm or har m to others might ensue stay ing within ones rea lm of expertise in therapy and kee ping up w ith the latest techniques a nd standards of ones discipline. She also mentioned the a ccounta bility of the discipline

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142 training prog rams to take r esponsibility for sc ree ning out pe ople who ar e unfit to serve as the ra pis ts o r c ou ns e lor s. M.D./P h.D.s on Accountabil ity and E thics Be n spoke of the la ck of suf ficient sanc tions for thera pists. He noted that thera pists who should chang e their pr actice s have not. Jack fe lt that ex ploitation of the patient in any way and neg lect of issues whic h would help patients we re of major importance He a lso spoke of the e thical problems re lated to conf identiality due to the n ew s o ci al cl i m at e t h at t h er ap y i s co n fr o n t i n g.

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143 CH APT ER 9 L EG AL I SSU ES A ND TH ERA PY The a ttribution of deviance whether of par ticular ther apists or of tre atment prac tices, is manifest in cha ng es in the ethica l standards a nd in the imposit ion of laws that aff ect the pr ocedur e of the rapy This is often a re flexive process, but re cently laws ar e influencing thera py prac tices more tha n prac tices ar e lea ding to c hang e in laws. F orce s ou tsi de the ins tit uti on s o f S ta te a nd Me nta l H e a lth ha ve up se t th e ba la nc e O ne of the se forc es is the public exposure of the f act that psy cholog ical theor ists are e ng ag ed in a polemical disag ree ment about re pression of memor y and re g ression thera py A re lated forc e is the drive to c odify heig htened ideolog ical conc erns a bout child abuse. Combini ng these two for ces be came one of the main thrusts for the implementation of g round-br eaking leg al ruling s which ar e now in some wa y s eff ecting the pra ctices of mental hea lth providers. My rese arc h focuse s on three le g al issues: licensure and ce rtification of thera pists; t he Ra mo na v I sa be lla case (which f irst provided for thera pists’ tort responsibility to third parties); and the fede ral law mandating the re porting of suspec ted a b u s e f i r s t e n a c t e d i n 1 9 7 4 [ C h i l d A b u s e P r e v e n t i o n a n d T r e a t m e n t A c t ( C A P T A ) ( P L. 93-247) a nd last rea uthorized on J une 25, 2003, by the Kee ping Children a nd Fa milies Safe A ct of 2003 (P.L 108-36)]. Additionally the subjects ar e probe d reg arding any oth e r l e g a l is su e s th a t th e y mig ht c on sid e r i mpo rt a nt f or the ir pr a c tic e s o r f or the ra py in g ener al. While refe renc ed by name by only two thera pists, the Tarasov v. Rege nts of the

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144 Un iv e rsi ty of C ali for nia case (1976) ( which provide d for ther apist liabilit y in case s where po ssi bil ity of ha rm fr om c lie nt h a s b e e n r e ve a le d d ur ing the ra py ) w a s th e on ly oth e r c a se which wa s mentioned. I was intere sted in how much vulnera bility thera pists felt from the new leg alities wh ic h w e re a ff e c tin g ma ny of the the ra py pr a c tic e s, a s o utl ine d in pr of e ssi on a l jo ur na ls, and that ofte n have be en assoc iated with re g ression thera py and re presse d memories of CSA. One of the c riteria f or potential interview ees w as that they had bee n cer tified or licensed since the Ra mo na v I sa be lla c a se in 1 99 4. As su c h, the y we re a mon g the fi rs t cohort of the rapists that would have to consider the le g al ra mifications that it entails. I wa s in te re ste d in dis c ov e ri ng wh e the r t he the ra pis ts h a d d on e a ny thi ng in s e tti ng up the ir pr a c tic e s th a t w a s d ir e c tly or ind ir e c tly re la te d to the se le g a l de ve lop me nts Reflexively I was a lso interested in how ther apist attitudes, rea ctions, and inn ov a tio ns in fl ue nc e d b y c on sid e ra tio n o f t he le g a l r a mif ic a tio ns mi g ht i n tu rn po ssi bly act to influenc e fur ther c ertifica tion, licensing, a nd leg islation chang es. The le g al re sp on se to t he dis c ou rs e on re pr e ssi on a nd re g re ssi ve the ra py ha s a lr e a dy pla y e d a ro le in chang ing the lang uag e of r ece nt state laws on tort (i.e., f or the fir st tim e re cog nizi ng thirdpa rt y la ws uit s a g a ins t th e ra pis ts) to lli ng the sta tut e of lim ita tio ns (e .g ., a c c or din g to wh e the r a me mor y of c hil d a bu se ha s b e e n s up pr e sse d o r r e pr e sse d) le g a lly a c c e pta ble tr e a tme nt p ra c tic e s ( e .g ., un de r w ha t c ir c ums ta nc e s c a n a c lie nt t e sti fy a ft e r h y pn os is, psy choac tive drug trea tment, guide d imag ery etc.) and on the use of thera pists as ex pert witnesses (e .g confide ntiality require ments and per sonal ag endas) I used the qua litative resea rch me thod of open intervie w with four L icense d Clini cal Social Worker s with MSW deg ree s, one Educa tional Counselor with a Ph.D.,

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145 three Clini cal Psy cholog ists with P h.D.s, and two psy chatr ists with M .D.s and Ph.D.s. This method allowed maximum disclosure with minimal chanc e of c ontamination by the interviewe r. The intervie wed ther apists were very reluc tant to define f ellow thera pists as deviant. Eve n when they would cite a br eec h of ethics that they knew a bout, they moved to a dd re ss h ow tha t ba d b e ha vio r m ig ht b e c ha ng e d r a the r t ha n f oc us ing on wh a t sh ou ld be do ne wi th t he the ra pis t. T he be ha vio r w a s d e e me d d e via nt, bu t no ne of my int e rv ie we e s w ou ld l a be l th e the ra pis t a s d e via nt o n e ve n th e te c hn iqu e s. I t w a s th e re su lt which wa s so descrie d. Fa ulty or inappropr iate socia liz ation of the ther apist had produce d an outcome in whic h the client’s sug g estibilit y was e x ploited. This was rela ted as a fix ab le pr ob le m. The na tional org anizations and, to an extent, the courts wer e looked to for definition of who is deviant. The national org anizations could, and on occ asion had labeled some thera pists as deviant. The sa nctions imposed could rang e fr om a nasty letter of conde mnation to a temporar y suspension of ce rtification. An e x amination of lexi s/nex us and other inter net sea rch e ng ines found no cr iminal indictments t hat wer e based on ha rm done fr om a thera pist’s deviant use of the client’s/patient’s sug g estibilit y No ind ic tme nts we re e xpos e d in the hu nd re ds of a rt ic le s o f s oc ia l sc ie nc e jou rn a ls revie wed in re sear ching this topi c, nor w ere any reve aled in the popular media. Howe ver, in c ivi l c ou rt to rt sa nc tio ns we re imp os e d o n s ome the ra pis ts. Cer tification an d Li censure Ea c h o f t he c lin ic a l so c ia l w or ke rs fe lt t ha t th e re sh ou ld b e a t le a st s ome c ha ng e in licensing and ce rtification of the ir discipline. Amy was c oncer ned that the law s

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146 g overning her pr ofession we re not be ing stre ssed enoug h during training Amy noted that the L CSW national licensing exam was comprised of two parts: a law s and rules e x am a nd the na tio na l c lin ic a l e xam. At the un ive rs ity s he sa id, la ws we re no t c ov e re d s o muc h a s e thi c s, so c ia l w e lf a re a nd fa mil y c ou ns e lin g H e r m e nta l he a lth c on c e rn a s a social worke r appe are d to be entire ly encompa ssed by her de sire to per form the duties a nd responsibilities of a wa rd re source manag er. When ther e we re pr oblems which the patient had or might enc ounter, she w ould recom mend to t he a tte nd ing ph y sic ia n a c ou rs e of ac tion which that doctor c ould act upon or ig nore. L arr y was ba sically satisfied with the wa y cer tification and lice nsure is now done but felt that there should be some streng thening at the national leve l and supervision at the loc a l le ve l. T his L CSW no te d th a t “ g oo d a s my he a rt a nd int e nt w a s p ri or to m y fo rm a l tr a ini ng a nd lic e ns ur e ,” he wa s n ot a s f it, su ita ble a nd c a pa ble a s h e pr e se ntl y deeme d nece ssary to be g uiding the me ntal health of othe rs. L a rr y : So I c le a rl y thi nk the re sh ou ld b e ri g or ou s li c e ns ing pr oc e du re s. T h e t e c h n i c a l d i f f e r e n c e b e t w e e n c e r t i f i c a t i o n b e i n g s o m e b o d y, body of people that' s familiar with the standa rds of the pr ofession a re sa y ing to a sta te a g e nc y wh o li c e ns e s y ou tha t th is p e rs on is f it and they are suitable, and their lice nsure be ing the actua l g overnme nt body rec og nizi ng that capa bility and for mulating how y ou exercise it. L a rr y : I n my fi e ld, the NC E, the Na tio na l Co un se lor Exa m, I thi nk is administered to all thre e disciplines within L ine Statute 491 that we' re unde r, and tha t seems to provide some c ommon thread throug hout. Fee ls like . y ou' ve g ot the national, y ou' ve g ot the s t at e, an d t h en y o u 'v e go t t h e v ar i o u s as s o ci at i o n s s o rt o f b ri d ge that. I like how that is rig ht now. I don' t think I can g ive a more definitive answe r.

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147 Whil e in g ener al L arr y thought that ther e could be some streng thening of standards a t a national leve l, he was sa tisfied with the way the social wor k discipline approa ches c ertifica tion and licensure now. Will w a s mu c h le ss s a tis fi e d th a n th e oth e r L CSWs. He fe lt t ha t th e dy na mic controlling the direc tion of the discipline was the influe nce of the power of money He was c oncer ned about the pr esent c ondition of licensure: Wil l: You have the L PCs, t he license d profe ssional counselors . which includes a lot of things. Ahh, I don’t know the whole . they went throug h, a number of y ear s ag o, a big g randf ather deal. Th e y wa nte d to e xpa nd the ir tr ip. So t he y g ra nd fa the re d in ever y body and their dog with a B .A. or, uh, I don’t eve n know wh a t th e ir c ri te ri a a re b ut I kn ow if y ou a re if y ou ha ve a n M .A in ps y c ho log y w hic h is a bo ut a s y ou kn ow ‘ Wha tta y ou do wi th tha t?’ Wel l y ou be c ome a n L PC. Y ou g e t that cer tification, licensure and that allows y ou do to some> Mike: You ca n g et licensure too? Wil l: Oh y eah. L PC, l icense d profe ssional counselor. The y have a uh I mean that’ s uh I don’t know the whole orig ins of it, but it allows pe op le wi th e du c a tio n d e g re e s, pr ob a bly e ve n s oc iol og y de g re e s. Wil l was also conc erne d that training to be a soc ial worke r has be come more a c a de mic tha n c lin ic a lly or ie nte d. I a sk e d Wil l if he tho ug ht t his is a pr ob le m? Wil l: Uhhh, Not nec essar > I think it's probably the whole, y ou know, that, that doesn' t gua rante e any thing. My understanding was that psy chiatrists have very intensive, psy chother apy y ou know, they g o throug h all this . big ty pe > Mike: They have lots of hour s W i l l : > t ri p an d ev er y t h i n g, b u t I d o u b t i f c l i n i ca l p s y ch o l o gi s t s go throug h. . I mean they may test them. I mean I don' t know. But I k n o w s o ci al wo rk er s ar e n o t re q u i re d t o d o t h at T h e> t h er e's supervision, is the main thing. And, he ll, it's like any thing e lse, y ou kn ow y ou g e t a de g re e or y ou g e t a lic e ns e a nd a ll t ha t do e s is put y ou in the ball g ame. . The n y ou start lear ning ( laug h).

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148 Throug hout our discussion of ce rtification and lice nsure, Will noted the influence of money on what is done, whe ther the subjec t be re g arding who g ot/ge ts certifie d and lic e ns e d, wh e the r t he re sh ou ld b e su pe rv ise d th e ra py se ssi on s d ur ing tr a ini ng w ho g e ts third-par ty pay ments [i ..e., fr om HMOs or insuranc e compa nies], or whether ps y c ho log ist s sh ou ld p re sc ri be me dic ine O ne e xamp le fo llo ws : Wil l: You know, y ou have a state boar d—there ’s a c erta in thing. Tha t’s le g isl a te d a nd uh th e re I wa s e mpo we re d b y the sta te a nd it’ s a lso . it ’s e mpo we re d to uh be pu nit ive if ne c e ssa ry y ou kn ow to sanction, and uh a nd all that. But it reg ulates the ong oing uh, profe ssional life of the pr ofession, if y ou will. You know. How much educ . continuing e ducation y ou need. U h, the ethics. The ethics ar e leg islated, and uh so, y ou know, it’s it’s . raises the level of a ccounta bility and, empowe rs the prof ession. The more y ou’ve g ot of that the more pow erf ul y ou, y ou know, y ou are Mik e : Um hm. W i l l : U h i t c o m e s b a c k t o t h e m o n e y. L CSW B e tty wa s th e mos t po sit ive a bo ut t he ne e d f or na tio na l li c e ns ur e of a ll me nta l he a lth so c ia l w or ke rs Sh e us e d th e na tio na l li c e ns ur e e xam o f a c up un c tur ist s with state licensing [due to state laws for diff ere nt professions] as an example which c ou ld b e se t up Sh e fe lt t ha t th e pr of e ssi on a l a sso c ia tio ns sh ou ld d o th is w ith so me reg ulation from a g overnme nt org anization, such as the De partment of H ealth. Be tty : I think social worker s should be nationally licensed—doc tors—, a nd ma y be the y ne e d to jus t ta ke a re fr e sh e r c ou rs e or wh a te ve r i n the state they ’re g oing to be prac ticing, so the y know the laws of that state. B eca use the law s are differ ent, in some way s . for eac h of the prof essions. When Kare n was in a N orthea stern city this P h.D. in Educa tional Counseling had be e n c e rt if ie d b y the Na tio na l B oa rd of Ce rt if ie d Co un se lor s, bu t th e re wa s n o s ta te licensing that state. She had be come lice nsed subseque ntly when she reloc ated to the

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149 Southern state whe re she now pra ctices. I asked he r if she thoug ht that there should be n a t i o n a l l i c e n s u r e i n a d d i t i o n t o d i s c i p l i n e c e r t i f i c a t i o n a n d s h e r e s p o n d e d e m p h a t i c a l l y: Kar en: No. No, I think licensure by state is okay I think it keeps people a lit tle mor e a c c ou nta ble to t he la ws of the sta te F ir st o f a ll i t' s g ot a littl e bit more tee th. I mean they pull my license if the national bo a rd of c e rt if ie d c ou ns e lor s p ull e d my c e rt if ic a tio n a nd my licensure board f ound out about it. I mean if I didn't tell them a bo ut i t. T he re s a c ha nc e tha t I c ou ld p ra c tic e bu t . if I g e t my license pulled in [her pre sent state], I can' t prac tice. I mean licensure s g ot highe r standar ds and stricter standards by law than c e rt if ic a tio n. So I thi nk it' s im po rt a nt. I thi nk lic e ns ur e by sta te is okay Gail expressed dismay that people we re c alling the mselves psy cholog ists without even ha ving a deg ree in psy cholog y whether Ph.D. or PsiD. Ga il: I fi nd my se lf e xtre me ly dis ma y e d, by w ha t th e ra ng e is o f p e op le that can c all themselves, psy cholog ists. I mean, I ’m not even any more[? ], but I do know, uhm, I reme mber re ading rec ently I do n’ t e ve n th ink y ou ha ve to h a ve a uh u hm, Mike: PsiD? Ga il: Ye a h, I do n’ t th ink y ou do to b e a ps y c ho log ist I asked if she thought that just any body should be able to do ther apy Gail thoug ht tha t th e re sh ou ld b e lic e ns ing wh ic h s ho ws tha t th e the ra pis t ha s g on e thr ou g h c ou rs e work, super vised clinical e x perie nce, a nd mentoring She would like for ther e to be a way to tell ex actly what one’ s specialty in psy cholog y is so that clients could select the ty pe of ps y c ho log ist ba c kg ro un d ma tc he s th e ir pr ob le m. S he ru e d th a t so me psy cholog ists who are pr oficient in testing or other psy cholog ical ar eas a re doing thera py wh en t h ei r t ra i n i n g m i gh t n o t h av e i n v o l v ed co u n s el i n g. Mike: I want to g et bac k to licensing and, ce rtification. What do y ou think shou-. Do y ou think>

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150 Gail: No. I think that y ou should have to be lice nsed and I do think that it’s uh, it’s an important part of tra ining that y ou have in y our course work a nd, clinical experienc e that’s supe rvised and y ou know and a lot of mentoring And what I would like, eh that I don’t lik e in m y fi e ld o f p sy c ho log y is t ha t y ou c a n g e t li c e ns e d, bu t, i n psy cholog y y ou can ha ve a r ang e of, tra ining ba ckg rounds to g et licensed a s a psy cholog ist. And I rea lly think y ou know, just like if I ’m g oing to a phy sician’s a ssistant versus an RN, y ou know, I might alr eady know some of wha t those training differ ence s are and I might be c omfortable g oing to one just as another, or there m i g h t b e t h i n g s w h e r e I’ d g o t o o n e a n d n o t t h e o t h e r B u t I know what ea ch of the m is, and I think sometim es uh, it’s a proble m for instance w hen y ou have the term ‘psy cholog ist’ but someone’s training can be rea lly varia ble. and y our not nec essar ily g onna kn ow w ha t th e ir ps y c ho log ist a re the y d o th e y ha ve a do c tor a te in counseling do they have uh uhm a Ph.D., y ou know? Mike: Yea h Gail: Ex actly what is their bac kg round. Mike: Do they g ive Stanford B inet tests. orG a i l : U m h m m E x a c t l y. Rick had quite a diff ere nt idea. Similar to W ill, he considere d the ec onomics of his profession. Rick said that licensing was primar ily a re straint of trade He pr efe rre d a sy ste m w he re wo rd of mou th w ou ld p ro vid e inf or ma tio n f or c lie nts to m a ke c ho ic e s a s to wh ic h th e ra pis t to us e H e fe lt t ha t li c e ns ing do e s n ot w or k a nd mig ht g ive pe op le a fa lse sense of comfort that the lice nsed ar e prof icient in thera py when some of the leg al ca ses ha ve pr ov ide d e vid e nc e tha t so me of tho se lic e ns e d a re no t. Rick: I n essenc e, the whole licensing proce dure is simply a uh uh uh uh a fanc y leg al re straint of trade prac tice. Uh uh. I f y ou’re g ood, y ou ’r e g oo d, if y ou ’r e ba d, y ou ’r e ba d. An d h op e fu lly pe op le wi ll fig ure it out at some point. uh, does licensing work for me? Can I c ha rg e mor e be c a us e I a m? Surr re u h u h A t a p e rs on a l le ve l, w o u l d I l i k e t o s e e l i c e n s i n g g o a w a y? I, I’ m p o o r e n o u g h a l r e a d y, I pr ob a bly wo uld be po or e r w ith ou t it [la ug hs ] B ut a t a c e rt a in philosophical level. I think it. I t a.) re ally doesn’t wor k and b.) I

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151 think in certain c ases it might g ive people a false se nse of c omfort. You know the the, the Ramona case the Tar as off case all the oth e rs y ou ta lke d a bo ut, pr e su ma bly we re with licensed pr of e ssi on a ls. He f elt that if licensing was no long er r equire d that there would be abuse s for a while, but then people w ould learn to a sk around to dete rmine who is g ood at helping with the problems they have. Rick: I think, if y ou took away licensing today uh tomorrow and f or, probably for f orese eable future the re w ould be a lot of a buse. Be cause people ha ve bee n so trained to have some body else prote ct them and take car e of the m that they ’re they ’re they ’re not, us e to it. Uhh, probably won’t be in e ither one of our life times that thi ng s w ou ld g e t ba c k to no rm a l. B ut o ve rtim e p e op le wo uld lear n that, -y ou ask ar ound. and y ou find out and y ou g et, g ood word of mouth. and y ou don’t trust somebody just because they ca l l t h em s el f s u ch an d s u ch b u t b ec au s e y o u h ea rd go o d t h i n gs about them. The be nefit he sa w from lice nsing w as that it provided an e x tra push to continue the thera pists education. B eca use licensing require s a ce rtain number of course s eac h y ear licensing reinfor ces ne cessa ry continuing e ducation despite individual diffic ulties tha t mi g ht o the r w ise le a d a the ra pis t to sk ip t ho se c ou rs e s. Rick: As silly and trivial as it bec omes in civil service I have to sa y one of the g ood things a bout licensing is that they are able to enf orce cer tain standards. B ut ag ain, if in some way that people know tho se sta nd a rd s a re e nf or c e d, it h e lps the ma tte r. An d th e y a re a ble to enforc e, ce rtain thing s like, doing c ontinuing educ ation. y ou k n o w a h e v e n t h o u g h s o m e o f t h e c o u r s e s yo u g o t o a r e r e a l l y a joke. uh uh, just there to g et y ou an hour or so[? ]. At l east, ke eps y ou a t le a st p re te nd ing to b e loo kin g [la ug h]. I f y ou ’r e . if y ou’re either busy or broke or wha tever and for whateve r re ason y ou kn ow wa nt t o g e t to it o the rw ise a nd sa y “ No w n e e d to g e t my fiftee n hours in this y ear Uh in fairne ss apply it to me. You know, I g ot my fiftee n hours this y ear and bec ause I neede d it for the license y ou know, and I didn’t have the uh the money ’s bee n tight and pr obably wouldn’t have g one other wise.

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152 When I asked a bout cer tification and lice nsing, Z oe first talke d about the nee d for continuing e ducation to make sur e that people keep the ir skills up t o date. She wa s please d that with the require ment to take thirty hours of tra ining pr og rams eve ry two y ear s, but thought that licensing boards do not have enoug h information about the menta l health of the rapists except in very blatant ca ses. I hy pothesized that a psy cholog ist who had bee n censur ed by the licensing board of one state could just go to the ne x t state and be come lice nsed there I then aske d whether there should be some kind of national a nd Z oe supplied the wor d “re g istry .” She said “I think they ’re I think they ’re talking a bout doing that a nd y et. . I think we do need to, to do that. B y the time y ou g et y our license revoke d, there is some pr e tty heavy du ty e vid e nc e th a t y ou sh ou ld [l a ug h] ha ve y ou r l ic e ns e .” She no te d th a t in a dd iti on to the licensing by state that the APA ha s an ethics boa rd. When I asked a bout supervisory responsibility Be n mentioned that the Amer ican Psy chiatry Association is self-monitoring “kee ps itself in line.” We had bee n talking a bo ut d oin g no ha rm a nd I a sk e d h im w ha t is the job of his pr of e ssi on a t th e na tio na l, sta te a nd loc a l le ve ls. Be n: Well, at a national level I think there ne eds to be uh um, a c ode, there needs to be a ce ntral, uh uh Mike: L ike its ethical code ? Be n: Ex actly That eve ry one ag ree s to and that eve ry body can a bide to. Ex actly And then as y ou g et smaller a nd smaller y ou g et more a nd more loca l. I think uhm y ou just need to consider the ra mifications of a pp ly ing tha t c od e to t ha t pa rt ic ula r a re a A nd y ou ne e d to adjust things slig htly So, within t he fr amewor k of that code there may be some pa rticulars tha t that code wa sn’t awa re of beca use of y our ar ea tha t y ou do business in.

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153 I me nti on e d th a t ps y c ho the ra pis ts i n N e w Y or k Ci ty f or e xamp le d o n ot h a ve to be ce rtified or lice nsed and a sked wha t he thoug ht about acc ountability and sanc tioning acr oss the entire institution of mental health. Be n: Certainly Well, y ou know y ou’re talkin’ to somebody who’s spent four y ear s in medical school and f our y ear s in a reside ncy and another y ear of additional training outside my residenc y So of course I ’m g oing to wa nt other people to have a dequate training and super vision before they attempt to do the same thing I that I ’ve been tr ained to do, and it’s not just cause I g et a M.D. tha t e ve ry bo dy e lse sh ou ld h a ve to d o it B ut I thi nk tha t it is r e a lly i m p o rt an t t h at I wa s i n s t ru ct ed . t o s u p er v i s e w h at I ’m d o i n g. Be cause I ’m impacting other pe ople and ther e is. . I t can be do ne ina pp ro pr ia te ly a nd c a n a c tua lly c a us e ha rm if y ou do it inappropria tely so I want that ac countability acr oss the board. Uh m, t he re a re dif fi c ult ie s th a t a re e nf or c e d in tha t a c c ou nta bil ity a nd ho ldi ng e ve ry on e to t he sa me sta nd a rd s. B e n: I ’d lov e to h a ve so me ty pe of so me ty pe of na tio na l r e qu ir e me nts for, f or training and super vision and making sure, making sure ever y one is abiding by some principles that would make sure that the the ra py is d on e a pp ro pr ia te ly T he re a re so me lim ita tio ns in asking for that. I t’s g onna cost pe ople to g o throug h that training at the sa me le ve l I did T he re ’s th e re ’s so me ma jor sa c ri fi c e s in doing tha t and we’ re a lrea dy at a de ficit for me ntal health as f ar a s car e g ivers ar e conc erne d. We’re putting more re quirements and demands for the training that’s involved and, a nd the way that people a re doing the thera py is lim ited more. I ’m just concer ned that y ou may uh cause that defic it to increase Mike: Yea h Be n: L ess people w illing to help in the mental hea lth area So I think y ou have to ba lance what I want as a as a tra ined and supe rvised clinician, the r ealities of a . out in the field, and the suppor t that we ha ve to provide me ntal health tre atment. I rela ted that New York City and some other place s did not require c ertifica tion or licensing for psy chother apy and aske d what Jack thoug ht of ce rtification and lice nsure. He c onsidered its importance from the standpoint of the junc ture of the body and the

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154 mind. That same per spective is shown in his discourse on psy chiatrists as ther apists who h av e b o t h t h e m ed i ca l s i d e a n d t h e t h er ap y s i d e c o v er ed b y t ra i n i n g. J ack: I think if any thing, I d have to sa y more towa rd having it reg ulated in s ome fo rm T he re a so n b e ing tha t> I me a n, the re s w e ll documented studies that ther apy can c hang e bra in chemistry the same wa y that our medicine s, medications do. So, it's not just, ‘I t h i n k a l o t o f p eo p l e h av e t h i s b en i gn i d ea t h at o r t h i s i d ea t h at i t 's a benig n thing that y ou just talk to people and y ou can' t do any damag e.’ B ut that is definitely not the case You ca n do just as much damag e as g iving somebody the wrong medication and not following them. And so I think that having it re g ulated would be a n im po rt a nt t hin g to p re ve nt, jus t th a t. f ro m so me bo dy wh o ju st needs to make some money g oing out a nd hang ing up a shingle and becoming a psy chother apist (bre ath) uhm and the y can do mor e damag e than, g ood. J ac k : R i gh t W el l I t h i n k as a p s y ch i at ri s t t h er e a re s o m e, go o d t h i n gs obviously I mean this is what I do (both laug h) so I I fee l, I felt for me at lea st that this was the best choice For me, I think one of the strong er suits of psy chiatry is we consider not just t he, the thera peutic> the thera py side of the pa tient. Uhm but we also look at the biolog ical side. So, I m trained a s a medica l doctor, so I have a g ood understanding about diabete s, high blood pre ssure., surg erie s, ah and othe r issues like that. B ut we also re ceive the tr a ini ng in t e rm of the the ra py sid e a nd so I m a ble to k ind of he lp assimilate the two. And so, fr om my standpoint, I think that's one of the de finite positive suits of psy chiatry is that we' re a ble to . we' re tra ined as medic al doctors, a nd ar e medical doc tors, and ar e able to ther efor e, assimilate the two—g o the thera peu> the psy chother apy side and the me dical side. To the probe who should reg ulate these two sides, J ack f elt that this was tricky sin c e sta te s h a ve dif fe re nt l a ws H e did a dv oc a te na tio na l r e g ula tio n o f t he ra pis ts i n a ll dis c ipl ine s, bu t a pp e a re d to be fo rm ula tin g his op ini on a s h e dis c us se d it J ack: I think,> that part g ets a little tricky beca use I think some of the states have differ ent interpre tations of some of the law s. And so I thi nk if the na tio na l or g a niza tio n. . Y ou re g oin g to r un int o some problems. enf orcing those, bec ause some of the states may interpre t those mandates a littl e diffe rently without. . I think that ideally that would be the be st—would be to have a national

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155 m a n d a t e d s ys t e m w h e r e yo u s e t t h e s t a n d a r d a n d t h e n t h a t w a y, beca use patients re alistically do> uh . . Mike: Who would adminis ter it if y ou did? J ack: Well, (laug h) there d need to be some sort of national uh> like our APA is a national org anization but I think I >, What we we re talking a bout ear lier is very true—they don' t have it, a r ecor d of enfor cing many of the issues. or pr oblems that come up. Uhm they re notorious for having y ou know, y ou may g et a r eprimand from them for something. B ut that's a bout it. Uhm and so, I think having some sort of national a g ency that would be able tooo enfor ce the se rules. a nd, to dole out the punishment, when, ne c e ssa ry I thi nk wo uld c e rt a inl y ma ke it a n e a sie r, sy ste m, t o navig ate throug h. Be cause y ou would have. ultimately one body that was doing this. Jac k: Rig ht. Wel l, a g a in I thi nk the re ne e ds to b e so me kin d o f n a tio na l, reg ulation of that. And > Mik e : B y wh om? I m a so c iol og ist ( la ug hs ) Jac k: Rig ht. Wel l. I thi nk the re sh ou ld b e so me so rt of ina c > Whe n it comes to> I f y ou’re reg ulating a ll therapists, I don' t think the Americ an Psy chiatrist Association would be the corr ect boa rd. Be cause we. . The y re not a ll psy chiatrists. So I think just by sh e e r d e fi nit ion tha t w ou ldn t w or k. I m no t sa y ing tha t th e APA sh ou ld n ot b e inv olv e d b e c a us e I thi nk wh a t th e y sh ou ld d o is to re g ula te the ir ow n g ro up s o f p sy c hia tr ist s. Just b e c a us e it' s in place a we ll established org anization, and it has a set of e thics and it has some standards a nd things whic h we g et re g ulated throug h. Mike: There is also the NMSW and the APA, psy cholog ists. Do y ou think may be these should ge t toge ther a nd cre ate a board? J ac k : Ye s I d o I d o n 't t h i n k t h at >. W el l I wo u l d n 't ev en s ay t h at I d o n 't think. I don' t know that consolidating the g roups into one g iant thing would wor k so well. But I think having a national boar d that would consist of, y ou know, seve ral membe rs from e ach, c oming tog e the r a hm t o r e g ula te tho se kin ds of thi ng s b e c a us e it i s a commonality for a ll of them. I think that would certa inly be acc eptable, a nd actua lly pref era ble . bec ause y ou' d have input f r o m a l l t h e a r e a s o f t h e r a p y.

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156 LCSWs on Cer tification an d Li censure Ea c h o f t he c lin ic a l so c ia l w or ke rs fe lt t ha t th e re sh ou ld b e a t le a st s ome c ha ng e in licensing and ce rtification of the ir discipline. Amy was c oncer ned that the law s g overning their prof ession wer e not being stressed e noug h during training Her solution to this problem would involve chang e at the e ducational/org anizational level. L arr y was basica lly satisfied with the wa y cer tification and lice nsure is now done but felt that there sh ou ld b e so me str e ng the nin g a t th e na tio na l le ve l a nd su pe rv isi on a t th e loc a l le ve l. Wi ll was much le ss satisfied. He f elt that the dy namic contr olling the dire ction of the dis c ipl ine wa s th e inf lue nc e of the po we r o f m on e y H e e xpre sse d a c e rt a in r e sig na tio n to thi s st a te of a ff a ir s. He did be lie ve tha t th e re sh ou ld b e mor e su pe rv isi on of the ne op hy te clinical socia l worker during ear ly thera py sessions. Be tty felt that the org anization of the clinical socia l worker s would be streng thened by using a plan more similar to that of the medical model, in par ticular of tha t of ac upuncture Of the soc ial worke rs interview ed, sh e pr ov ide d a mor e e xha us tiv e vie w o f c lin ic a l so c ia l w or k a s a dis c ipl ine wi th imp or ta nt f un c tio ns be ing fo rm e d a t e a c h le ve l—l oc a l, s ta te a nd na tio na l. P sychologists and a Counselor on Certification and Licensure Th e the ra pis ts w ith Ph. D. s in ps y c ho log y or c ou ns e lin g a lso va ri e d li ttl e in t he ir response s. Kare n had thoug ht that eac h state should license the rapists. She had said that she believe d that national ce rtification ac cording to discipline worked. She e x plained her pref ere nce by noting that e ach sta te had slig htly differ ent laws whic h aff ecte d thera py Gail had f elt that there should be licensing in all states. She said licensing let’s the client know that the the rapist had g one throug h a ce rtain ty pe of c ourse wor k, been su pe rv ise d d ur ing e a rl y c lin ic a l e xpe ri e nc e a nd ha d b e e n me nto re d w ith in h e r/ his

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157 discipline. She wanted the licensing to refle ct the ar eas of expertise and rue d that having the ac ademic c rede ntials (Ph.D., Psi D, or M.S.W.) did not show what are as of tra ining had bee n focuse d upon. Rick did have a differ ent idea a bout licensing He f elt it was an inef ficient a nd counter productive r estraint of tra de. His idea l ty pe would be one in which people w ere socialized to use word of mouth to deter mine who was a g ood thera pist and what ar eas wer e cove red by a par ticular ther apist. He wa s in favor of cer tification that tells what training had bee n underg one and sa id that licensing did perfor m the function of impelling thera pists to continui ng educa tion in their field. Z oe also talke d about the nee d for c ontinuing educ ation and the r ole of lice nsing a nd c e rt if ic a tio n to ma ke su re tha t sk ill s w e re ke pt u p to da te Sh e fa vo re d a sy ste m in which the lice nsing boa rds could find out more a bout mental health ther apists before case s beca me blatant. Tha t would allow problems, whethe r problem ther apists or problem tec hniques, to be re veale d so that measure s could be take n to rec tify them at an e a rl y sta g e a nd ke e p th e ra pis ts h e lpi ng the ir c lie nts Wh e n w e ta lke d o f t he e a se wi th wh ic h a pr ob le m th e ra pis t c ou ld m e re ly mov e to a dif fe re nt s ta te wh e n s he /he ha d lo st their license or ce nsured or expelled from the national or g anization, she reve aled that she favor ed a na tional reg istry of problem ther apists and said that there is talk about doing t h a t w i t h i n p s yc h o l o g y. P sychiatrists on Cer tification an d Li censure The psy chiatrists also expressed ba sic satisfac tion with certifica tion and licensure As with the social wor ker the rapists who had M.S.W.s and national ce rtification and the thera pists (psy cholog ists and educa tional counselor) with the aca demic cr edential of a

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158 Ph.D. and national ce rtifications, these psy chiatrists with M.D.s/Ph.Ds did not have r eady response s to how cer tification and lice nsure should be done and at wha t levels. During their discussions of ce rtification and lice nsure, a ll the therapists, of whateve r ac ademic or medical c ertifica tion and state and/or na tional licensure themselves, did not speak of an expanded r ole in sanctioning by any of the boa rds. Severa l expressed an intere st in some cross-disciplinary ethical g uidelines at a na tional le ve l, b ut d id n ot h a ve a pa rt ic ula r f or ma t f or ho w i t sh ou ld b e or g a nize d a nd the ir response indicated that they had not g iven this possibi lity much consider ation. M.D./Ph.D.s on Certification and L icensure The psy chiatrists also expressed ba sic satisfac tion with certifica tion and licensure As wi th t he the ra pis ts w ho ha d M .S. W.s a nd na tio na l c e rt if ic a tio n a nd the the ra pis ts w ith the a c a de mic c re de nti a l of a Ph. D. a nd na tio na l c e rt if ic a tio ns th e se ps y c hia tr ist s w ith M.D.s/Ph.Ds did not have r eady response s to how cer tification and lice nsure should be done and a t what levels. During their discussions of ce rtification and lice nsure, none of the ther apists, of whateve r ac ademic or medical c ertifica tion and state and/or na tional licensure themselves, spoke of an expanded r ole in sanctioning by any of the boa rds. Sever al expressed an inter est in some cross-disc iplinary ethical g uidelines at a na tional level, but did no t ha ve a pa rt ic ula r f or ma t f or ho w i t sh ou ld b e or g a nize d a nd the ir re sp on se indicated that they had not g iven this possibi lity much consider ation. Ramona v I sa be lla and T hird-party Sui ts There is an incre asing number of tor t case s in which the diag nosis and trea tment prac tices of menta l health provider s have c ome into question. My sear ch of the literature

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159 T he T a ra so ff v R e g e n ts o f t h e U n iv e rsity o f C a lif o rn ia 197 4, ca s e h ad r ej ect ed t he cl ai m t hat 1 c o n fid e n tiality l im its t h e li a b ili ty o f t h e ra p ists w h o ha v e re a so n a b le c a u se to b e liev e tha t t h e p a tien t i s d a n g e ro u s to him se lf, o the rs o r p e rs o n a l p ro p e rty. re ve a le d th a t Ramona wa s th e fi rs t a nd mos t pu bli c ize d la ws uit a ff e c tin g c ulp a bil ity to third-par ties. The publicity broug ht a heig htened public a war eness of thera py and had implications for L CSW s. This ruling wa s the first allowing third-par ties to demand c omp e ns a tio n f or tor t ha rm wh e n th e ra py pr a c tic e s h a ve be e n in str ume nta l in le a din g to damag e to someone othe r than the the rapy client. L oss of consortium (i.e., a lienation of aff ection), da mag e to re putation, or preve ntable dama g e to third-par ties discovere d du ri ng the ra py (i .e ., c lie nt i s li ke ly to c a us e ph y sic a l ha rm to a no the r i nd ivi du a l) a re a ll torts for which the thera pist is now li able. Except for the latter, the Ramona case was the 1 primary leg al ruling that established liability and outlined what some of these pra ctices may be. When I asked a bout the Ra mo na v I sa be lla suit, L CSW Amy said that she had not hear d of it nor of third-pa rty tort liabilit y She was not at a ll concer ned about he r own lia bil ity sin c e the na tur e of he r j ob a s a c a se ma na g e r i ns ula te d h e r f ro m su its in m os t ins ta nc e s. Amy : Umm. Well, as I said, I don’t know any thing, a bout it. I ’m kind of skeptical, we ’re y ou know, ver y litigious society And a lot of p eo p l e w h o ar e gu i l t y as s i n s o t o s p ea k ar e ge t t i n g p re t t y h u ge pay outs. [ laug hs, joined by M]. Um. P erha ps that’s why I ’m doing case manag ement now a nd. . Mik e : Yo u’ re pr e tty we ll i ns ula te d f ro m th a t, y ou fe e l? Am y : Ye s.

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160 When asked his re action to the Ramona case and third-pa rty lawsuits, L arr y spoke of ethics c lasses at that time but had a hazy rec ollection of it and did not speak on the imp or ta nt a re a of a c c ou nta bil ity to t hir d p a rt ie s. Mik e : At a ny ra te n ow the ra pis ts a re a c c ou nta ble to t hir d p a rt ie s. Di d y ou kn ow a bo ut t his ? Th e re a re so me oth e r c a se s si nc e thi s. L arr y : I t probably isn't ve ry profe ssional to say I usually g et my clues on re c e nt c a se la w b y wa tc hin g ‘L a w a nd Or de r' be c a us e the y us ua lly d u p li c a te [b o th la u g h ] M ik e : T h e y u s e s o me o f th o s e [c a s e s ]. L arr y : You ca n look at ever y one y ou' ve see n and that theme c omes out. But if it was in 1994, I mean, the na me Ra mo na v I sa be lla is ring ing a bell, but I couldn' t have na med the ca se. I was taking two ethics cla sses, one of the m in ‘95 so they probably cover ed that but [l aug hs] I don' t . . Whe n a sk e d d ir e c tly a bo ut c on c e rn a bo ut t hir dpa rt y la ws uit s, L a rr y sp ok e of his relig ious stance towa rd life a nd thera py of being cautious, and of not letting conc ern a bo ut t he m in fl ue nc e his lif e ou tsi de the the ra py se ssi on s. Mike: Yea h. So, this has not bee n a matter of conc ern? L arr y : At the risk of sounding other-w orldly I seek not to do har m—I se e k to do g oo d, a nd I ho pe tha t G od pr ote c ts t ho se wh o p ut t he ir hear ts in the right plac e. I m pretty cautious by tempera ment. I g uess, I fee l intuit ively if y ou' re tre ating y ourself a nd that person with integr ity that y ou can' t stay up at nig ht, having done nothing—wor ried that y ou haven' t cover ed y ourself. I t's ve ry dif fi c ult to c ov e r t ha t pe rs on of wh a t y ou ne e d if y ou do n' t e xpos e y ou rs e lf on so me a re a T he y c ou ld w a lk i n a nd ult ima te ly I c ou ld be quiet or be . Whil e the Ramona case was ha zy for L arr y Wil l said that “all of this” wa s coming back a fter I reve aled some of the details re g arding the ca se. Wil l: You know, y ou’re talking a bout> Well, the sugg estibilit y —how y ou le a d th e qu e sti on s I me a n, tha t’ s a big thi ng in c hil d, c hil d

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161 abuse c ases a s well—who’s doing the interview ing. T hat’s why they have to tape ever y thing now, be cause that the, the questions are leading I f y ou’re talking a bout all this hy pnothera py And ag ain, what a re y ou dealing with to start off with, y ou know, what is the (? )itic? I f y ou’ve g ot a thera pist, a psy chi . y ou know. E v e n a p s y c h ia tr is t i n th is . [c a s e ?]. Will w a s n ot m uc h c on c e rn e d w ith the po ssi bil ity tha t he mig ht b e a ff e c te d b y thi s c a se sin c e he us e d b ri e f t he ra py I n r e g a rd to t he ra pis ts n ow be ing mor e su sc e pti ble to tort suits brought by third parties, he laug hed as he said, “Tha t’s why I car ry lots of liability .” Will had also seen ec onomic power at the hea rt of licensur e. Be tty was finishing her tra ining f or ac upuncture and had not be en doing much social work w ith clients at the time I interviewe d her. When I mentioned that she wa s subject to the ruling on third-par ty suits that the Ramona case had opene d, she said: Be tty : I think that I ve proba bly stay ed aw ay from clinica l social work beca use of a ll the leg al stuff. Rea l serious, private pr actice clinical social work. U hm beca use I don' t fee l equipped to do some of the stuff that I hear people doing with people. Uh I haven' t gone to> I ve g one to, minution(? ), I ve done f amily thera py workshops, I ve done some e clec tic ty pe ahm wor kshops, but I ve neve r done something like just hy pnosis, or just guided imag ery . . And I ’ve never done any thing, uhm priva tely beca use of the le g al stuff. When I asked he r wha t she did with her patients who sa id they had bee n v i c t i m i z e d i n c h i l d h o o d s h e h a d t h i s t o s a y: B e tty : I do n' t . I do n' t bu y int o v ic tim stu ff I do a lot of uh m, ref raming y ou know. Help them r efr ame the w ay that they look at a nd a hm d e a l w ith a nd a nd the wa y tha t th e y u h in c or po ra te whateve r bad thing s happene d to them. I just, I just move them way out of, stay ing in the vic tim role and stay ing in the ‘ ever y body do e s e ve ry thi ng to m e ro le a nd c a us e I > Th e y ne e d to mov e int o taking responsibility for their choice s the day that they come to see me.

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162 At thi s p oin t B e tty ta lke d a bo ut h ow sh e g e ts t he c lie nt o ut o f f e e lin g tha t he /sh e is a victim. Psy cholog ist Gail was not sure whe ther she ha d hear d of the Ramona case After I g ave a sy nopsis of it, she said: Gail: I haven’ t hear d about that ca se bef ore. Mik e : D o y ou kn ow a bo ut t hir dpa rt y la w s uit s? Gail: Uhm Mik e : O r d id y ou kn ow be fo re I ta lke d a bo ut i t? Gail: No. Of a ll the therapist I interviewe d, the thing most notable a bout Gail was that she wo uld a ns we r f ull y a nd ve ry c og e ntl y a ny dir e c t qu e sti on b ut s he wo uld no t r e sp on d w ith a ny inf or ma tio n n ot d ir e c tly a sk e d. She c ou ld n ot b e “ ba ite d” int o s ho wi ng int e re st i n elements of the third-par ty culpability (which subse quent statements showe d she had thoughts a bout and that she wa s indeed intere sted). Rick had a va g ue memory of the Ramona case but did not remember mor e than that it was about re presse d memories that we re f ound not to be repr essed. He felt that the pr ob le ms t ha t Ramona made sa lient were a nonissue for him because of the wa y he pr a c tic e d th e ra py H e pr ov ide d a n e xamp le of a c lie nt w ho ha d b e e n mu lti ply a bu se d a s a child. His tack wa s to work to g et her to stopping taking responsibility for wha t others had done to he r. He was ve ry emphatic that the w ay he pra cticed the rapy could not convince someone who ha d not been a bused as a child that they had bee n. After I re min de d h im o f s ome of the de ta ils of the c a se a nd tha t th is c a se ma de the ra pis ts l ia ble f o r t h i r d p a r t y s u i t s h e s a i d t h a t h i s t h e r a p e u t i c a p p r o a c h w o u l d n o t p r o d u c e t o r t l i a b i l i t y.

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163 Ric k: Wel l th e re ’s th e re ’s so me thi ng imp lic it, uh in w ha t I ’m . in my approa ch that proba bly come throug h from eve ry thing y ou’re he a ri ng B e fo re I sa id u lti ma te ly y ou r a c c ou nta bil ity is t o th e c lie nt, wi th c e rt a in e xce pti on s. (c le a rs thr oa t) y ou r a c c ou nta bil ity a lso is, to, truth. I t’s not pushing a n ag enda. I like to think the kind of wo rk tha t I do wo n’ t pr od uc e tho se ty pe s o f t he ft s. Mike: Umhm Ric k: So t he n it ’s > I n e sse nc e it’ s a no nis su e I ’m no t tr y ing to f it somebody into, [ clea rs throat] a> my mold. I f y ou’re having such and such sy mptoms and obviously there ’s this [ raps de sk] and “Da mn it, [ rap] I ’ve g otta convince y ou [rap] t hat that’s wha t’s g oing on” and, “w ho car es wha t y our fa mily or y ou think, or . .” There ’s a c erta in, brusqueness that pr oduces tha t which, I find, a n a t h e t i c a l t o t h e t y p e o f t h e r a p y t h a t I do I ha ve a c lie nt, c u r r e n t l y, w h o a b s o l u t e l y was abused. N o question about it. She uh uh uh uh was subjec ted to, uh uh sexual contact fr om her fa ther, from, a, ste p-brother and fr om an older c ousin. [ clea rs throat]. Uh, she’s ve ry open in thera py and uh, she doe sn’t even like the word abuse. She likes c alling the m “the re lationships” now. I n my . that’s the plac e whe re, w here work ne eds to be done to kinda g et her to, y ou know, to separ ate a nd divide and to stop taking on the u h u h u h t h e r e s p o n s i b i l i t y f o r w h a t t h e y did And y et, still. . You know, eve n with a client, with a c lient who was a bused and the re ’s no qu e sti on a bo ut i t. Wh e re I ’m kin d o f r e sp e c tin g the ir pace and their, w ay of moving That ty pe of a pproac h is never g oing to take somebody who was ne ver a bused and c onvince them that they wer e. I had thoug ht that Z oe would be f amiliar with the Ramona case since in addition to having thera py clients, she tea ches psy cholog y at a univer sity As I ref reshe d her memory she re membere d that Ramona had sue d the thera pist and the clinic for tort damag es but did not remember the outcome of the suit. I had starte d say ing, “ Whether the client had be en abuse d or not, it was dee med impossible . .” meaning to conclude “that she w as not influence d by the thera pist,” when Z oe interr upted: Z oe: She believed tha t. She was by the time they wer e finished. Mike: She was g oing to be lieve it.

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164 Z oe: Umhm. That’s why y ou have to be so car eful whe n y ou’re doing child sexual abuse interview s. Be cause children a re so sug g estible. Mike: Absolutely And if y ou’re try ing to r emember y ourself, y ou know. Z oe: Well we all know y ou rec onstruct memory in the way that it makes sense a nd if someone is providing y ou with context . > Mike: You conf abulate. Z oe : Rig ht. We d isc us se d a na tom ic a lly c or re c t do lls fo r t ri a ls a nd the no ve lty of the se x pa rt s fo r t he c hil d. Z oe me nti on e d th a t tr a ini ng on ho w t o d o th os e int e rv ie ws ha s n ow be c ome standard pr actice to make them re ally be cour t-admissible. About harm to third-par ties fr om t he ra py its e lf sh e sa id t ha t sh e c on sid e re d h e rs e lf to b e low ri sk Sh e do e s n ot p us h he r c lie nts to c on fr on t ot he rs a nd if the c lie nt d e c ide s o n h e r/ his ow n to c on fr on t ot he rs she helps them proje ct possible incomes, both neg ative and positive. B esides not probing for memor ies, Z oe pre pare s her c lients for conf rontations by role play ing a nd clar ify ing how the client f eels towa rd others. She a lso prepar es sig nificant other s for sig ns of chang e in the client. Z oe : I do n’ t w or ry muc h a bo ut t ha t. M a y be . ma y be in p a rt be c a us e I ’m pretty adher ing to e thical, standar ds—I consider my self a ‘ lowrisk’ per son, cause I g o the conse rvative [laug h] route, when I trea t. May be bec ause in my thera py with others, I try to consider other pe op le in t ha t pe rs on ’s sys tem, and, > Mike: You fee l that’s their support sy stem or> Z oe : Ye a h w e ll t he y c ou ld, the y c ou ld j us t r uin e ve ry thi ng I do in the ra py wi th t he pe rs on b y no t pr ov idi ng a su pp or tiv e c on te xt. So I have to he lp that person, i-mag -ine, or or g ener ate how mig ht others’ r eac t to any chang es in beha vior . or help pr epar e other people they ’re close to for those cha ng es. Mike: Do y ou have the m con—y our clients—conf ront people? I n their, >

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165 Z oe : Uh hm, I do n’ t kn ow so muc h a s, a s c on fr on t, a s d isc us s th ing s w ith them. Uhm. L ike, I never >. L ike for se x ually abused a dults, I have se en uh, more often than not, wha t I advise them to do—one of the ma ny thi ng s I a dv ise the m to do —is to w ri te ou t le tte rs stating how they fee l about the abuse to the abuser But whe ther they want to g o and conf ront that person is re ally their own de c isi on I t’ s n e ve r b e e n s ome thi ng I re a lly pu sh e d f or A nd th is is, I mean these are clients wher e—it’s neve r in a re cover ed me mor y —it ’s . . Th e y ’v e a lw a y s k no wn tha t th e y we re se xua lly abused or Mike: Suppressed? They said it’s not tim e to think about it cause I ’m not strong enoug h or wha tever ? Z oe: Well, or they they ’ve ha d problems throug hout, their adolesc ence beca use of it and into adulthood, but. they ’ve just now g ot to the po int wh e re the y ’r e re a dy to a dd re ss i t. S o. Uh mm, if the y wa nt t o confront them, I would . I would role play with them, way s to do it, a nd he lp t he m uh pr oje c t po te nti a l ou tc ome s b e c a us e th a t c ou ld e ith e r w or k o ut n ic e ly or po or ly I me a n y ou ne ve r k no w t ha t. S o be pre pare d for a ny set of cir cumstance s. But, I don’t rea lly worry a bo ut t hir dpa rt ie s. Psy chiatrist B en had he ard of the Ra mo na v I sa be lle c a se a nd thi rd -p a rt y lawsuits, but was able to c onverse d about it only afte r being informed of some of the de ta ils of the c a se H e re c og nize d th e g ra vit y of e xpa nd e d v uln e ra bil ity to t hir dpa rt ie s, bu t f e lt t ha t th is w a s ju st a n e xten sio n o f t he po ssi bil ity of su it. He op ine s th a t th e ra pis ts c a n le a rn to d e a l w ith so tha t f e a r o f s uit wo uld no t in te rf e re wi th t he ir pr a c tic e s. Be n: For me I mean it’s something that I ’m awa re of There alway s was a possibility of litiga tion. There’ s third-party liability but we have lia bil ity y ou kn ow in a nu mbe r o f w a y s. We h a ve le g a l li a bil ity an d we h av e c i v i l l i ab i l i t y I ca n b e s u ed fo r a n y n u m b er o f t h i n gs that g o on in a cour se of tre ating someone. So it’s something that we’ re a war e of a nd we a ttempt to protect ourselve s as much as w e c a n b ut y ou c a n’ t le t it lim it y ou I f y ou ’r e tha t uh m a fr a id o f i t, y ou shouldn’t probably be in the prof ession at this point and so uh Be n: I mean they ’re extending it more than it have been in the pa st when t h e y a l l o w e d t h i r d p a r t i e s t o f i l e s u i t s b u t t h e l i a b i l i t y h a s a l w a ys been the re. We’r e a ve ry litiginous society and it’s one of the more

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166 neg ative aspe cts of wha t I do, is that there’ s alway s a possibilit y So it’s som ething y ou lear n to deal with. You do the be st y ou can for y our patients y ou abide by y our belief s and y our ethics a nd pr ov ide the be st c a re y ou c a n f or y ou r p e op le a nd tr y no t to le t it influence y ou. J ack a ppear ed to be more familiar with the Ramona case than any of the other the ra pis ts. He sa id t ha t he ha d h e a rd of it a nd wa s tr y ing to r e me mbe r t he de ta ils A s I attempted to fre sh his memory sever al time he said, “ Right,” in a g ree ment and whe n I mentioned that Ramona ha d sued for tort damag es his response was e ven more supporting: “ That’s rig ht.” I n conclusion I said: Mike: So. Third-party suits. Now y ou’re susceptible to third> that’s the first time that a thera pist could be sued by any one other than the c lie nt, or the pa tie nt > J ack: Right Mik e : > or the —a n a g e nt. Jac k: Or a n a g e nt f or the m. Mike: Have . . Do y ou ever think about that or . ? J ack: Uhm, somewhat. I mean, it doesn’t ope n up the door, for leg al actions to be take n ag ainst the thera pist or org anization. However ahm At some leve l, when y ou rec ommend, as a the rapist to a patient, to take a course of ac tion—confront her fathe r, for e xamp le —th e re is s ome re sp on sib ili ty in t ha t. Mike: Do y ou have y our patients conf ront people or > J ack: Not ty pically What I will do is t alk to them and, in terms of our the ra py we tr y no t to ma ke s ug g e sti on s f or the m to do —c on c re te sug g estions for them to do. What we ofte n do is try and lea d them down a r oad and . so the y can ma ke their ow n discoverie s and their own de cisions, as opposed to having us make the de cisions for them. We ofte n will try and make ahh make the patient make their own de cisions. We can help them, g uide them down the r ight road but they ultimately need to be the driver

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167 Mike: What do y ou think about uhm while we’r e on this, the patient as victim, or victimhood, y ou know. What do y ou think about that situation? Are they ? Do y ou see pa tients as victims? . of, I don’t know, of wha tever social intera ctions or how . J ack: I g uess it depends on wha t y ou are defining as a vic tim. I ’ve c e rt a inl y se e n p a tie nts lik e we ’v e a lr e a dy ta lke d a bo ut w ith po st traumatic stre ss that have be en victims of cr imes. uhm I do see pa tie nts tha t ha ve a ssu me d a lmo st, a vic tim ro le if y ou wi ll. They ’ve ha d enoug h bad thing s that have ha ppened to them that they sort of take on the role of perpe tually being a victim—putting themselves in situations where they ’re g oing to be abused or mistreated or taken a dvantag e of. uhm Tha t’s not uncommon, actua lly for us to see uhm I g uess eh I . . I s that answer ing y our question, or I I I don’t know. I briefly rela ted Gail’s stanc e (a s one psy cholog ist) on victimhood in which she said that she neve r lets her clients see the mselves as victims. When I asked w hat he tho ug ht a bo ut t ha t, h e e nth us ia sti c a lly (r a pid ly a nd smo oth ly ) a g re e d w ith he r a sse ssm e nt. J ack: Right. Ac tually it’s pretty simil ar, uh, a g ain the proble m is that the pa tie nts is t o a ssu me thi s f ro m a vic tim a nd so ou r j ob a s th e ir thera pist, or psy chiatrist, is to chang e that. the be st that we ca n. or g et the patient to cha ng e it. And so, that is definitely the appr oach in t he or y tha t w e wo uld ta ke is tha t w e do n’ t w a nt t he pa tie nt t o see the mselves as a victim because that identifies as more a pa ssi ve ro le U hmm a nd tha t ‘ thi ng s ju st s or t of ha pp e n to me’—the w hole idea of lear ned helplessne ss, almost fits t hem to a victim role. Mik e : Uh mm J ac k : An d s o i t ’s s o m et h i n g t h at we wo u l d ce rt ai n l y t ry an d d i s co u ra ge from a pa tient, to assume a victim role be cause it does make them more pa ssive. What we enc >, instead, try to encour ag e is for the m to discover within themselves the ide a that do have some control ov e r t he sit ua tio n. Ye s, it w a s a ho rr ibl e thi ng tha t ha pp e ne d to the m. u h a nd y e s, ma y be the y c ou ldn ’t ha ve pr e ve nte d it B ut, wh a t th e y do fr om n ow fo rw a rd is w ith in t he ir a bil iti e s. An d th a t is what we try and foc us on. I s g etting he althy and fe eling better a bo ut t he mse lve s.

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168 LC SWs on Ramona v I sa be lla and T hird-Par ty Suits None of the L CSW s remembe red the Ra mo na v I sa be lla case When I g ave a sy no ps is o f t he c a se a ll b ut A my ha d f a int re c oll e c tio ns a bo ut i t bu t ha d n ot f e lt t ha t it a ff e c te d w ha t th e y we re do ing in t he ra py A my fe lt s e c ur e be hin d th e me dic a l c ur ta in (s inc e the do c tor mus t ma ke fi na l de c isi on s o n ma tte rs wh ic h mi g ht l e a d to c ulp a bil ity to third-par ties). B eca use they used var ious ty pes of g oal-orie nted, short-ter m therapy the oth e r t hr e e L CSWs d id n ot f e e l th re a te ne d b y thi rd -p a rt su its L a rr y tr us te d h is m or a lit y to k e e p h im f ro m ha rm Wil l tr us te d h is t y pe of the ra py wh ile c a rr y ing “ lot s” of lia bil ity insurance Be tty put her trust in turning conver sation to problems the client wa s having coping in the prese nt and g etting pa st the victim role. Partially the social wor kers we re insulated f rom the ef fec ts of the Ramona c a se and had not de alt with the liability to third parties base d on that knowledg e. The mag nitude of the tort aw ard, tha t I had re lated, broug ht exclamations of “Wow” from two a nd the oth e rs ind ic a te d a we Si nc e the y ha d s a id t he y re c a lle d s ome thi ng a bo ut t his top ic fr om t he ir e thi c s c la sse s, so me ho w i t f a ile d to ma ke a n im pr e ssi on a t th e tim e tha t w ou ld lead them to conside r it during their pra ctice of thera py One c an only specula te as to the rea sons for the lac k of aw are ness about such a n important piece of jurisprudenc e. One possible alterna tive might be tha t the nature of their soc ialization as social worker s (which looks for problem oriente d solutions for mental difficulties) c ombined with the fa c t th a t it wa s n ot s oc ia l w or ke rs wh o h a d b e e n s ue d a nd mit ig a te d th ou g hts of lia bil ity fo r t he m a nd re du c e d it s sa lie nc y fo r s e tti ng up pr a c tic e s th a t w ou ld b e pr ote c te d. De sp ite he r i nte re st i n th e le g a l e le me nts of the fi e ld o f t he ra py K a re n d id n ot h a ve so me rec og nition of the Ra mo na v I sa be lla tr ia l e ve n a ft e r h e a ri ng a br ie f s y no ps is o f t he ma in

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169 points. S he aske d for some c larifica tions about the suit and then the interview was shifted to some of the tre atment pra ctices tha t the suit had entailed. She a lso thought that thi rd -p a rt y su its wo uld be ins ur a nc e c omp a nie s o r p ro te c tiv e a g e nc ie s c on c e rn e d w ith mandatory repor ting of suspected a buse. She had not c onsidered tha t therapists are now a c c ou nta ble ind ivi du a ls f or tor t da ma g e s. P sy c hol og ist s a nd a C ouns e lor on Ramona v I sa be lla and T hird-Par ty Suits One of the clinical psy cholog ists (Rick) had said that he ha d hear d of the Ramona v I sa be lla trial and liability to third-parties. Rick re called only that it was about repr essed memor ies which ha d been f ound not to be repr essed. Ga il flatly stated that she ha d n e ve r h e a rd of the c a se no r o f l ia bil ity to t hir dpa rt ie s a nd did no t c on sid e r h e rs e lf to be at r isk of tort suit. S urprising ly Kar en who wa s interested in e thics and laws a nd mandatory repor ting ha d not hear d about the Ramona case She had conside red acc ountability to third-parties to be limited to acc ountability to insurance companies f or trea tment that had bee n done or pr otective a g encie s in reporting suspected ha rm or thre at of har m. She did not have an opinion on its effe ct on her prac tice. Z oe, who taug ht ps y c ho log y d id n ot r e me mbe r t he c a se by na me b ut r e me mbe re d it a s I sta rt e d my sy nopsis. She did not know the outcome of the c ase, just that there had bee n such a c ase. She considere d herse lf to be at low risk for suits for tort damag es bec ause he r ty pe thera py is not confrontational, pre pare s clients to rea listi cally consider the logic al conseque nces of their ac tions, and she involves the clients’ sig nificant other s when signific ant cha ng es ar e expected in the c lients’ behavior

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170 P sy c hia tr ist s o n Ramona v I sa be lla and T hird-Par ty Suits Of the psy chiatrists, J ack, e vinced some know ledg e of the Ramona case but was not so familiar with it that he did not have to be r eminded of some of the details. The psy chiatrists wer e re latively unconce rned a bout the peril of third-pa rty suits—medical liability insurance was see n as a ne cessity in this l itiginous society and they indicated that the Ramona case did not gr eatly incre ase the ir risk.. All Thera pists on Ra mo na v I sa be lla a nd Th ir dPa rt y Sui ts One ther apist from ea ch of the disciplines had indicated tha t, though r are ly they so me tim e s d isc us se d a c lie nt’ s me mor ie s— a ty pe of ps y c ho a na ly tic a pp ro a c h— bu t on ly a t th e c lie nt/ pa tie nt’ s r e qu e st ( L CSW Ric k, c lin ic a l so c iol og ist L a rr y a nd ps y c hia tr ist J ack) Whil e this may have put them a t some risk for tort dama g es, they did not have the client conf ront the ac cused pe rpetra tor, primarily beca use their ty pes of ther apy expressed self-e ffica cy (not victimhood), problem solving, pe rsonal g rowth, and situation ma na g e me nt i n th e pr e se nt e nv ir on me nt. M anda to r y R e por ti ng o f Abus e Amy had re ported suspec ted elder abuse throug h the abuse reg istry The c ases that she had r eporte d involved elder s who wer e neg lected ( e.g ., soiled, hung ry or not broug ht for esse ntial medical tre atment, such a s dialy sis), but she had not see n evidenc e of phy sical abuse The wa rd she wa s assig ned to did not have a pediatric s wing so she had not see n and ther efor e had not r eporte d any ty pe of c hild abuse. L arr y on the other ha nd had re ported a buse. He had re ported seve ral times in the past but found that he wa s discourag ed whe n in a non-ther apeutic r ole.

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171 L arr y : (bre ath) I ’ve ha d sever al. I have f ound that I want to look a per son in the ey e and te ll them, “I need to r eport this, and I ’m g oing to do that.” And, pr ior to my being in this field, where may be y ou’re encour ag ed ‘not to.’ I was a school principal be fore and y ou wer e so rt of e nc ou ra g e d ‘ no t to .’ B ut I fo un d th a t it re a lly br e a ks tr us t if y ou don’t. . L arr y : Two situations are immediate ly jumping to mind. I n one, a c lient had shar ed, but wouldn’t g ive details or na mes, and the ne x t day the suspec ted abuse r showed up a nd was in my waiting room and assumed I was re porting and wa nted to talk to me. I t was at that po int tha t he talked to me and I share d with him, “You’re coming here has now manda ted that I repor t. When y ou’re name wa s withheld, to keep me f rom that, and now y ou thinking that I ’m sh a ri ng tha t . . ” An d s o I sh a re d w ith him tha t I wa s r e qu ir e d to repor t it, in t hat situation. I called, a re y ou familiar with [name of a thera pist] . . L a rr y : An y wa y a g a in b e nig n f ro m th e sta nd po int tha t he ’s a n a uth or ity in that field, child protec tion team, and just wanted to be cer tain of my responsibilities there. He said repor t. I repor ted it. Other situation. My other situation that immediately comes to mind was . ag ain withholding of names by the par ty I t was something that had take n place in the past. And they didn’t know if they wanted to fac e the ha ssle that . and wor ked to influenc e them to re port. And they indeed r eporte d that situation. I then aske d if he would ha ve re ported the a lleg ations if there had not bee n the leg islated mandate L arr y : (Pause) The fir st I g ave y ou, back the n, my tendenc y beca use of how it came a bout was to attempt to influence the situation for g ood, was proba bly not the wi-, apa rt from the la w, apa rt from repor ting, wa s probably overr eac hing a t that point in m y life. And y e t I wa s w ise or se lf -p ro te c tiv e e no ug h ( la ug h) to a sk so me on e in a uth or ity wh a t I sh ou ld d o a nd did ind e e d d o th a t. A nd wa s a ble to have the best of both worlds in that I was a ble to influence the situation directly by telling the ma n “I ’m repor ting y ou, here ’s why I ’m not ag ainst y ou.” He had a dif fer ent explanation for wh a t ha pp e ne d; b ut ( I ) w a s a ble to h a ve so me po sit ive inf lue nc e in that situation. . L arr y : Going back to spe cifics of y our question, I ’m g lad the law is wha t it is. My tendenc y back the n was not. . Don’t g o throug h the

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172 hassle, but, ca n I save the world and f ind some way that’s for g ood. And I ’m g lad the law sa ves me fr om my ear lier inclinations of being a re scuer and manda tes that I do that and so that bec omes mor e ma tte rof -f a c t no w. I t ju st I ’m no t . I ’m no t e nc ou nte ri ng it as much be cause I don’t dea l with that popu-, I don’t dea l with the y oung er c hildren much, so I would have to. . I g uess we’ re talking spe cifica lly of abuse ? I had a situation whe re a client informed me tha t she had purc hased a hand g un and wa s on the thr e e da y wa iti ng pe ri od a nd I dis c ov e re d it ’s no t a g a ins t th e la w t o kill y ourself . to buy a g un and kill y ourself in F lorida. . Most of Be tty ’s social wor k car eer had bee n in ge rontolog y “Oh, I ve re ported financ ial abuse, f inancial e x ploitation, emotional abuse, phy sical abuse I ve re ported that for the g eria tric population.” When aske d about re porting child abuse, she said that she ha d n ot h a d o c c a sio n to do so in h e r p ro fe ssi on a l c a pa c ity b ut: B e t t y: I' v e b e e n t e m p t e d s o m e s o m e t i m e s j u s t t o r e p o r t o n s o m e b o d y I k n ew d o i n g s o m et h i n g wr o n g— a p er s o n al fr i en d — u m b u t I d i d n 't under one or two circ umstances. One was a minor who um who was living with somebody whose ove r 18 and the pare nts were encour ag ing tha t. Mik e : H mm Be tty : They wer en' t at all say ing this is wrong this is not rig ht. What happene d, someone who is 14 moving in with a 20 y ear old um and that' s statuary rape and that' s ag ainst the law a nd uh that was one tim e in a ll o f t ho se c ou ple of y e a rs wh e re I did no t r e po rt tha t. When I asked he r why she did not repor t it, she said that the pare nts felt that it was okay and the c hild “wanted to do it, was out the door it . was g rate ful to be out the door, I didn't a ctually blame her for wa nting to be out the door of that per son' s house [the p a r e n t ’ s ] ” a n d l a s t l y: Be tty : I wasn' t in the social work wor ld. I was in an a cupunctur e student ro le a nd it w a s a n o dd sit ua tio n. . B e c a us e I y ou kn ow . it was a n odd situation. Um so that's a . tha t could be a ve ry tricky situation to know.

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173 B e tty a pp e a re d to be ve ry c on fl ic te d a bo ut h e r r ole in t his no nre po rt Sh e a lso had not re ported a colleag ue whom she f elt had bee n impaired. B e tty : I me a n w ha t a re y ou su pp os e d to do ? Yo u k no w, uh a ny tim e y ou re a ny wh e re 2 4 h ou rs a da y ? B e a so c ia l w or ke r a nd re po rt y ou know—at seve n in the morning and 12 at nig ht, where ver y ou se e I t' s a lit tle bit tr ic ky So I thi nk I br ou g ht s ome bo un da ri e s to um when I repor t? I t's like, none of my business. . B e tty : An d I ha ve n' t r e a d th e le g a l di re c tor y re c e ntl y bu t, y ou kn ow b ut I . B u t i t s s o m e t h i n g t h a t I f e e l v e r y s t r o n g l y a b o u t I m e a n I have when somebody is doing something wrong The same with a c oll e a g ue if the y re imp a ir e d, y ou kn ow I c omf or t th e m a nd the n if I . I ve neve r re ported a n impaired c olleag ue but I comforte d t h e m a n d t h e y' v e c h a n g e d o r t h e y' v e m o v e d o u t o f m y w a y? She went on to talk about collea g ues whom she thoug ht were doing thing s that should not be done in their lives and pr actice s. She was conc erne d that she re ally did not know those per sons in those instances and f elt that there was a lso a cultural r eason tha t people [and she by extension] do not report. B e tty : I jus t do n' t th ink tha t ma ny pe op le do re po rt be c a us e the y liv e in Americ a I mean I ve lived a lot of diff ere nt countries and I ve bee n to a lot of place s where people a ren' t free and um so know wha t that fee ls like and so I can se e whe re pe ople in Americ a would fe el like they wer e over stepping there boundarie s as fa r as whe re people a re f ree cuz this country is very fre e. Be t t y : P eo p l e a re fr ee t o d o an d b e a n d s o o n M o s t p eo p l e t h i n k t h at 's the ir pr oc re a tiv e ri g ht. Be tty had talked w ith colleag ues about the pr oblems mentioned above She a pp a re ntl y c a me to t he c on c lus ion tha t th e ma nd a te to r e po rt a bu se wa s to o b ro a d a nd did not cover some situations in which factor s other than law wer e of importanc e.

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174 Ph.D. Kare n was more comforta ble with the conc ept of manda tory repor ting of abuse tha n she had be en on the other leg al topics. She said that she c ould not recite the law nor a particula r ca se, but she did know how it ef fec ts her. Ka re n: Wel l it is a har d question. Cause I want to be c are ful about it. B e c a us e wh a t I tr y to d o is r a the r t ha n ta ke a wa y the po we r f ro m a person a nd say I have to r eport this, is to work with that person and empower that person to bec ome the re porter. Works a lot better than just blowing the w histle on somebody There ’s a lot of, now the re ’s of t> th e re ’s y ou kn ow th e re ’s lot s o f r e se ntm e nt b e c a us e of the fa ct that it’s just a lot of, y ou know, disempower ing of someone. So, I . . There ’s a lot of . I mean whe n that stuff c ome s u p in the ra py th a t’ s o ft e n w he n I se e k c on su lti ng the mos t, wi th o the r p ro fe ssi on a ls, a nd of te n w ith my hu sb a nd w ho is a ps y c ho log ist a nd w ho u hm d oe s c ou rt te sti mon y a nd r e a lly kn ow s u hm a lot a bo ut m e nta l he a lth a nd the la w. So, I a bs olu te ly seek c onsultation, when I fff I am in a position to do, that kind of repor ting. I do not do it in a vacuum. I mean, f irst of all, y ou know, I consult with colleag ues . and a lway s let my supervisor kn ow . a nd it g e ts j us t im po rt a nt, to d oc ume nt v e ry we ll. Th ou g h s he sa id s he ha d n ot w a nte d to re po rt s he ha d r e po rt e d b oth a no ny mou sly and af ter letting clients know that she wa s g oing to r eport. Thr oug hout her intervie w, Kar en re fer red to “ law.” I t was the c entra l theme of he r interview She said she could not cite the law on mandatory repor ting but she c erta inly was a war e of its ra mifications for he r a s a ma nd a tor y re po rt e r. Whe n s he fe e ls t ha t a le g a l is su e mig ht c ome up sh e wo uld consult with her husband w ho is a fore nsic psy cholog ist, her collea g ues and he r supervisor, a nd the university attorney when a question of law c omes up. Kar en: That' s rig ht, and I don' t become a n attorney I mean if the university . . I would consult with colleag ues, and the n su pe rv iso rs a nd the n u niv e rs ity a tto rn e y So I m no t g oin g to int e rp re t th e la w. I me a n th a t' s n ot m y . my ro le is t o in iti a lly int e rp re t th e la w a nd the n it s my du ty to t a lk w ith pe op le wh os e job that is, to fully interpre t the law for me. I don' t mean to be vag ue, but I came to . y ou know. . L ike. . You know, I can' t even tell y ou whe re th e s ta tu te is [l a u g h ].

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175 Although she had a suppor t sy stem for these matters, she trie d to remembe r the laws themselves. When que stioned about law a nd confide ntiality she had sa id that she tried to g ive people f rom the beg inning a view about wha t confidentiality entails and that she is leg ally subject to having to report a buse. Ka re n: Oh y e a h. y e a h y e a h. I le t pe op le kn ow tha t th ing s th a t w e ta lk about in the thera py session are confide ntial betwee n the two of us unless something. . I can' t even r emember the words, c ause I ve been on le ave f or almost two y ear s. Wi thin the, within the lim its of the law. And w hen some pe ople ask more about that, they say wh a tta y ou me a n w ith in t he lim its of the la w?" I sa y by la w, in the state of F lorida I m a mandator y repor ter of c hild abuse and elder abuse. Ga il h a d a lso re po rt e d s us pe c te d c hil d a bu se Sh e sa id t ha t it wa s “ e xtre me ly stressful and upse tting.” She told the pa rents that she ha d to report a nd did so with them in the room. “I did it with t hem.” I ask her if she would have repor ted it if there ha d not be e n a le g a l ma nd a te to r e po rt Gail: Probably not, in this situation. Bec ause I didn’t rea lly believe he r. So I pr ob a bly wo uld n’ t ha ve re po rt e d it Ga il: I ’v e I me a n, if y ou ha d n o d ou bt t ha t sh e wa s ly ing th e n I g ue ss y ou wouldn’t nee d to report it. B ut I think when y ou’re not cer tain, y ou ’r e su pp os e to r e po rt it, a nd I kn ow wh e n I re po rt e d it I sa id over the phone in my repor t “This g irl has a history of ly ing a bout dif fe re nt k ind s o f t hin g s. ” I do n’ t kn ow if sh e ’s e ve r l ie d a bo ut thi s pa rt ic ula r t hin g be fo re w hic h w a s b e ing sla pp e d b y he r d a d, bu t, she ce rtainly had a history of ly ing a bout other kinds of thing s. An d th e y we re ve ry muc h li ke “ Wel l, t ha nk y ou fo r r e po rt ing it, we’ re the ones that nee d to investiga te the re ality of that.” The y wanted to ha ve that say Stil l . . Mike: And y ou repor ted to a socia l worker ? G a i l : T o t h e d e p a r t m e n t o f C h i l d r e n a n d F a m i l y.

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176 After listening to my explanation on the Ramona case third-par ty lawsuits, the le g a l r uli ng s o n s ome tr e a tme nt p ra c tic e s, ma nd a tor y re po rt ing a nd the de c lin e in t he us e of ps y c ho log ic a l e xpe rt wi tne sse s a s I un de rs too d th e m f ro m my lit e ra tur e re vie w, Ga il explained in depth how her tre atment pra ctices a re de signe d to help clients see th e ms e lv e s a s s o me th in g o th e r th a n a v ic ti m, h o w h e r tr e a tm e n t w o u ld e mp h a s iz e forg iveness and e mpowerme nt, and how she e mphasizes healing and communica tion rathe r than sea rching for r esolution of rela tionships. Each of these wer e ele ments which sh e fe lt p ro te c te d h e r f ro m le g a l a c tio ns Gail: Well. I think. . I t's f unny that coming from the law perspe ctive, none of the things y ou' ve shar ed fe el stressful, or upse tting or like they are taking power awa y And may be par t of it is because I don' t rea lly fee l like I have a cer tain orientation towar d thera py but I do think that I would almost alway s work with the people I worke d with towards moving awa y from per ceiving themselves as victim. And I would alway s be working towards f org iveness and for try ing to r epair rela tionships as is pos sible, and so, I think the wa y I wo u l d em p o we r s o m eo n e w o u l d h o p ef u l l y b e a wa y t h at 's not going to be har mful to other people or . . I would never for instance, e ncoura g e someone to pursue some dra stic course of action in their lives, without finding some way s—even w hen someone is hy sterica lly making decisions for the mselves, it's g oing to i mpa c t so me on e e lse a nd ma y be in a po ssi bly ha rm fu l w a y —to still communicate a s lovingly as possible. Why for instanc e, they re le aving a mar riag e or w hy they ve dec ided to stop interac ting. I think law g ets involved in these kinds of situations when c ommunication is broken down and r elationships fee l very wounded. I mean, I think that may be in a r ow betwe en a f ather and his daug hter, pa rt of why things g ot to the level they g ot was beca use there wasn' t a strong enoug h influence there that was helping for some kind of he aling or some kind of re solution or ma y be su pp or tin g a lot of the se ns e of be ing a vic tim T ha t' s ju st not something I would do in the thera py situation. Gail: So the law doesn' t upset me. I t doesn' t. I don' t fee l worried a bout it. I don' t fee l like it im pacts my prac tice. What' s funny is to me, wher e I fee l more constra ined is by things like insura nce. I fee l

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177 much more c onstrained by it. I think therapy has cha ng ed in an enormous amount bec ause of . . Mik e : Te ll m e a bo ut t his Gail: Well, I think insurance c ompanies wa nt to, really dictate the w ay t r e a t m e n t h a p p e n s a n d h o w l o n g i t s h o u l d b e a n d h o w l o n g s o c i e t y. . Gail had e arlier equate d acc ountability and ethics w ith law (above ). This was the only time that “law” was a topic of conve rsation during Gail’s intervie w. Rick had not had a n occa sion in which he fe lt that the mandate to re port applied. He fe lt t ha t su c h ma tte rs we re “ ind ivi du a l.” He ha d ta lke d mo re a bo ut h ow he wo uld wo rk wi th t he c lie nt d ir e c tly ra the r t ha n o the rs ou tsi de the the ra py se ssi on s. Under the hea ding of mandate to r eport, Z oe included w arr ant to repor t the possibili ty that a client may do harm to self or others. She wa s comforta ble with the mandate to r eport a buse and ha d done so somewhe re be tween f ive and ten times with her own clients and more when supe rvising inter ns’ ca ses. Neve rtheless, she r eg retted ha ving to report be cause she found that r eporting often ha d neg ative conse quence s for the the ra pe uti c re la tio ns hip Sh e no te d f ro m he r e xpe ri e nc e tha t di ff e re nt s ta te s h a d s lig htl y differ ent statutes and r eporting require ments. I n addition, she had to bre ach c on fi de nti a lit y fi ft e e n to tw e nty tim e s b e c a us e of ri sk of su ic ide I a sk e d h e r i f s he wo uld have r eporte d without a leg al mandate Whil e she c ited the ethica l mandate to re port she n o t e d t h a t d i f f e r e n t t h e r a p i s t s d e f i n e “ r e a s o n a b l e s u s p i c i o n ” d i f f e r e n t l y. Z oe: Humm. That’s an inter esting question. I think, well, our ethics would sug g est that we should re port. So I think I would have . repor ted. Uhm. . I think every mental hea lth care provider probably has their own de finition of what is a reason a ble suspicion—that abuse or ne g lect is occ urring —and, how little y ou ne e d, to m a ke it r e a so na ble su sp ic ion a nd ho w m uc h y ou ha ve to

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178 make it re asonable suspicion. I think every one has the ir own thr e sh old on tha t. I next asked her if she thought that ther e mig ht be a tende ncy to over-r eport. She sa id t ha t sh e tho ug ht t ha t, “ Ye s. I thi nk the re ’s a te nd e nc y to e rr on the sid e of fa lse p o s i t i v e s . b e c a u s e t h e w a y t h e l a w s a r e w r i t t e n t h e y say rea sonable, suspicion.” She was c oncer ned that the c hildren mig ht be phy sically abused be cause of the re port, but that this possi bility was something that must be borne since sometimes many repor ts are ne c e ssa ry be fo re pr ote c tiv e se rv ic e s d o s ome thi ng to r e c tif y it. Z oe: But, I look at,> I know sometimes it’s like, the critica l number of repor ts it’s necessa ry for the c hild to be removed, a nd if I can a dd to t ha t weight like if I ’m repor ting it and someone else is re porting it. I look to it as ult imately someone is g oing to do something that’s an e ffe ctive, wa y of re lieving tha t child from that situation, whether it’s removal fr om the home or g etting the pare nts to, have pare nt-training or some t h i n g. S o m et h i n g. Z oe also said that the sta tutes she has see n ty pically call for more than a rea sonable suspicion. That they often c all for “ something c loser to a, de fined plan or a definite, a definitive intent or an intende d victim.” She conclude d, “So, we ha ve to be. We have to be g iven more de finitive, I think, information. Reasonable suspicion is not enoug h.” Psy chiatrist B en had a more string ent standar d for r eporting suspected a buse than the oth e r t he ra pis ts. He fe e ls t ha t pa rt of a re po rt wo uld be a sta te me nt t ha t th e the ra pis t has some evide nce tha t the abuse is g oing on. H e had not pe rsonally repor ted child or elder abuse. I asked him if he kne w someone w ho had and he said, “I have, a nd they ’ve done that, and it’s a lway s a ca se by case situation, y ou know. You know wha t’s g oing on uh but if I felt there was a buse g oing on, I would fee l obligate d to report it.”

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179 Jac k h a d r e po rt e d c hil d a bu se “ 10 -1 2 ti me s “ a nd e lde r a bu se tw o o r t hr e e “ With the childre n it was mostly I ’m try ing to think. Most of the enc ounters, not all of them, but mos t of the e nc ou nte rs a re thr ou g h th e e me rg e nc y ro om. Whe n w e we re w he n I wa s in training .” He was a war e of the mandate to r eport a nd knew e x actly wher e to re port the c hil d a bu se b ut h a d f or g ott e n w hic h s ta te a g e nc y he ha d u se d f or the e lde rs LC SWs on M anda to r y R e por ti ng L CSW Amy had re ported e lder a buse and ne g lect throug h the abuse reg istry The ho sp ita l w he re sh e wo rk e d d id n ot h a ve a pe dia tr ic s w ing Sh e ha d n ot b e e n e xpos e d to children in he r ca pacity as a L CSW and had ne ver ha d occa sion to report child abuse L arr y had re ported a buse seve ral times as a L CSW He told of be ing e ncoura g ed to re port while func tioning in the ther apy setting a s opposed to encour ag ement “not to re port” in an educa tional setting. He told of an instance in which he ha d not decided w hether to report un til the su sp e c te d a bu se r c a me to t a lk t o h im. He fe lt t ha t c omi ng to t a lk w ith him mandated tha t he re port. He did so af ter c onsulting with someone knowle dg eable about c hil d p ro te c tio n s e rv ic e s. I n a se c on d in sta nc e h e ha d in fl ue nc e d f a mil y me mbe rs to repor t suspected a buse. L arr y said he wa s g lad that re porting is mandated. He fee ls that e a rl y in h is c a re e r h e wo uld ha ve tr ie d to ta ke c a re of the sit ua tio n w ith the c lie nt a s a resc uer r ather than putting the r esponsibility for the c ase in the more experience d hands of the state c hild protection ag ency Be tty had not re ported a nd had fe lt conflicted a bout her decision in a pa rticular c ase; ne verthe less she stood by her de cision. Wi ll had not had occa sion to report abuse

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180 P sy c hol og ist s a nd a C ouns e lor on M anda to r y R e por ti ng Of tho se ps y c ho log ist s w ho re po rt e d s us pe c te d a bu se a ll h a d e xpre sse d s ome mis g ivi ng s. Ka re n’ s st a te me nt a pp e a rs to i nd ic a te tha t sh e fe e ls t ha t r e po rt ing is indicative of some sor t of failure She works to empowe r her clients. By repor ting she takes a way the power of the c lient and place s it in t he hands of others. She pre -wa rns the client in the intake inter view that she is leg ally require d to report a buse and likelihood of ha rm de sp ite he r a dh e re nc e oth e rw ise to t he e thi c of c on fi de nti a lit y Sh e a lso c on su lts her suppor t sy stem—her husba nd who is a for ensic psy cholog ist, her supervisor a t the university wher e she w orks, and the la wy ers pr ovided by the university for that a nd other tr e a tme nt r e la te d p ur po se s. When psy cholog ist Gail had repor ted the one instanc e of possible c hild abuse, she informed the a lleg ed per petra tor(s) ( in this case a pa rent a ccuse d of slapping the child) tha t sh e wa s le g a lly bo un d to do so Sh e a lso ha d c on su lte d w ith the oth e r p ro fe ssi on a ls in her c linic for advic e. When aske d if she would have repor ted if there had not bee n a leg al mandate she said, “Proba bly not.” She went on to explain that the child had a his tor y of ly ing a nd tha t sh e ha d r e la y e d th a t f a c t to the Pr ote c tiv e Se rv ic e s. Ga il a lso went into some detail about how he r trea tment prac tices help to kee p the client fr om se e ing he r/ him se lf a s a vic tim H e r t re a tme nt e mph a size s f or g ive ne ss, e mpo we rm e nt, healing and communica tion rather tha n a re acting as a vic tim. Unsaid but im plied was that a client who thinks she/he ha s been a bused would re port the abuse her/himself. Psy cholog ist Zoe also reg retted the nece ssity of re porting abuse a lthough she had repor ted more of ten than the other clinical psy cholog ists. S he base d her r eg ret on the neg ative conse quence s for the the rape utic rela tionship t hat usually ensued a nd on the

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181 likelihood that the client would be punished or a bused bec ause of the re port. Her decision to repor t never theless, was ba sed on the ne cessity for se vera l reports fr om differ ent source s, in many case s, befor e Protec tive Service s would do something that would end the a buse. She also wa s conce rned a bout the ambig uity of the de finition “re asonable suspicion.” She noted that this term ca n be and ha s been inter prete d in a number of dif fer ent way s by repor ters or nonrepor ters of a buse. This has sometimes led to erring on the side of f alse positives (re porting suspected a buse whe n there is none). She said that eve n without the leg al mandate to report, she would have r eporte d the ca ses sh e did b e c a us e of he r p ro fe ssi on a l e thi c s. P sy c hia tr ist s o n M anda to r y R e por ti ng A psy chiatrist, J ack, ha d repor ted elder abuse ma ny times, and child abuse mor e often than a ny of the other thera pists. P art of his re porting may have to do with his work in emerg ency rooms, wher e phy sical abuse is more likely to be first re ported. He was not conflicte d about the nec essity of re porting Be n on the other ha nd had not had oc casion to report. He had a mor e string ent standar d for r eporting but felt that if conf ronted with a case he had a clea r idea of whe n he would re port, and would do so without hesitation.

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182 CHAPTER 10 CONCL USI ONS AND DI SCUS SI ON Th is d iss e rt a tio n a na ly zed int e rv ie ws wi th l ic e ns e d o r c e rt if ie d th e ra pis ts t o investiga te how devia nce in ther apy is constructed a nd manag ed. I t used narr ative analy sis, supplemented by content ana ly sis and conver sation analy sis, to st udy four common narr atives addr essed by the thera pists in t heir intervie ws. Open inter views we re c on du c te d s o th a t th e the ra pis ts c ou ld d e fi ne the c on c e pts s e t pr ior iti e s f or the int e rv ie ws and minimiz e the inter viewer s role. One of the limitations of the re sear ch re g ards the sa mple of thera pists who were int e rv ie we d. Ho w m a ny the ra pis ts s ho uld ha ve be e n in te rv ie we d? Whic h o ne s sh ou ld have be en intervie wed? There is no way to determine how ty pical the inter viewee s were Th e pu rp os e h ow e ve r, wa s to e xplor e the c on str uc tio n o f d e via nc e a nd no t to e sta bli sh para meters a bout deviance in therapy To ac complish this, t hera pists from differ ent tr a ini ng ba c kg ro un ds we re int e rv ie we d. Sa mpl ing wa s su sp e nd e d a ft e r t he te nth interview be cause salient themes we re e merg ing tha t provided insight into the construction of de viance Th e loo se ly str uc tur e d in te rv ie ws y ie lde d n a rr a tio ns a bo ut: 1) or ie nta tio ns to thera py ; 2) memory suppression, and r epre ssion; 3) acc ountability and ethics; a nd 4) leg al issues and ther apy Eac h bore a rela tionship t o how devianc e is construc ted and manag ed. The se nar ratives be came repe titive in content and satura tion was rea ched on ma ny po int s, a lbe it n ot n e c e ssa ri ly on tho se tha t w e re a nti c ipa te d a t th e ou tse t.

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183 Or ie nt at ion s t o The r apy The fir st saturation point emerg ed as I soug ht to find out what therapy rea lly was for these thera pists. S omewhat surpr isingly no overarc hing the oretica l or disciplinary orientation dominated their or ientations to therapy No patter ns emerg ed that distinguished one g roup fr om another. Rathe r, the nua nced na rra tives reg arding orientations to thera py left little doubt about how individualist ic thera pists have bec ome. No party line" e merg ed that re flec ted disciplinary training Although some identified schools of thoug ht that had influenc ed them, they did not ex press spec ial alleg iance to a pa rt ic ula r o rt ho do xy I n f a c t, m os t of the int e rv ie we e s h e sit a te d a nd ha d to wo rk ha rd to articula te an or ientation to therapy They did not have pat de finitions. One admitted that it had been a long time since he had e ven thoug ht about the topic. What emerg ed instead w as consistenc y in how the thera pists defined their r oles. They knew, immediately how to talk about their role in relationship to their clients. One of the c ommon emphases wa s on interac tions designe d to assist the client. All display ed a ser vice or ientation. The c hoice of role bridg ed the knowle dg e base obtained during training and the struc ture of the ir occ upation with the particula r dema nds of pra ctice, wh ic h w e re c lie ntba se d a nd ind ivi du a lis tic T he g uid ing e tho s o f t he ir pr a c tic e s w a s to do no harm. This included a ) kee ping c lients in therapy long e noug h to help; b) rele asing them from ther apy if it is not helping; and c) not substit uting their own ag enda f or the client’s. Th e se the ra pis ts a lso a do pte d a pr ob le mso lvi ng or ie nta tio n. Th e y ha d a n e c le c tic approa ch to technique s and strate g ies so they could tailor thera py to the particula r nee ds of the c lie nt, c on c e ntr a tin g on wh a t w ou ld w or k f or e a c h c lie nt. Th e se the ra pis ts

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184 attended to individual diffe renc es in clients. The pr ag matic bent mea nt that the int e rv ie we e s u se d a dif fe re nt m ix or c omb ina tio n o f t e c hn iqu e s to tr y to p ro du c e re su lts fo r e a c h p a rt ic ula r c lie nt. F utu re re se a rc h s ho uld e xami ne wh e the r t he ra py ha s b e c ome mor e e c le c tic a nd pr a g ma tic a nd if so w ha t ha s c on tr ibu te d to thi s d e ve lop me nt. The proble m-solving f ocus had se vera l other implications for the c onstruction of devianc e. F ocusing on the problem sepa rate d the problem be havior fr om the person, making the thera pists reluctant to label pe ople as de viant. The proble m-solving or ie nta tio n a lso fo c us e d o n th e he re -a nd -n ow n ot t he pa st, so the pla c e of me mor ie s in the ra py wa s mi nim ize d. Th e se the ra pis ts f oc us e d o n c ur re nt p ro ble ms a nd be ha vio rs wi th an ey e towar d improving the quality of life of their clients. The y did not seek out me mor ie s o r d we ll o n p a st c on dit ion s. Th e re wa s a lso a n e mph a sis on g e tti ng c lie nts to self-a ctualize as a pa rt of this problem solving. Tha t emphasis minimi zed rea sons for confr onting third-pa rties who may have w rong ed them. Sa tur a tio n w a s a lso re a c he d o n s ome be ha vio rs wh ic h w e re de fi ne d a s c le a rl y de via nt. Th e int e rv ie we e s a ll a g re e d th a t so me a c tio ns we re de via nt. I t w a s w ro ng to have se x with a client while unde r thera py (or late r). I t was wrong to brea ch client confide ntiality unless leg ally mandated to r eport. I t was wrong to dominate the interac tive proce ss in therapy and over power the client. I t was wrong to harm or contribute to the ha rm of third-pa rties, including thera py interns/students or other third parties who a re c onfronted by patients for r eal or perc eived a ffr onts that emerg e during the ra py I t w a s w ro ng to e ng a g e in p ra c tic e s th a t e xploi t th e su g g e sti bil ity of c lie nts Some anticipated theme s did not emerg e fr om the interviews. The rapists wer e se le c te d f ro m di ff e re nt t ra ini ng ba c kg ro un ds in a nti c ipa tio n th a t di ff e re nt t ra ini ng wo uld

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185 le a d to dif fe re nt o utl oo ks on the ra py a nd pr of e ssi on a l de via nc e T ra ini ng did no t se e m to a ff e c t or ie nta tio ns to t he ra py F or e xamp le th e re sp e c tiv e or ie nta tio ns of the the ra pis ts wer e quite individualistic, which meant that the soc ial worke rs wer e as diff ere nt from eac h other a s they wer e fr om the psy cholog ist or psy chiatrists. One of the social wor kers key ed on the g uiding na ture of a persona l relationship to the client with his model being su g g e ste d b y his re la tio ns hip to h is G od T o a no the r, the ra py wa s a pr oc e ss b y wh ic h o ld hu rt s a re he a le d s o th e y wo uld no t in te rf e re wi th c on te mpo ra ry liv ing A thi rd L CSW saw c oping w ith past problems more as ove rcoming obstacles than a s healing proce ss. To a four th, therapy was a n opportunity for the the rapist and c lient to gr ow and g ain insight. The psy cholog ists each put his/her own spe cial spin on thera py as we ll. One tho ug ht i t w a s a sp e c ia l po sit ion of tr us t f ro m w hic h th e the ra pis t c ou ld h e lp c lie nts believe tha t they could have a better life—one of g rea ter ha rmony and pea ce. A nother saw ther apy as solving pr oblems of stress—exploring options for ma king c hang es. A third ag ree d about the ce ntrality of making wanted a nd healthy chang es but did not link the problems to stress. A f ourth psy cholog ist saw thera py in very broad te rms as helping to e nh a nc e liv ing T ha t c ou ld r a ng e fr om a dd re ssi ng low -l e ve l f un c tio nin g g e ne ra lly to isolated and spec ific aspe cts like asser tiveness. The psy chiatrists did stress that thera py is used to overc ome the disorder of mental illness rather tha n primarily a proble m to be solved with the client. One psy chiatrist used a psy chody namic appr oach a nd felt that drug s were a usef ul and helpful tools for acc essing memories. The other downpla y ed the psy choana ly tic approa ch and stre ssed su pp or tiv e the ra py wh ic h w a s c a uti on a ry a bo ut t he us e of me mor ie s.

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186 Im portance of Mem ory, Supp ression, and Repression Me mor y s up pr e ssi on a nd re pr e ssi on we re no t im po rt a nt t o th e int e rv ie we e s, inc lud ing tho se wh o h a d u se d p sy c ho a na ly tic the ra py a nd tho se wh o d e a lt w ith c lie nts who had suff ere d CSA. I expected more varia tion across ther apists on these matters if f or no other re ason than the me dia and a cade mic attention g iven them. The r esea rch approa ch wa s premised in par t on an initial working assumption that suppression and re pr e ssi on of me mor y in c hil d s e xua l a bu se c a se s w ou ld p ro vid e fe rt ile g ro un d, a t le a st a mon g re c e ntl y tr a ine d th e ra pis ts, to p ro mpt thi nk ing a bo ut h ow de via nc e in t he ra py is constructe d. That assumption proved to be ina ccur ate. These the rapists structure d their pra ctices a nd pursued tec hniques that deemphasized memory They adopted 1) a her e–andnow orienta tion; 2) a problem-solving orientation; 3) a c lient self-a ctualizing orie ntation; and 4) sensitivity about inducing su g g e sti bil ity in c lie nts T he ir pr a c tic e s st e e re d th e m a wa y fr om t e c hn iqu e s th a t w ou ld e xploi t su g g e sti bil ity T he int e rv ie we e s p e rc e ive d th a t te c hn iqu e s d e sig ne d to e lic it memories posed pr oblems for g ood thera py The ther apists were all leer y of the proble ms associated w ith notions of repr ession, but disag ree d about the validity of the c onstruct. Some acc epted the c oncept and ag ree d that memories could be repr essed; other s were more skeptica l. Be cause they str e sse d th e he re -a nd -n ow ," no ne of the the ra pis ts d we lt o n o ld m e mor ie s o r a c tiv e ly soug ht to draw them out. I f the c lients presente d them, the thera pists would deal with the memories but primarily in terms of the memory being an obstac le to solving c urre nt problems. They rec og nized that memories are imperfe ct under the best of c ircumstance s and nee d to be dea lt with care fully and put into context. No one thought, for example,

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187 that a discove red me mory should be the basis for making acc usations. Some recog nized the difficulties in ver ify ing the information. Most thought that the ther apist' s primary conce rn should be with helping the per son develop skills for coping in the "he reand-now a nd did not think t hat re quired re turning to the past. Fe w of the the rapists eve r used tec hniques that are centr al to reg ression thera py (e .g ., hy pn os is, ima g ing ) a nd no ne of the m di d r ou tin e ly T he pr a g ma tic a nd e c le c tic or ie nta tio ns me a nt t ha t th e y did no t ha ve a vis c e ra l di sd a in f or re g re ssi on the ra py or its associate d technique. I n some instances some mig ht actually use one of the technique s. More of ten, they considere d that 1) they wer e not suffic iently trained in the te chnique or 2) thoug ht that they could pursue mor e promising approa ches or combinations to help the client. For these re asons they could and did avoid the te chniques a nd situations that have g ive n r ise to c on tr ov e rs y ov e r d e via nt t he ra py pr a c tic e s. Th e y str uc tur e d th e ir wo rk in way s that minim ized the chanc es that re presse d memories and r eg ression tec hniques would come into play They limit ed their e x posure to the most controve rsial situations. Future rese arc h should ex amine whe ther a kind of “de fensive” prac tice pre dominates thera pists so t hat they can limit their exposure by avoiding risky or controve rsial te c hn iqu e s. Part of the wa y in which thera py was struc tured re sulted from work c ontext s. Severa l therapists, for e x ample, oper ated in lar g er me dical org anizations and worked f or doctors who e njoy ed prof essional dominance (see Fr eidson 1970a). T hey provided inf or ma tio n a nd ins ig ht t ha t be c a me pa rt of a mor e c omp re he ns ive int e rv e nti on bu t di d not make lone de cisions about client nee ds or problems or tre atment. This rese arc h was

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188 not desig ned to examine sy stematically the way in which work c ontext s aff ect pr actice s (including deviant ones) I t may be a f ruitful site for futur e re sear ch. The intervie ws raise d sever al other issues a bout how thera py is conducted tha t wa rr a nt m or e c a re fu l c on sid e ra tio n. Th e re pr e ssi on de ba te wa s r e ve a le d to be a c a de mic rathe r than play ed out in prac tice. The rese arc h did not provide the strate g ic site for explaining how devia nce is de fined a nd labels applied a s had bee n expected. F uture rese arc h may need to look at more prag matic, pra ctical ther apy -oriente d issues to ge t more c omplete information about the c onstruction of devia nce. One of the fe ature s of these the rapists’ pra ctices w as that they used brief thera py rathe r than e x tended number s of sessions (as would of ten be r equire d in memory retrie val). The interviews sug g ested that brie f thera py was influenc ed by such thing s as pay ment schedule s of HMOs, insuranc e compa nies, and g overnme nt aid prog rams. Future rese arc h should ex amine more sy stematically how these e x terna l demands and conditions are c onstraining and influenc ing the rapy (and pote ntially reduc ing the likelihood of using r isky or controve rsial technique s). Acc ountab ility and Ethics The topics of e thics and ac countability also educ ed univer sal response s. The the ra pis ts e nd or se d th e inj un c tio n to do no ha rm a pr of e ssi on a l st a nd a rd tha t ti e s in to their ser vice e thic. Thera py was to help the c lient. This service e thic play ed out in how they define d devianc e. The line betwee n g ood and bad the rapy was ofte n deeme d to be crosse d when ther apists were hurting instead of he lping. Eve ry one conc urre d that having sexual relations with a client cr ossed that line. Most refe rre d to harm ca used by violating confide nces, by substitut ing the thera pist's ag enda f or that of the c lient, or by continuing

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189 thera py when it was not he lping. Some eve n extended the injunction bey ond the bar e minimum require d by their prof essional org anizations, for example by limit ing a ll social rela tions (going well bey ond the proscr iption of no sex with clients). The the rapists wer e also war y of tec hniques which mig ht prey on the client’s sug g estibilit y and they war ned ag ainst substit uting their own ag enda f or the c lient’s needs or client’s ag enda. T hat would cross the line into “ba d” pra ctice. The ther apists also acc epted the pr ofessional org anizations’ guide lines without qu e sti on T he y tho ug ht t he se we re su ff ic ie nt f or c on tr oll ing de via nt t he ra pis ts. Th e ir po sit ion on br e e c h o f c on fi de nti a lit y wa s c on sis te nt w ith the pr of e ssi on a l or g a niza tio ns ’ standards. The y also ac cepte d the proscr iption aga inst having se x with clients. Although the interviewe d thera pists had simi lar idea s about what “ bad” pr actice they wer e univer sally reluc tant to label a ther apist as deviant. The y separ ated be havior fr om t he pe rs on T he be ha vio r m a y pr e se nt a pr ob le m to be so lve d, bu t th e so lut ion did no t se e m to inv olv e la be lin g the pe rs on Wh e the r t his re luc ta nc e to l a be l de via nts is a matter of pr ofessional c ourtesy /defe renc e or de rivative fr om other training and occupa tional fac tors needs to be studied in more detail in the future We might expect that many prac tices and situations in therapy will remain sec ret and priva te—bec ause ne ither the ther apist nor the client will ra ise the issue. I f other thera pists are a lso reluctant to labe l someone as de viant, the problem of c ontrol is raised. I n other a rea s of profe ssional prac tice (e .g ., surg ery ), norms abse nt some form of sa nction fail to control devia nce ( L anza-Ka duce 1980) I ndeed, f or prof essions, there ma y be a p a r a d o x.

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190 One of the major c onsequenc es of pr ofessional a utonomy is the diminis hed proba bility that compliance will be secur ed by the coe rcion of superior a uthority (see Fr eidson 1970a; 1970b). The two primary informal means of c ontrol exercised by fellow pra ctitioners—talking to (Fr eidson a nd Rhe a 19 63 ) a nd pe rs on a lly bo y c ott ing (F re ids on 19 70 b) —a pp a re ntl y have little impact on prof essional misconduct. . [T] he most eff ective mecha nisms are those in which a n err ant doctor is more likely to be detec ted. (L anza-Ka duce 1980, 35051) L anza-Ka duce g oes on to arg ue that in the ca se of unne cessa ry surg ery the eff ectivene ss of fellow pr ofessionals to control de viance is aug mented by instances of detec tion and neg ative re action. He notes that informal mea ns (boy cotting othe rs or talking to other s about their pra ctices) are less eff ective be cause "suc h informal methods are open to interpre tations other than prof essional ce nsure. Why some proce dures a re eff ective a nd others ar e not may be best e x plained by differ ence s in the cer tainty of establishing poor prac tice" (L anza-Ka duce 1980, 351) These the rapists allowed w ide be rt h to oth e r t he ra pis ts f or the a pp ro a c he s th e y us e d to tr y to s olv e the pr ob le ms o f t he ir clients. The inter viewee s rec og nized the uncer tainty that is inherent in modern the rapy I t seems these the rapists shifted the re sponsibili ty to their profe ssional or g a niza tio ns to h e lp d e fi ne a nd re g ula te de via nt p ra c tic e s. Som e e xplic itl y pu t f a ith in the ability of prof essional ethica l standards a nd cer tification proce dures to che ck devia nt thera pists. They saw their ow n prac tices as be ing c onsistent with professional norms that p u t cl i en t s n ee d s fr o n t an d fo re m o s t i n d o i n g t h er ap y T h ey s aw t h ei r r o l e a s as s i s t i n g, g uiding, a nd fac ilitating client-c enter ed ef forts to cha ng e for the better The g oal was f or the c lie nt t o a c hie ve se lf -e ff ic a c y wi th t he ir he lp. I n th is s e ns e s oc ia l c on tr ol s e e me d to stem from an oc cupational or profe ssional cultural conse nsus rather than disciplinary actions or c ensure from one' s peer s.

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191 Legal F actor s The intervie ws obtained infor mation about three leg al issues to see how f ormal social control a ffe cted the c onstruction of prof essional devianc e by these ther apists. Thera pists agr eed on se vera l matters. I n terms of c ertifica tion and licensing the thera pists basically liked the cur rent leg al ar rang ements and thoug ht they wer e ef fec tive for the most par t. They rec og nized that some area s could be improved, but we re unc lear about what the r espec tive roles of the local, state, a nd fede ral re g ulators should be. The intervie ws produce d unexpected re sults in t erms of c ourt ruling s. The the ra pis ts w e re un ive rs a lly un a wa re of pa rt ic ula rs of wa te rs he d le g a l c a se s w hic h d ir e c tly aff ecte d thera py prac tices (notably the Tar as off and the Ramona case s). They understood, howeve r, the dire ctive to re port possibili ty of har m by the client (a lthough some did not know the Tar as off case by name) and appr oved of it. They did not identify the Ramona case but thought that third-pa rty suits were unlikely to affe ct their pra ctices. The ther apists were awa re of the statutory provisions on mandated re porting of child or elde r abuse and all but one ha d repor ted abuse For all, the def initions on when to report a nd what trig g ere d the nee d to report we re ne bulous. They wer e all conf licted about whethe r a r eport would he lp the client in all instances. I n problem ca ses, they would consult others both in and out of ther apy to ge t fee dback a bout what is deviant and how to control their pr actice s. For e x ample, ther apists sought the a dvice of peer s and other prof essionals (e.g ., administrators and/or la wy ers) when c onfronted by ambig uous s i t u at i o n s t h at m ay t ri gger d ec i s i o n s ab o u t m an d at o ry re p o rt i n g. Statutes and court c ases invoke f airly cer tain interpre tations of standards a nd drama tiz e dete ction and neg ative re actions. B ut the leg al deve lopments did not

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192 nece ssarily contribute to the c onstruction or control of devianc e among these ther apists. All the thera pists were a war e of the mandatory repor ting statutes. Only some of them wer e fa miliar with the court ca ses that war rante d repor ting of dang erous c lients and the prospec t of damag es if they failed to make such re ports and a third pa rt was injure d ( Tar as ov v R e ge nts of t he Un iv e rsi ty of C ali for nia ). They wer e mostly unawa re of the Ra mo na v I sa be lla decision that established tha t therapists wer e liable f or injuries ca used by a client' s acc usations based on unre liable memories r ecove red dur ing the rapy Reg ardle ss of the leve l of knowledg e about the la w, its impact on the prac tices of these ther apists was limited. For e x ample, some ther apists who knew they had to re port a bu se we re c on fl ic te d a bo ut d oin g so So me pu rs ue d w or ds tha t of fe re d p se ud ole g a lis tic rea sons to ex cuse the m from the oblig ation. I f the pe rpetra tor was not name d, they may n o t h a v e t o r e p o r t If t h e r e f e r e n c e w a s t o o v a g u e t h e y m a y n o t h a v e a n o b l i g a t i o n In other wor ds, even the mandatory statutes left wig g le room for interpre tation. Perhaps for some the conf identiality of thera py sessions and their a utonomy reduc ed the c hance of de te c tio n s o th a t, c on sis te nt w ith the ir ind ivi du a lis tic or ie nta tio ns th e y we re wi lli ng to construct their own ideog raphic standards a bout reporting The leg al standar ds could be pu rs ue d w ith lit tle c ha nc e tha t th e y wo uld be se c on d g ue sse d o r h e ld a c c ou nta ble T he se data pr ovide little evidence that leg al social c ontrol ag ents constitute a salient a udience for de fining devianc e or a djusting prof essional beha viors. Future rese arc h should ex plore the fa ctors that contr ibute to this i nsulation from leg al controls.

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193 APPENDI X A CONTACT L ETTER Dea r Dr. ( Mr. or Ms.) ( insert name) F or my do c tor a te in s oc iol og y a t U F I a m in te rv ie wi ng the ra pis ts o n p ra c tic e s, opinions and outlook in t he pre sent leg al and soc ial atmosphere You uniquely fit the rese arc h desig n as a loc al (inser t licensure or cer tification) orig inally cer tified since 1996. I sincere ly hope to intere st y ou in being an intervie wee for my rese arc h. Sho uld y ou a g re e to b e int e rv ie we d, I be lie ve tha t be y on d s a tis fy ing the APA e thi c a l di re c tiv e fo r p sy c ho log ist s to c on tr ibu te to p ub lic un de rs ta nd ing of me nta l he a lth issues, this int ervie w ca n be intere sting for y ou—For example: this interview c an provide a sociolog ical template f or under standing y our own plac e within the discipline of ther apy Your e x pertise is in doing thera py mine is in understanding the bre adth and r ang e of the field of ther apy My rese arc h at this point i ndicates tha t a new e thical and leg al climate e x ists for all thera pists reg ardle ss of discipline or theore tical per spective, due primarily to the controve rsy over r epre ssion, reg ression, and r ecove ry of memories. I explore the revise d direc tives for prof essional ethics a nd some rele vant leg al ruling s. Additionally the so me tim e s se ns a tio na l me dia c ov e ra g e on the re g re ssi on de ba te ha s b e e n in str ume nta l in a dv a nc ing a n u np re c e de nte d p ub lic a wa re ne ss o f t he e xiste nc e of po la r p os iti on s w ith in mental hea lth. I focus on y our insights, fe eling s, and knowledg e about these within the p r a c t i c e o f t h e r a p y. As a sociolog ist I have studied both the history and the r ece nt chang es now transfor ming the f ield of thera py without being dir ecte d to specialize in only one ther apy theore tical per spective. F rom this paradig m I am likely to have infor mation which y ou may wish to ex plore fur ther, e specia lly on leg al ruling s and the intrusion of the media I int e nd to d isc ov e r w he re the lin e is d ra wn be tw e e n g oo d p ra c tic e a nd un a c c e pta ble prac tice. How g ood thera py prac tices (of fice s) ar e now be ing se t up with the moral standards pr escr ibed by these leg al ruling s and the re vised APA opinions on ethics. How do the g ood purvey ors of menta l health purve y it? What do the therapy disciplines of co u n s el o r, cl i n i ca l p s y ch o l o gi s t an d p s y ch i at ri s t h av e i n co m m o n an d wh at i s t h e r an ge o f d i f f e r e n c e s b e t w e e n t h e m ? Please a g ree to be interview ed, y ou are one of the few who meet the qua lifications require d for the study I will call y ou on (date to be supplied) to see when y ou may be interviewe d. I enclose a copy of the I nstitut ional Review B oard c onsent form, re quired by the National I nstitut e of H ealth whe n doing r esea rch c oncer ning huma n subjects and a n op tio na l de mog ra ph ic da ta fo rm Thank y ou for y our consider ation, Mike Ry an Do ct o ra l C an d i d at e; De p ar t m en t o f S o ci o l o gy Pho ne : 37 422 94 Em a il: mry an@soc.uf l.edu

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194 APPENDI X B I NFO RMED CONSENT FOR I NDI VI DUAL I NTERVI EW My na me is M ike Ry a n. I a m a do c tor a l c a nd ida te in s oc iol og y a t th e Un ive rs ity of F lorida. I am cur rently doing r esea rch f or my dissertation on eff ects, similarities, and differ ence s in insights, socialization methods, knowledge and fe eling s within and be tw e e n th e ra py dis c ipl ine s w hil e fo c us ing on the de ba te on re pr e sse d a nd /or fa lse memories of c hildhood sex ual abuse I f y ou c ho os e to p a rt ic ipa te w e sh a ll e ng a g e in a n in te ra c tiv e int e rv ie w w hic h w ill la st a pp ro xima te ly on e ho ur Y ou do no t ha ve to a ns we r a ny qu e sti on y ou do no t w ish to answe r. I will audio tape re cord the interview. A fter tr anscr iption the tapes will be era sed and de stroy ed. Your identity will be protec ted. The inter view will be conf idential to t he e xten t pr ov ide d b y la w. An y da ta tha t id e nti fy y ou by na me or ph on e nu mbe r w ill be destroy ed upon completion of this projec t. There are no anticipated r isks or direct be ne fi ts i n p a rt ic ipa tin g Y ou wi ll r e c e ive NO c omp e ns a tio n f or pa rt ic ipa tin g A ft e r m y rese arc h is completed, I will be happy to discuss my g ener al conc lusions with y ou. I f y ou should ag ree to participate y ou are fre e to withdraw y our conse nt at any time and discontinue par ticipation at any time without prejudice or r eper cussion. I f, at any time, there a re que stions about this proce dure, c ontact me or my dissertation cha ir, Dr. L onn L anza-Ka duce, a t the numbers listed below. I f y ou would like to participate please rea d the following statement and sig n and date the appr opriate line be low.

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195 I have r ead the proce dure de scribed a bove. I ag ree to participate in the proce dure and I have r ece ived a c opy of this description. _______________________________________________ Participant' s Signature Date ___________________ _______________________________________________ Mike Ry an, Ph.D. Candidate/I nterview er Date ___________________ ; or 352 3742294 _______________________________________________ Dr. L onn L anza-Ka duce, Committee Chair Date ___________________ or 352 392-7648 I f y ou ha ve a ny qu e sti on s o r c on c e rn s a bo ut y ou r r ig hts a s a re se a rc h p a rt ic ipa nt, please contac t the UFI RB off ice, B ox 12250, University of F lorida, Ga inesville, Florida 32611-2250 (phone : 352 392-0433).

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196 APPENDI X C DEMOGRAPHI C DATA I f f or a ny re a so n y ou fe e l un c omf or ta ble in a ns we ri ng a ny or a ll o f t he fo llo wi ng o mit t h a t c a t e g o r y. Circle re levant ca teg ory 1. Ag e: I am 21 or older Yes No 2. Ge nd e r: M F 3. Race : Blac k, Hispanic, Na tive Americ an, Or iental, White, Other______________________ 4. Educa tion: L ast y ear of cour se work: ________________________________________ 5. Completed course work (MA AB D, Psy D, Ph.D., M.D. Other_________________________________________________________ 6. Number of y ear s y ou have a ctively counsele d (worke d as a the rapist) whe ther during formal e ducation or a fter f inishing: 0, >0 to 1, 1 to 2, 2 to 3, 3 to 4, 4 to 5, More than 5 7 D i s c i p l i n e : M e n t a l H e a l t h T h e r a p y, C l i n i c a l S o c i a l W o r k C l i n i c a l P s yc h o l o g y, Psy D, Ot he r P sy c ho log y Ps y c hia tr ist Other _____________________________________________________________ 8. Theore tical per spective: ____________________________________________________________________

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197 APPENDI X D C O N T A C T P H O N E C A LL (Note: since a phone c all is an interac tion and actua l conver sation varies w ith the circ umstances a nd the par ticipants, this appendix rela tes an idea l ty pe for asking if they re c e ive d th e ma te ri a l, u nd e rs too d it h a ve a ny qu e sti on s r e g a rd ing it, a nd if the y a g re e to se t up a n a pp oin tme nt) Hello, Dr. ( Mr. or Ms.) _________. I am Mike Ry an, the soc iologist who sent y ou a letter re questing to interview y ou for my dissertation. Did y ou g et that mater ial? I s there any thing y ou would like me to clar ify about any of it or would y ou like me to ref resh y our memory on it? I cer tainly hope that y ou will ag ree to be interview ed. Can we set up an a pp oin tme nt? Thank y ou.

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198 APPENDI X E TYPES OF PROBES USED To pic s ( With Pos sib le Qu e sti on s) 1. The The rapy Situation a. What branch of thera py do y ou identify y ourself w ith (i.e., Yung Adler, F reud, behavior ist, etc.)? b W h a t t h e r a p y s i t e s h a v e y o u e x p e r i e n c e d o r b e e n i n v o l v e d w i t h ? i. Sites: P rivate pr actice ? Hospital? Etc.? ii. What is y our off ice like? Set up where thera py is done? c H o w d o y o u d o t h e r a p y ? i. Authority --how importa nt is it how maintained? What does it invol ve? ii. Wha t di sc ov e ry te c hn iqu e s d o y ou us e or mig ht y ou us e in f or e se e a ble c ir c ums ta nc e s? 2. Memories a. I mportance in therapy b. How re trieved? Dre ams? Dec onstruction? Pursuing lines of inquiry from c or re la tio ns wi th p re se nt s y mpt oms ? 3. Diag nosis and Trea tment of Persons Reg arding Represse d Memories a Do y ou dif fe re nti a te in d isc ov e ry a nd tr e a tme nt o f r e pr e sse d a s o pp os e d to suppressed me mories? What does this invol ve? b. Ha ve y ou e ve r t re a te d a ny on e wi th R e pr e sse d me mor ie s? i. Ho w d e te rm ine d? Met ho ds us e d? I nq uir y ba se d o n s y mpt oms ? ii. Ho w d id/ c ou ld y ou us e re pr e ssi on in t re a tme nt? c. Should counselors attempt to verify alleg ed abuse ? Question the re pression? 4. Th e I nd ivi du a l Cli e nt a. How do y ou fee l about victimhood of client--H ow deter mined, How appr oache d to c lie nt i. At lived border of re ality of client (1) How is this approac hed? (2) What sy mptoms are looked f or and w hy those? ii. I n p a st-H ow dis c ov e re d ( e .g ., me mor ie s, re c or ds ; w ho : c lie nt, oth e rs thera peutic tec hniques)? b. Con str uc tio n o f a via ble se lf i. Wha t is the ro le of the the ra pis t? I mpa rt ia lit y ? I nv olv e me nt a s a c o i n t e r e s t e d p a r t y? ii. What adaptive ideolog ies, attitudes and beha viors are used? Gene rally and fo r t re a tme nt o f a pa rt ic ula r c lie nt?

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199 i i i Is c o n f r o n t a t i o n o f o t h e r s b y t h e c l i e n t n e c e s s a r y? iv. Other r equire ments (i.e., support g roups, re levant assig ned re ading s, living g roups, etc.) ? 5. As pe c ts B e a ri ng on the Th e ra pis t O the r t ha n th e I nd ivi du a l Cli e nt: F a lse me mor ie s? H o w d e t e r m i n e d ? Im p o r t a n c e t o t h e r a p y? 6. Effe cts of leg al ruling s on prac tice of the rapy a. Which? b. I mportance of Ramona and Tar as off ? c. Ex pert witnesse s in tort cases involving memories re cover ed? 7 R e t r a c t o r s ( h o w d e a l w i t h w h a t t o d o a b o u t ?) 8. I n w ha t w a y s d o y ou se e dif fe re nc e s b e tw e e n d isc ipl ine s? a Te c hn iqu e s? b. Wha t a re the se lf -i nte re sts of dis c ipl ine s? Mone ta ry a nd sta tus e ff e c ts? 9. Do y ou think the prac tice of the rapy is chang ing f rom way s it was prac ticed bef ore y ou beca me ce rtified? How? 10. How is the conc ept of re pression construc ted in y our discipline? a Ho w i mpo rt a nt a re me mor ie s in dia g no sis a nd tr e a tme nt? b. How ar e y ou trained a bout repre ssed memories? How ar e they used? Questions va lid ity of re pr e sse d me mor ie s? Disr e g a rd s th e po ssi bil ity of fa lse me mor ie s? Do e s n ot m e nti on the po ssi bil ity of fa lse me mor ie s? c Wha t di sc ov e ry me tho ds sh ou ld b e us e d to se a rc h f or sa lie nt c hil dh oo d e ve nts when r epre ssed memories a re suspe cted? d. Should the validity of memories r eca lled during thera py be ver ified by means oth e r t ha n th e c lie nt' s me mor y ? At tr ibu te s th e lik e lih oo d o f p a st s e xua l a bu se to c lie nt s ole ly on the ba sis of pr e se nt s y mpt oms ? e. What treatment methods ar e used w hen re presse d memories ar e found. D oes trea tment involve "surviva l gr oups" a nd remova l from influenc e of f amily of orig in? f. Ca n r e pr e sse d me mor ie s b e de te rm ine d f ro m sy mpt oms su c h a s: i. I ndirec t associations: dissociation, PTS D, anor exia or bulimi a, slee ping disorders, or depre ssion. ii. Di re c t a sso c ia tio ns -se xua l di so rd e rs g What kind of training, e ducation ar e nec essar y for tre ating persons who a re suspected to ha ve bee n abused a nd their life c ourse a ffe cted by the abuse ? h. Ar e tr a ini ng e du c a tio n, or pr of e ssi on a l a sso c ia tio n s a me a s p re vio us ly ( p r e 1 9 7 0 s ) a s s o c i a t e d w i t h c o u n s e l i n g o r d o yo u t h i n k t h e r e i s a c h a n g e ? W h y? i. Have y ou hear d of the ter m survivors. Some people use it to desig nate those w ho profe ss memories of c hildhood sex ual abuse What do y ou think about this usage ? j. There is discussion of backlash in the litera ture, how is it used within y our thera py discipline? For example for ther apists who now: i. Qu e sti on the va lid ity of re pr e sse d me mor ie s? ii. or Ad vo c a te de fe ns ive me tho ds to b loc k to rt su its iii or Re fe r t o s ome re tr a c tor s

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200 iv or T alk abo ut "sho dd y prac ti ces? 11 Wha t sh ou ld ( or sh ou ld s ome thi ng ) b e do ne a bo ut t he ra pis ts w ho e lic it f a lse me mor ie s? 12. What methods (if any ) of tra ining or what assoc iation memberships should be r e q u i r e d f o r a l l t h e r a p i s t s ? a. I s there a decline of heg emony of psy chiatrists in mental hea lth and trea tment--Do y ou fee l that untrained ther apists and others with per sonal ag endas a re ta king ove r many of the a naly tic positions i n this area ? b. I s there ne ed for more c ertifica tion for psy chiatrists, psy cholog ists, psy cholog ical d e g r e e r e c i p i e n t s c l i n i c a l s o c i a l w o r k e r s ?, e t c ? B y w h o m ( a s s o c i a t i o n s ?, g overnme nt? I s there a need f or a unifie d cer tification)? I ssues How ar e memorie s, espec ially false me mories, construc ted in society ? (More broadly I am intere sted in how y ou perc eive diff ere nces in c onstruction by the leg al profe ssion, media, and public and pr ivate intere st gr oups as well as the other c ounseling profe ssions.) Should memories be used a s a basis for thera py ? I f so, what a re the ramifica tions of dif fe re nc e s o f m e tho ds fo r c on str uc tio n o f m e mor ie s? What are the foundations of produc ing f alse memorie s of childhood sexual abuse? What are a naly tic prac tices lea ding to f alse re presse d memories of c hildhood sex ual abuse? Question of who is making the ac cusations--the child of y ear s ag o or the a dult of n o w v a l i d i t y q u e s t i o n d i f f e r e n c e s i n b e l i e f o f t e s t i m o n y? The re sear ch sites vs. the counse ling sites (diff ere nces in sites by discipline). Wha t do y ou ha ve to s a y a bo ut t he ro le of la w i n e xpe rt te sti mon y by the se a na ly sts ? Ha ve y ou c ome a c ro ss s ta tis tic s o r a rt ic le s o n r e me mbe re d c hil dh oo d s e xua l a bu se which y ou consider of questionable va lidity ? Which? Wha t do y ou thi nk a bo ut t he ne wl y inv olv e d p ra c tic e s ( fa mil y pr a c tit ion e rs uncer tified psy chother apists, educa tional counseling psy cholog ists, and others) whe n compar ed with medica lly trained the rapists (psy choana ly sts and other psy chiatrists) and the older more traditional thera py prac tices (psy cholog ists). Who will advoca te methods confor ming to the r epre ssion paradig m rather than foc us o n t h e d i s c o v e r y o f p o s s i b i l i t i e s o f a f a l s e o r m a n u f a c t u r e d m e m o r y? Wil l students who are rese arc hers/ac ademicia ns offe r more c avea ts to confrom more closely to scientific methodolog y than those written by clinicians. (Va ntag e Point Diffe renc es). Ar e dis c ov e ry me tho ds v e ri fi c a tio n a tte mpt s, a nd tr e a tme nt d e sig ns c on du c ive to fi nd ing re pr e sse d me mor ie s a nd e xclu siv e of po ssi bil iti e s f or dis c ov e ry of fa lse memories? (Methodolog ical Diff ere nces) Saliency of the re presse d memory conce pt for the r esea rch pa rticipant and a ttitude toward the strug g le for c ontrol in mental health and profe ssional dominance" by the

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201 medical a nd traditional profe ssions can be studied throug h examination of the usag e of va lue la de n te rm s a nd iss ue s a s a pp lie d b y re sp on de nts

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202 APPENDI X F UNDERSTANDI NG THE SUB J ECTS’ PERS PECTI VES I f we are analy zing how a te x t works, we should not for g et how our ow n te xt ha s it s o wn na rr a tiv e str uc tur e d e sig ne d to pe rs ua de the re a de r t ha t, confr onted with any g iven textual frag ment, ‘we can se e that’ a favour ed rea ding a pplies. (Silverman 1993, 75-6) Be low are data a nd finding s from the c onversa tional analy sis for the first two interviewe es. Diff ere nt perspec tives were discerne d: Lang uag e of M or al E xa c ti tu de Kar en, a doc tor of educ ational counse ling, wa s a license d mental hea lth counselor. Throug h the interview she bec ame a person—a living re prese ntation of a pa rticular point of vie w i n th e his tor y of the ra py H e r i nte rv ie w, a fr e e ly -o ff e re d s tor y of he r p la c e in thera py provided me w ith my first data f or under standing thera pists and their view of the line betwee n g ood and bad the rapy at this point i n theory and pra ctice of thera py What he r r ole ha s b e e n, wh a t sh e thi nk s a bo ut o the r t he ra pis ts, a nd wh a t sh e fe e ls a bo ut h e r r ole and the line be tween g ood and unac cepta ble pra ctices of the other the rapists ca me out during the interview from a mor al-leg alistic perspe ctive. This interview of K are n was mar ked with hesitations and re quests for clar ifications. Since Ka ren’ s responses indica ted that intellige nce w as not an issue a nd sin c e the int e rv ie w p ro be s w e re so g e ne ra l, I su sp e c te d th a t sh e wa s tr y ing to a sc e rt a in m y po sit ion a s in te rv ie we r b e fo re g ivi ng he r o wn a ns we rs on so me of the c on c e pts I wo uld ha ve to r e ph ra se the pr ob e in s e ve ra l di ff e re nt w a y s b e fo re sh e wo uld c ome fo rw a rd wi th

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203 her f eeling s or thoug hts. The ver y first and unde manding task—putting the c ontent car ds in order—r equire d my input severa l times. (The conte nt car ds were discussed in Chapter 4.) Secondg uessing of my motives beca me evident a t this poi nt and continued to a g rea ter or le sser de g ree throug hout the interview. Sin c e sh e wa s th e fi rs t su bje c t I int e rv ie we d, I bo re in m ind tha t so me of my qu e sti on s mi g ht n ot h a ve the po lis h th a t su bs e qu e nt i nte rv ie ws wo uld pr ov ide Si nc e it wa s n e c e ssa ry to e lic it h e r s tor y on the c on c e pts a nd he r p la c e in t he ra py I a tte mpt e d to eliminate, as much a s possible, interactions as a n interviewe r that would influenc e her answe rs. I did this by limit ing my probes to providing conce pts and asking what she thought a bout them and there afte r using her a nswers a s spring boards f or deta il and exploring links betwee n the conc epts. The pa rticular c oncepts on the c ards ha d been chosen a s the terms that we re most often a pplied in articles whic h discussed re pression and the line be tween a cce ptable and una cce ptable ther apy prac tices and te chniques. Due to m y g ro un din g in t he vo c a bu la ry of the se top ic s f ro m my lit e ra tur e re vie w, I wa s a ble to take c are to rephra se questions in way s that eventua lly allowed he r to unveil her ow n trajec tory rathe r than fr om any vantag e that I might provide Although K are n appea red e x tremely eag er to do the inter view and pr oved to have a se ns e of hu mor I ha d d if fi c ult y in g e tti ng he r t o r e sp on d to pr ob e s. Ma ny tim e s w ith in the int e rv ie w I ha d th e imp re ssi on tha t sh e wa s a wa iti ng a c ue fr om m e a s to ho w I fe lt about a pa rticular issue. She c omplained, thoug h laug hingly of the g ener ality of the “ qu e sti on s. ” I e xpla ine d to he r t ha t th e qu e sti on s w e re to g ive he r a ll t he le e wa y po ssi ble to direct the te nor of the r esponses.

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204 Th is s e a rc h f or c ue s b e c a me a pp a re nt f ro m th e ve ry on se t of the int e rv ie w, a s I g a ve he r t he c on c e pt c a rd s a nd a sk e d h e r t o p ut t he m in or de r. I t to ok ne a rl y fi ve fu ll minutes for her to select five of them. M i k e: Fi rs t I h av e s o m e c ar d s an d I wo u l d l i k e y o u t o j u s t go t h ro u gh them and put them in order Kar en: Oh, my g oodness. Put them in order in terms of. . Mike: Of wha tever Kar en: Okay put them in an order Mike: Any order K a r e n : O K A l l o f t h e m h u h ? Mike: Yea h . there are some of them that ar e re peats. Kar en: This is projective? Good thing this is not a video looking at me. (B oth laug h). . Mike: At least the five that y ou think are most important. Kar en: Most important . hmh t e hmm hum (humming). As time continued to pass I reminded he r of the topic of the interview Mike: What we ar e looking at is the line betwe en g ood prac tice and questionable pra ctice. K a r e n : T h a t s h o w y o u w a n t m e t o t h i n k a b o u t t h i s a s I s o r t ? Mik e : Ye a h th a t' s o ne of the ide a s, a nd wh e re the ra py is n ow a t th is po int About four minutes af ter I had first a sked her to select the f ive topics from the c a rd s, sh e sa id: Kar en: I know what I am g oing to do—just dec ided what I am g oing to do wi t h t h es e. (Ind ec i p h er ab l e) . p ro ce s s i t an d o n e o f t h e t h i n gs that g et sorted a re pe ople with tests like these ar e quick to make

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205 ju d g me n ts o r th e y th in k a b o u t t h e p o s s ib il it ie s f o r e v e r [l a u g h s ] I k n o w. I k n o w, b u t I 'm j u s t t h i n k i n g. . Yo u 'v e go t s o m eo n e w h o 's g onna try to think li ke, Well if I put these, then wha t will that mean." Rather than Oh this, this, t his, this.” A minute of uninterr upted silence ensued, w ith no sound ex cept the sound of her, fl ipp ing thr ou g h th e c a rd s. Th e n s he sa id, Ok th e n th e se a re a ll n ot d on e ," ind ic a tin g a ll but five of the c ards. I t was only afte r I had sug g ested that she c ould use the topic of the interview a s a g uide that she made had prog ress in her selec tion. W hile it is poss ible that this one cue influe nced he r to use a le g al per spective in he r re sponses throug hout the int e rv ie w i ns te a d o f o the r r e sp on se s ( so me of wh ic h a re c ov e re d b e low ), re pe tit ion of thi s theme showe d that it was not the dec iding f actor As the interview rea ched it' s final stag e, she r eturne d to a consider ation of the c on c e pt c a rd s. Ra the r t ha n f oc us ing on the lin e be tw e e n a c c e pta ble a nd un a c c e pta ble prac tice she r elated tha t she order ed the c oncepts a ccor ding to he r “pr ofessional interests.” Ka re n: Do y ou wa nt t o k no w w hy I . . Ho w I or de re d th e m? Mik e : I kn ow ho w y ou or de re d th e m. Kar en: No, no. B ut, why I mean ha ve y ou fig -, in terms of. . Mik e : Why did y ou or de r t he m. Kar en: What did I put? ‘Do no ha rm . for I do believe that above a ll. Uhm. I put these. . (F umbling with ca rds on her lap) Oops! I won' t lose them. I n order of my sort of prof essional intere sts. (Lau gh ) Y ea h y ea h M ea n i n g wh at d o I ch o o s e t o go t o t ra i n i n gs a bo ut. Wha t do I lik e ta lki ng a bo ut t he mos t, w ha t do I w ha t a m I mos t c ur iou s a bo ut t he se da y s. An d, I a m in te re ste d in fo re ns ic work, so I . . Yea h. That' s why I put law and menta l health up there I m very I find criminals endle ssly fasc inating.

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206 I was una ble to deter mine definitively whether she wa s just nervous at being interviewe d or ca ref ul due to her of ten expressed intere st in lega l matters when c on fr on te d w ith ma tte rs a s c on tr ov e rs ia l a s th e c on c e pts of a c c ou nta bil ity e thi c s, repr ession, and re g ression thera py As the interview proce eded, she was a ble to answe r probes on these seeming ly without undue nervousne ss, leading me to conclude that her objection to the g ener ality of the probe s was more likely due to her interest in leg al exactitude and equa ting mora lity with leg ality Two other e x cer pts also indicate her “mock” objection to the g ener ality of q u e s t i o n s a g a i n l a u g h i n g l y: 1. Mike: Okay Now wha t do y ou think, perce ive of > Kar en: (L aug hs) nohohoh. Mike: > the law in terms of abuse child abuse? 2 M i k e : W h a t d o y o u t h i n k a b o u t a n o r e x i a a n d b u l i m i a ? Kar en: [ex haling and laug hing] Your que stions are so openended I think the ir a ww fu l. Mike: Do y ou think that that's a [l aug hs]. . Kar en: I think they ’re awf ul and I don' t (laug hing) wish it on any one. [l a u g h s ] Mike: Well, I want to see wher e y ou g o with it, in t erms of > Kar en: Yea h. L ike if y ou’re . . After raising the objection in both instances, she immediately responde d to the initial probes. Although he r interview was my first and my delivery may not have be en as po lis he d a s it la te r b e c a me s he sp ok e in a la ng ua g e of mor a l c or re c tne ss. Ka re n, wh o in addition to her Ph.D. in educa tional counseling was a licensed me ntal health counse lor,

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207 evince d her inter est in, and commitment to, leg al cor rec tness far more ofte n and emphatica lly than the other interviewe es. Th is w a s d e mon str a te d in thr e e wa y s d ur ing the int e rv ie w. F ir st, sh e dir e c tly stated that she wa s interested in leg al matters. Sec ond, in adaptation to this, she spent much more time in discussing leg al aspe cts of ther apy and ce rtification than a ny of the other intervie wee s. Third, three of the five conce pt car ds she selec ted for disc ussion ( pr im um no n n oc e re —“ do no ha rm ,” e thi c s a nd the ra py a nd a c c ou nta bil ity a nd la w) a ll contain ele ments of morality and leg al substance Her protrac ted attention to choice of car ds evince s the signif icanc e of the se par ticular sele ctions. Her insistence on seeing the conce pt car ds as a test, ra ther than me rely an orde ring desig ned to provide a rea s of dis c us sio n, wa s n ot d up lic a te d b y su bs e qu e nt i nte rv ie we e s. Langu age of Pr ecision Gail, a Ph.D. in clinical psy cholog ist, evinced a ssuranc e, compe tence compre hensivene ss, and pre cision. She did this i n sever al way s. Throug hout the interview he r deme anor w as re laxed. Her tone of voice wa s well modulated and e ven. She almost alway s used complete, c ompound, and cohe rent sente nces. H er e x positions wer e so cohe rent that I would have thoug ht that she saw the c oncept c ards be fore the interview if I had not known that she c ould have little idea of what the pr obes would or could be. She would cover a topic to her satisfac tion without s eeking approva l (e.g ., asked for c larifica tion of probes be fore delivering her r esponse; pre sented he r fe eling s on controve rsial issues—reg ression thera py use of r italin, etc.—matterof-f actly ). She ver y seldom used superf luous phrases or words: “y ou know,” “ I mean,” “uh,” “ er,” or eve n

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208 silences, whic h are often used in spe ech to indica te discomfort, that the spe aker is putti ng her/his thoug hts toge ther a nd will have more to add, or that ther e is a bre ak so that the other pe rson ca n take a discussion turn. When she had finished on a topic to her sa tis fa c tio n, sh e wo uld de fi nit ive ly sto p a nd wa it f or the ne xt pr omp t. Whe n s he fe lt t ha t sh e ha d c ov e re d a top ic a nd ha d n oth ing mor e of re le va nc e to add, she w ould list en to what I was say ing a nd indicate he r attention by say ing “ um hmm ,” bu t w ou ld n ot a dd to t he c on ve rs a tio n u nle ss s he ha d s ome thi ng me a nin g fu l to say For example, late in the interview I broug ht up the topic of ethics f or a se cond time. Ea rl y in t he int e rv ie w s he ha d ta lke d a bo ut h e r s e le c tio n o f t he “ a c c ou nta bil ity a nd e thi c s” conce pt car d. As a re newe d probe on e thics, I noted that published standar ds of ethics we re ve ry sim ila r a mon g the the ra py dis c ipl ine s. Mike: Yea h. I n my revie w of the e thics, the statements on ethics in ea ch of these disc iplines that I ’ve me ntioned—they ’re . very simil ar. Ga il: Um hmm Mik e : Uh a nd it’ s a So it’ s. I t se e ms l ike tha t uh th e re ’s a c e rt a in e l e m e n t o f u h c o m m o n a l i t y > Ga il: Um hmm Mike: > alr eady Ga il: Um hmm Mike: And they ’re . . Gail: Also y ou g ot . . Mike: I mean, I ’m I ’m not advoca ting a position here. Gail: Um hm Mike: I ’m, y ou know, >

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209 Gail: Umhm Mike: > stating what I what I know > Gail: (indec iphera ble) Mike: > to g et y our > Ga il: Um hmm Mike: > fe edbac k acr oss from it. . Ahm, I I ’ve, I don’t know, but I but I wonder y ou know, shou-should there should uh there be a na tio na l, s ome kin d o f n a tio na l in pu t? and if so w ha t? Fr om her use of “um hmm” to show that she under stood what was be ing sa id but not chose not to pick up her turn in the conve rsation at obvious brea k points, revea led that she had sa id what she wa nted to say on ethics ea rlier ( very concise ly and thoroug hly ) and did not respond to my cues to a dd comments about similarities or diffe renc es betwe en the disciplines, which she mig ht have noted. She sta rted to say something onc e but stopped and I did not pick up on it enough to a sk more dire ctly I n the end I asked dire ctly for he r fee dback. G etting a period of silenc e to that probe and no fur ther a nswer, I then re luc ta ntl y mov e d to a no the r r e la te d c on c e pt f e e lin g tha t so me thi ng ha d b e e n le ft un sa id a nd tha t I ha d b e e n u na ble to e lic it i t. When I asked if she paid much attention to cour t case s and par ticularly about the Ramona case she said, “I ’m not sure, but just let me know.” I explained the ruling on the case and the f ollowing inter chang e tra nspired: Mike: Did any of that bec ome fa miliar to y ou as y ou rea d that particula r c a se o r a bo ut i t? Gail: I haven’ t hear d about that ca se bef ore. Mik e : Do y ou kn ow a bo ut t hir dpa rt y la w s uit s?

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210 Ga il: Uh m. Mik e : Or did y ou kn ow be fo re I ta lke d a bo ut i t? Gail: No. Since the only information she ha d on this came fr om me as interview er, w ithout a po log y Ga il w ou ld n ot a nd c ou ld n ot p ro vid e a n a ns we r t ha t w a s a ssu re d, c omp e te nt, compre hensive, or pr ecise She did not speculate dur ing a ny seg ment of the intervie w.

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216 M i l l e r G a l e 2 0 0 1 C h a n g i n g t h e S u b j e c t : S e l f C o n s t r u c t i o n i n B r i e f T h e r a p y I n J. Gubrium & J .A. Holstein (Eds.). Institutional Selve s: Troubled Identities in a Po stm od e rn W or ld (p p. 64 -8 3) N e w Y or k: O xfor d U niv e rs ity Pr e ss. Napoli, Donald. 1981. Architects of Adjustment: The History of the Psy chological Profession in the United States Po rt Was hin g ton N Y: Ke nn ika t Pr e ss. Nelson, Eric L & Simpson, Paul. 1994. First Glimpse: An I nitial Ex amination of Subjects Who Have Recove red V isualiz ations as Fa lse Memories. Is su e s in Chi ld Abuse Ac cusations 6(3): 123–133. Newma n, David M. 2000. So c iol og y : E x plo rin g th e Ar c hit e c tur e of E v e ry da y Life Th ou sa nd Oa ks Ca .: P ine F or g e Pr e ss. Ofshe, Richa rd. 1992. I nadver tent Hy pnosis during I nterrog ation: False Confession Due to D iss oc ia tiv e Sta te : Mi sI de nti fi e d M ult ipl e Pe rs on a lit y a nd the Sa ta nic Cul t Hy pothesis. In te rn ati on al J ou rn al o f Cli nic al a nd Ex pe rim e nta l H y pn os is 40(3): 125156. Ofshe, Richa rd & Watters, Ethan. 1993. Making Monsters. So c ie ty : 4–16. Olio, Kare n. 1994. Truth in Memory Am e ric an Ps y c ho log ist 49(5): 442–443. Olio, Kare n A. & Cornell, Wil liam F. 1993. The thera peutic re lationship as the foundation for trea tment with adult survivors of sexual abuse. Psychothe rapy 30(3): 512–523. Paterson, Dona ld. 1992. The Doc tor of Psy cholog y Deg ree I n Fr eedhe im, Donald (Ed.). History of Psychotherapy : A Century of Change (p. 836). Washing ton, DC: American Psy cholog ical Associa tion. Pfohl, St ephen J. 1977. The Discove ry of Child Abuse. So c ial Pr ob le ms 24(3): 310-323. Pope, H. G., Jr., & Hudson, J. I 1992. I s Childhood S exual Abuse a Risk Fa ctor for Bulimia Ne rvosa? American J ournal of Psychiatry, 149(3): 455 _____. 1996. Recove red Me mory Thera py for Ea ting Disorde rs: I mplications of the Ramona Ver dict I nte rn ati on al J ou rn al o f E ati ng Di so rd e rs 19(2): 139–45. Punch, Maurice 1985. Conduct Unbec oming : The Social Construction of Police De viance and Control New Y ork: Tavistock Publications. Ra mo na v I sa be lla e t al 1994. Napa Superior Court Case No. 61898, N apa, CA. Riesmann, C. K. 1993. Nar ra tiv e An aly sis Newbur y Park, CA: Sag e.

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217 Ror ty M a rc ia ; Y a g e r, Joel ; a nd Ros so tto E liza be th. 19 94 Ch ild ho od Se xua l, P hy sic a l, and Psy cholog ical Abuse in Bulimia Ner vosa. Am e ric an J ou rn al o f P sy c hia try 151(8): 1122-1126. Ry an, Willi am. 1976. Bl am ing the Vi c tim (re v. ed.). N ew Yor k: Random House. S c h e i b e r S t e p h e n 1 9 9 4 T h e P s y c h i a t r i c In t e r v i e w P s y c h i a t r i c H i s t o r y a n d M S E In Hales, R. E.; Yudofsky S. C.; & T albott, J A. (Eds.). The American Psychiatric Pre ss Textbook of Psyc hiatry 2 e dit ion (p p. 18 722 0) Wa sh ing ton D C: nd Am e ri c a n Ps y c hia tr ic Pr e ss. Showalter, Elaine 1997. Hy sto rie s: Hy ste ric al E pid e mi c s a nd Mo de rn Cul tur e New Yo rk : Co lum bia Un ive rs ity Pr e ss. Silverman, David. 1993. Interpreting Qualitative Data: M ethods for Analyzing Talk, Text, and Interac tion L ondon: Sage S k o w J o h n 1 9 9 4 C a n M e m o r y b e a D e v i l i s h I n v e n t o r ? Time, May 16(7): 1, 33, 35, 37, & 38. Sor e ns e n, T. & Sno w, B 1 99 1. Ho w C hil dr e n T e ll: Th e Pr oc e ss o f D isc los ur e in C hil d Sex ual Abuse. Child W elfare, 70(1): 3–15. Street, W. R. 1994. A Chronology of Notewort hy Ev ents in American Psy chology Washington, D.C.: Americ an Psy cholog ical Associa tion. Tar as off v R e ge nts of t he Un iv e rsi ty of C ali for nia 17 Cal.3d 425 (1976). Terr L enore 1994. Unchained M emories: True Stories of T raumatic Mem ories, Lost and Found. Ne w Y or k: B a sic B oo ks Thomas, W. I 1966. W I Th om as on So c ial Or ga niz ati on an d P e rso na lit y ( Mo rr is Jano wi tz, e d. ). Chi c a g o: U niv e rs ity of Chi c a g o Pr e ss. W e e n e K A 1 9 9 3 I s C h i l d h o o d S e x u a l A b u s e a R i s k F a c t o r f o r B u l i m i a ? American Journal of Psychiatry, 150 (2): 357–358. Wellford, Charles. 1975. L abeling Theory and Criminology : An Assessment. Social Pr ob le ms 22(F ebrua ry ): 313–32. W es t l ey W i l l i am A. 1 9 7 0 S ec re cy an d t h e P o l i ce I n Ni ed er h o ff er A. an d Bl u m b er g, A. S. (Eds.) The Ambivalent Forc e: Pe rspective on the Police (p p. 12 913 2) Wal tha m, MA: Ginn and Co.

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218 Whit aker Robert. 2002. Mad in Americ a: Bad Scie nce, B ad Medic ine, and the Enduring Mi str e atm e nt o f th e Me nta lly Il l Ca mbr idg e M A: Pe rs e us Whit field, Charle s L 1995. Me mo ry An d A bu se : R e me mb e rin g a nd He ali ng the Ef fe c ts of Trauma D e e rf ie ld B e a c h, F L : H e a lth Com mun ic a tio ns Wil liams, Mary R. 1996. Sui ts by Adults for Childhood Sex ual Abuse: L eg al Orig ins of the “Repr essed Me mory ” Controver sy Journal of Psychiatry & Law, 24(2): 207– 228. W o o l e y S u s a n 1 9 9 4 S e x u a l A b u s e a n d E a t i n g D i s o r d e r s : T h e C o n c e a l e d D e b a t e In Patricia F allon, Melanie A Katzman, & Susan C. Wooley (Eds.). Feminist Perspec tives on Ea tin g D iso rd e rs (p p. 17 121 1) N e w Y or k: N Y: Gu ilf or d Pr e ss. Wright, L awr ence 1994. Reme mbering Satan New Y ork: Knopf. Young Alison. 1993. Femininity in Dissent. Sig ns 18:3: 688–693.

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219 B I OG RA PHI CA L SKE TCH I wa s b or n a t ho me in L ub bo c k, Te xas, No ve mbe r 2 1 94 0. Th e do c tor wa s la te but I was not. My childhood was ha ppy and ac tive with three br others and thr ee sister s. Thoug h poverty -stricke n, both of my pare nts devoted their lives to making our lives happy and fr uitful. I g r a d u a te d f r o m M o n te r e y H ig h Sc h o o l i n L u b b o c k T e xa s in 1 9 5 9 T h e n e xt y ear I started my colleg e educ ation with a psy cholog y course from the Unive rsity of California Extension in S an F ranc isco. I studied at City College San Fr ancisc o, from Spring 1961 throug h Spring 1963; San F ranc isco State from F all, 1963 to Spring 1965 and Summer of 1967; San F erna ndo Valley State College Northridg e, California from Spring 1966 to Spring 1967; Way land B aptist Coll eg e, Plainview, Te x as, in the Summer and F all of 1981; and Te x as Tec h University from F all of 1992 to Spring 1997. I rec eived a Ba chelor of Arts de g ree in sociology with a psy cholog y minor Dec ember 18, 19 93 a nd the n a Ma ste r o f A rt s d e g re e in s oc iol og y fr om T e xas T e c hn olo g y Un ive rs ity May 10, 1997. I also attende d the Univer sity of F lorida fr om Fall, 1996 to Spring 2002, and Summer and F all, 2004. During my adulthood, I held many jobs—from in the trade s, throug hout the cl er i ca l re al m o wn i n g a b u s i n es s an d t ea ch i n g i n a p ro p ri et ar y s ch o o l an d i n a h i gh school. I moved from L ubbock to Ft. Or d, California, in 1959 and the n to San Fra ncisco in 1960. I lived in many cities in California including about five y ear s eac h in San F r a n c is c o a n d B e r k e le y I mo v e d to B o s to n in 1 9 7 5 a n d to M a d is o n Wi s c o n s in th e n e xt

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220 y ear I moved bac k to L ubbock in 1976. I lived in Gainesville, F lorida, fr om 1996–2002, when I moved to L afa y ette, L ouisiana, to teac h at the Univer sity of L ouisiana at L afa y ette, whe re I am cur rently I wa s ma rr ie d in 19 63 a nd div or c e d in 19 65 I re ma rr ie d in 19 76 a nd div or c e d in 1989. Eac h marria g e blessed me with a son, Eric L ee Ry an and Wesley Gilbert Ry an, and cur sed me with the leg al pain of be ing se para ted from their socialization during much of their c hildhoods. My plan af ter re ceiving the Ph.D. is to teach a nd do rese arc h at a tobe -d e te rm ine d u niv e rs ity a nd be a s a c c e ssi ble a s p os sib le fo r m y so ns w ho re sid e in California a nd Texas.


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THE REPRESSION POLEMIC: CONSTRUCTING NORMALCY
AND DEVIANCE WITHIN THERAPY DISCIPLINES
















By

MICHAEL RYAN


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2004






























Copyright 2004

by

Michael Ryan































I dedicate this dissertation to my parents, Pansy Anna Kelly-Ryan and Venice
Alton (Pete) Ryan, Sr., who have dedicated their lives to their children. I also dedicate it
to Eric Lee Ryan and Wesley Gilbert Ryan, my children, who have filled my heart and
thoughts with joys and pains every day of my adult life. My brothers and sisters (Alton,
Danny, Kay Ryan-Niemeyer, Louis, Rita Ryan-Pinner, and Linda Ryan-Waddell) have
supported my efforts throughout, and cheered me in my endeavors. Finally, I dedicate my
dissertation to all of the non-traditional students who will join me in fulfilling the dream
of sailing the academic-scholar ship once again.














ACKNOWLEDGMENTS

I received a tremendous boost from Dr. Lonn Lanza-Kaduce, chairman of my

supervisory committee. Dr. Lanza-Kaduce picked up on the depth and intricacies of

possibilities of the research and encouraged me, while giving me leeway to develop. His

assistance in the final stages of the writing verged on heroic. The advice and assistance in

research of my other committee members (Dr. Ronald L. Akers, Dr. Richard Hollinger,

Dr. Constance Shehan and Dr. Joseph Spillane) contributed greatly to the success of this

dissertation. I cannot express sufficiently my gratitude for Dr. Terry Mills and Dr. Chuck

Peek, who saved me by substituting at the last minute when a member could not be there

during my hearings. The thoughtful suggestions and review by all the above have helped

keep me focused while confronting the confounding morass of inter- and intra-

disciplinary, micro/macro research. Dr. Jaber Gubrium also provided a tremendous

amount of information and assistance on the qualitative elements of the dissertation while

he was at the University of Florida. While I was happy at his promotion to chair another

sociology department, I sincerely regretted his absence for the final stages of the

dissertation.

I do not know how my dissertation would have been completed without the

sociological discussions with my friends, Dr. Sylvia Ansay, Dr. Amir Marvasti, and Dr.

Erica Owens. On numerous occasions when complicated concepts and hard and

discouraging days cooled the embers of my endeavors, they stoked my passion by

providing sorely needed compassion, insightful observations and helpful suggestions.









Drs. Felix Berardo, John Scanzoni, and Hernan Vera all offered me advice and

encouragement to complete this work even though none were on my. I am very grateful

for the assistance and advice on teaching issues tendered by Drs. Marian Borg and Chuck

Peek. Without their help I would have needed hours and hours of time away from my

dissertation. I am deeply appreciative of the devotion to scholarship and to graduate

members of the Sociology Department exhibited by all these professors.

Drs. George Lowe and Charley Peek of Texas Tech University were instrumental

in the earliest phases of planning my dissertation; and their concern from afar was very

heartening during many times when my progress was less than I hoped. Many unnamed

professors at both Texas Tech University and the University of Florida provided

encouragement through their own exemplary scholarship and devotion to academia.

















TABLE OF CONTENTS


page

ACKNOWLEDGMENTS .......... ,, .....,, .......... iv


ABSTRACT ......,,,.........,,, ........., viii


CHAPTER


1 INTRODUCTION .......... ............. .......


2 THERAPISTS' CONSTRUCTIONS OF THERAPIST DEVIANCE .. .. .. .. 7


"Soft" Reactive Defilnition of Deviance .. . . .. . .. 8
Constructionist Versus the Essentialist View of Deviance .. .. .. .. .. .. .. .. 16
Elite-Engineered Deviance? ......... . .. . .. .. 18
Formal and Informal Labeling of Therapists ... .. .. .. .. .. .. .. .. .. 18


3 HISTORY OF NORMALCY, DEVIANCE, AND CHANGE IN THERAPY 22


Therapy and Change ........... .... ., .......... ...,.........22
Emergence of Modern Psychiatry, Psychology, and Social Work . . 24
Variety of Therapies: The 20th Century . ... ... .. .. .. .. 29


4 REGRESSION POLEMIC ............... .................. 39


TheDebate ........... .. ...... ...... ...........39
Contexts of Therapy-Assisted Self Construction .. .. .. .. .. . .. .. .. 43
Consequences for Therapists and Clients . . .. .. .. . 47
Labeling and Imputing Victimization . .... .... .. .. .. 50


5 METHODS ............... ......... .............54


Subj ects/Interviewees/Resp ondents . ...... ..... .. .. . .. 5 6
Interviewing ............., .............. ......,58
AnalyzingInterviews ............... ....................62











6 ORIENTATIONS TO THERAPY ............... .............. 65


Interviews with Licensed Clinical Social Workers .. .. .. .. .. .. .. .. 66
Overview of How LCSWs Define Therapy Practices and Therapists .. .. .. .. 76
Interviews with Psychologists and an Educational Counselor .. .. .. .. .. .. .. 81
Overview of How Psychologists and a Counselor Define Therapy Practices and
Therapists ......... .............. ...........95
Interviews with Psychiatrists . . . . . 101
Overview of How Psychiatrists Define Therapy Practices and Therapists .. 107


7 MEMORY, SUPPRESSION, AND REPRESSION . . .. ... 109


M.S.W.s on Memory, Repression, and Regression Therapy .. .. .. .. .. .. .. 126
Ph.D.s on Memory, Repression, and Regression Therapy . . .. 126
M.D./Ph.D.s on Memory, Repression, and Regression Therapy . . 127


8 ACCOUNTABILITY AND ETHICS . .... .. .. .. .. 129


M.S.W.s on Accountability and Ethics . . .. .. . 140
Ph.D.s on Accountability and Ethics . ..... ..... .. . .. 141
M.D./Ph.D.s on Accountability and Ethics .. .. .. . ,. .. .. .. .. 142


9 LEGALISSUES AND THERAPY ............... ............. 143


Certification and Licensure ......... .. ..... . .. 145
Ramona v. Isabella and Third-party Suits . . .. .. .. .. 158
Mandatory Reporting of Abuse ......... .. ...... .. . .. 170


10 CONCLUSIONS AND DISCUSSION ............. ...........182


Orientations to Therapy .. .. . .. ..... . .. .. 183
Importance of Memory, Suppression, and Repression .. .. .. .. .. .. .. .. .. 186
Accountability and Ethics ............... .............. 188
Legal Factors ............... .......... ...........191

APPENDIX ............... ..........................193


A CONTACT LETTER ............... .............. ... 193


B INFORMED CONSENT FOR INDIVIDUAL INTERVIEW . . 194


C DEMOGRAPHIC DATA .......... ,, .... ....,,.....196


D CONTACT PHONE CALL .............. ............... .197












E TYPES OF PROBES USED ............... .............. 198


Topics (With Possible Questions) ....... .. ... .. .. .. 198
Issues .......... ...........200........


F UNDERSTANDING THE SUBJECTS' PERSPECTIVES .. .. .. .. .. .. .. 202


Language of Moral Exactitude ......... .. .. .... .. .. .. 202
Language of Precision ......... . ... .. .. .207


REFERENCES .......... ...........211........


BIOGRAPHICAL SKETCH ......... . . .. .. .219














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

THE REPRESSION POLEMIC: CONSTRUCTING NORMALCY
AND DEVIANCE WITHIN THERAPY DISCIPLINES

By

Michael Ryan

December 2004

Chair: Lonn Lanza-Kaduce
Department: Sociology

My research adds to the sociology of deviance. Labeling and reactions to

deviance by therapists are examined. The debate over orientations toward the discovery

of repressed memories, and reactions to this debate, are used as a starting point for this

examination of how deviance is constructed by therapy practitioners. Interviews of

certified and/or licensed practitioners in the three major therapy disciplines of mental

health (clinical social workers, clinical psychologists, and psychiatrists) are subjected to

qualitative analysis.

This inquiry discusses the narratives of ten therapists who revealed four major

areas for conceptual analysis. These are orientations to therapy; memory, suppression and

repression; accountability and ethics; and the interaction of legal issues and therapy.

While little difference was found between the narratives when examined by discipline,

arenas of individual differences were uncovered.









Training did not seem to affect orientations to therapy. The therapists all related

narratives stressing problem solving in the present. Their definitions of good practice

included maintaining confidentiality, doing no harm to the client, and following an

agenda coming from and about the client rather than the therapist. Few of the therapists

used any practices that are essential for extracting repressed memories. The line between

normative practices and deviance was seen to be crossed when the above were violated.

While professional and legal sanctioning of deviant actions was advocated, the

therapists who commit breaches were seen as impaired. Remedy was expressed in terms

of how to get these individuals "repaired" and back to normative practice. Organizational

or institutional remedies were seldom recommended (e.g., change in socialization, closer

monitoring by local boards, national registries of deviance, etc.). Reclamation rather than

proactive action was advanced in all but two interviews. Conducting the research also

provided insights into problems encountered in cross-disciplinary study--namely the

study of therapy discipline (and effects of legal sanctioning) from a sociological vantage.














CHAPTER 1
INTRODUCTION

This dissertation examined how the labeling of deviance is affecting mental health

therapy. It contributes to understanding the construction of deviant therapy practices. To

this end, it considered the following: how therapists with different training and various

kinds of practices think about deviance in their work (i.e., how they draw the line

between "good" and "bad" applications/therapists); how professional ethics and training

affect therapists' constructions; and how therapy and legal developments that regulate

practice play off each other. Because important legal developments have keyed on

childhood sexual abuse and the discovery of memories, the controversy over regression

techniques that recover "repressed" memory provides a strategic site for studying how

deviance is constructed and normative practices affected.

Before the 1960s, the term "child abuse" was not in general usage. In 1967 there

were 7,000 cases of reported child abuse and neglect, but by 1981 there were 1.1 million

reported; and in 1989, 2.4 million (Hacking 1991). Child abuse had to be constructed as

deviance (Pfohl 1977), and was responded to accordingly. Not surprisingly, part of the

reaction to the problems associated with child abuse involved therapy. Some therapy

techniques were expanded or developed, including regression therapy, to meet the needs

of victims. Because the discovery of child abuse reflected changing definitions and

constructions as much as abusive behaviors, many victims entered adulthood without










having had their abuse treated or even recognized. The promise of regression therapy was

that it could address how past abuse was a factor in current problems.

The increase in the popularity of regression therapy can be documented. A review

of the professional and academic journals covered in Sociofile reveals that before 1965,

only one article contained the word "repression." From 1965-1975 there were 142

entries, 1976-1985 contained 483, and 1986-1995 had 672 entries.

This dissertation takes advantage of the changing constructions of child abuse to

study controversial therapy techniques and shed light on how the delivery of therapy may

be constructed as deviant. The concept of "Repression" as used in this research involves

lessening access to an unpleasant memory with the following characteristics: 1)

traumatic or negative events occurred to the person, 2) memory of that/those events

cannot be recovered by normal memory processes, 3) the repressed memory affects the

person's present behavior, and 4) the way to cure the effects of repression is to make the

event conscious and relive it.

My study adds to the sociological tradition of studying the construction of

deviance and the effects of deviance labels. Some examples of research in that tradition

illustrate the wide range of topics that informs our knowledge about deviance. Erikson

(1966) examined the construction of witchcraft by Puritan society. Construction of

deviance between officers by police internal organizations was studied by Punch (1985).

The construction of computer crime by lawmakers was detailed by Hollinger and

Lanza-Kaduce (1988). Gubrium and Holstein (1990) found that deviance in families can

be constructed by therapy organizations. Construction of addiction by practitioners and










researchers was recounted by Akers (1991). Holstein (1993) found that mental illness can

be constructed by attorneys in competency hearings.

A more complete exposition of how the study of therapy fits within a

comprehensive deviance framework is presented in the next chapter. By way of

introduction, suffice to say that the study of deviance poses two central issues according

to Akers (1977, 13) "how and why certain kinds of behavior and people become defined

and reacted to as deviant" and 2) "how and why some people come to engage in actions

or acquire the characteristics defined as deviant." Much of the study of deviance and

crime focuses on the second issue. The labeling or social-reaction perspective draws our

attention to the former, and focuses on "the behavior of those who label, react to, and

otherwise seek to control offenders" (Cullen & Agnew 2003, 295; emphasis in the

original) .

Social groups create deviance by making the redes whose infraction
constitutes deviance, and by applying those rules to particular people and
labeling them as outsiders. From this point of view, deviance is not a
quality of the act the person commits, but rather a consequence of the
application by others of rules and sanctions to an "offender." The deviant
is one to whom that label has successfully been applied; deviant behavior
is behavior that people so label. (Becker 1963, 9; emphasis in original)

The labeling perspective is similar to the conflict approach in emphasizing the

formation and application of definitions. Indeed, the two approaches have become so

closely identified in arguing that social interactions to deviance are unequally applied

against the less powerful groups that some sociologists see conflict and labeling theorists

as almost interchangeable (Hagan 1973, Wellford 1975).

The question of how labels are applied, therefore, revolves around the issue of

power. The behavior of less-powerful groups or individuals is more likely to be defined










as deviant; more-powerful groups or individuals are in a better position to resist labeling,

or to negotiate when or how behaviors are labeled (Hawkins & Tiedeman 1975).

The study of therapy and therapists involves groups and individuals that possess

education, status, and some level of power. They are not free to disregard external efforts

to regulate their practices and must work within the existing legal structure. As

professionals, they enjoy considerable autonomy over their work, and belong to

professional associations that are often successful in insisting on self-regulation through

certification and codes of ethics.' When professionals fail to regulate themselves

sufficiently, there is great pressure for external constraints.

Therapists hail from different training backgrounds, and therapy cuts across

different disciplines and schools of thought. Abbott (1988, 325) reminds us that we must

"start studying work" rather than the profession. He calls for the study of the history of

the work, who was involved and where they came from, how markets for their services

were created, and how conflicts shaped those who practiced.

Deviant therapy practices are the concern of both professional associations and the

law. The professional associations to which therapists belong promulgate ethical codes

and standards of practice in an effort to regulate therapists and therapy. Professional

associations also provide certification. Such efforts represent a form of self-regulation.

My study focused on how the practice of therapy has been affected by this self-regulation,




SCodes of ethics for therapists are similar to each other. These codes can be found through the national
organizations or online at:
1) National As sociation of Social Workers: http ://www.socialworkers .org/pub s/code/code.asp
2) American Psychological Association: http ://www.apa.org/ethics/code2002 .htin1
3) American Psychiatric As sociation: http://222.p sych.org/apa_1einbers/ethics~opinions53 10 1
.cfin










and what this effect on therapists has done to change conceptions of mental health

practice.

Deviant therapy practices can also give rise to legal controls that go beyond

self-regulation by the professional associations. One way this control is exerted is

through state licensure. Legal controls have also been imposed through court cases [e.g.,

Tarasov v. Regents of the Universityi of California (1976) and Ramona v. Isabella (1 994)]

and through legislation (e.g., mandatory reporting of abuse). Although therapists have

long been accountable to their clients for deviant practices, more recent case law has

established their potential liability to others. Tarasov was a landmark case in which a

therapist was held liable for his client's injuries to a third person because the therapist

failed to report credible threats made by his client. Ramona established that therapists

could be held liable in tort for damages caused by a client's accusations stemming from

therapy techniques which manufactured memories of childhood sexual abuse. Statutes

now mandate reporting of suspected child abuse, creating a quandary for therapists. They

are required to report suspected child abuse, but need to determine which accounts are

credible to stay within strictures to maintain the client's confidentiality. In the process,

they are potentially liable for tort suits if their techniques lead to false or unreliable

accounts of abuse. The legal problem is compounded by the power differential between

therapists and clients, and by different levels of suggestibility in clients. The role of court

cases and public awareness may be affecting therapists' practices in these disciplines, as

explored in the interviews. One focus of this study is on how the practice of therapy has

been affected by these legal controls and professional guidelines.











My research analyzed interviews with licensed and/or certified therapists to

investigate how the labeling of deviance within the institution of mental health is done


(constructed). This approach used narrative analysis, supplemented by content analysis

and conversation analysis. Cards that identified concepts frequently found in the


literature were offered to the interviewees. The interviewees' selections helped structure


the narrations. The goal was to allow them to define the concepts, set priorities for the


interviews, and minimize the interviewer's role. Accordingly the interviews were loosely


structured, but all of them provided for narrations on a series of topics: 1) orientations to


therapy; 2) memory, suppression, and repression; 3) accountability and ethics; and 4)


legal issues and therapy.




STwo types of deviance and two types of construction are discussed in this dissertation. The type of
deviance that is focal is deviance within therapy, which can mislead or harm clients and others. This type
of deviance is contrary to the ethical standards of each of the therapy disciplines and sometimes is
actionable. The deviance of perpetrators of childhood sexual abuse is also an element discussed in this
dissertation.
The construction that is focal involves how the therapist-respondents construct how therapy
should be done, and which therapy practices and therapists are labeled as deviant. Unfortunate for the sake
of clarity, the deviance of persons who commit childhood sexual abuse and the therapeutic method of
constructing a new life by confronting a past event are also essential factors. Rather than label them as
type "A" or type "B" or some other artificial demarcation, context within my text indicates which types are
under discussion in a particular segment.

SAn institution has been defined sociologically a "a major sphere of social life, or societal sub system,
designed to meet basic human needs" (Macionis 2004, 301); as "a collective solution to a problem of social
life [that] includes a variety of groups and organizations that address a problem of social life" (Lauer &
Laurer 1998, 124); and also as "stable set of roles, statuses, groups, and organizations .. which provides
for behavior in some major area of social life" (Newman 2000, 29). Mental health can be conceived as a
social institution under each of the above definitions:
A. The way of behaving is through the theory and organization of psychology. The human need is
mental health.
B. The problem of social life is maintaining an efficient populace and workforce.
C. The social structures (roles, statuses, groups, and organizations) are found in the disciplines that
include psychiatry, clinical psychology, and clinical social work--all of which have similar ethical
standards of action but different statuses, functions, and ways of interaction in pursuit of their common goal
of treating mental illness and, sometimes, providing theoretical and methodological resources for the
maintenance of mental health. The culture is a merged one stemming from neurology and psychological
foundations. Finally, the technologies of the institution of mental health are those which have evolved and
are evolving from neurology, psychology, and the needs of public service.












CHAPTER 2
THERAPISTS' CONSTRUCTIONS OF THERAPIST DEVIANCE

The study of deviance confronts the problem of defining deviance and identifying

who is considered deviant. Goode's exposition (1994, 1997) presents a framework for

considering deviance and therapy. His framework begins by discussing approaches to

defining deviance. Goode (1994, 12-15) rejects five "naive" and/or "misleading"

definitions based on absolute moral standards, statistical analyses, social harm,

criminality, and "positive" deviance. He then concentrates on two "fruitful (but flawed)"

approaches that focus on social norms (normative definition) and social reactions to

behavior (reactive definition). Goode notes that the normative definition is the most

commonly accepted approach.

"Norms define appropriate acts and conditions for a society's members" (Heitzeg

1996, 3). "The normative definition locates the quality of deviance not in actions or

conditions themselves but in the fact that they violate the norms of the culture or

subculture in which they take place and exist" (Goode 1994, 15). It "locates deviance in

the discrepancy between an act or a condition and the norms" present at that place at that

time (Goode 1994, 16). Goode also notes that it implies relativity-norms will differ from

group to group and time to time. "What makes a given action or condition deviant is the

fact that it is a violation of the custom, rule, law, or norm when and where it occurs."

(Goode 1994, 16).

One of the major problems that Goode (1994, 16) links to the normative definition

is that it "ignores the distinction between violations of norms that generate no special










attention or alarm and ones that cause audiences to punish or condemn the actor." For

over 80 years, social scientists have noted that relatively little attention has been paid to

societal reactions to deviance (Dewey 1922, Kitsuse 1968). The reactive definition

addresses that omission. "What makes an act or a condition deviant .. is how it, and the

individual who enacts or possesses it, are reacted to by actual people, audiences, or others

who punish or condemn the individual" (Goode 1994, 17). The reactive definition of

deviance requires "actual, concrete instances of punishment and condemnation" (Goode

1997, 26). One of the major problems with over-reliance on the reactive definition is that

it de-emphasizes the original behavior or condition that gives rise to the condemning or

punishing reaction. For example, Akers and Sellers (2004) argue that labels are attached

to behaviors and that deviance cannot be studied by only looking at the social reaction.

"Soft" Reactive Definition of Deviance

Goode offers a compromise by adopting a "soft" or "moderate" reactive approach

to defining deviance, the construction of deviance, and reactions to deviance.

In sum, by deviance, I mean .. behavior or characteristics that some
people in a society find offensive or reprehensible and that generates--or
would generate if discovered--in these people disapproval, punishment of,
condemnation of, or hostility toward the actor or possessor. Goode 1997,
37.

Goode (1997) adopts his "soft" reactive definition of deviance to incorporate three

features that he claims advance the conceptualization of deviance. First, since no rules are

absolute, "one should be able to infer from reactions by a wide range of audiences to

behavior and conditions what the norms are" (26). One of the goals of this dissertation is

to learn from therapists what "the norms are." That includes general normative

orientations to therapy that contextualize understandings of deviance in therapy. The










interviews explore how therapists understand the norms and how that reflects various

audiences. Goode notes that "It is the audience which determines whether something or

someone is deviant: no audience, no labeling, therefore, no deviance" (Goode 1997, 107).

A second advantage that Goode (1997, 26) claims for his soft reactive definition

of deviance is that it recognizes that "the enactor of potentially deviant behavior, or the

possessor of potentially discrediting characteristics must operate in a sea of imputed

negative judgments." Another of the goals of this dissertation will be to explore, from the

perspective of the therapists, how reactions by audiences affect the therapists' norms and

behaviors.

The third advantage is that the soft reactive definition allows Goode to escape

from the dilemma presented by "secret" or undetected deviance. If most norm-violating

behavior or conditions remain undiscovered, they are not reacted to. To the strict

reactivist, they would not be deviant. On the other hand, the normative approach, which

defines secret norm violations as deviant because they would be reacted to if they were

discovered, misses the important role that social reaction has in contributing to their

stigmatized status. "Although social reaction does not create the actual behavior ...., it

does lend to it a stigmatized status, and it influences certain features of that activity and

the lives of men and women who engage in it that would be lacking in the absence of

negative labeling" (Goode 1994, 21). Goode concedes that "the reactions of audiences

do not necessarily create the behavior in question out of thin air," but that social reaction

affects people who engage in that behavior regardless of whether their deviance is

detected. Secret deviance plays a role in forming the norms which other individual

therapists (as members of the audience) profess and that are revealed in their practices. A










goal of the dissertation is to learn about reactions by therapists to various therapy

practices and practitioners, regardless of whether norm violations have been detected.

What do therapists react to strongly when it comes to deviance within their ranks?

The literature on deviance suggests that Goode could have gone further in

developing the point. Social reaction has social utility in several ways. Durkheim

(1893/1933) noted how it could reinforce shared norms. To him, shared norms rather

than threats of punishment, were functional for social control. Erikson (1966)

demonstrated how social reactions helped establish and maintain the moral or normative

boundaries for groups. In this sense, social reactions to deviance are educative for those

who are compliant as well as those who are deviant. A goal of this dissertation will be to

explore how various social reactions to therapy practices and therapists, including some

official legal and professional reactions, have affected therapists' own views about

deviance and practice.

Audiences play a critical role in Goode's discussion. Their reactions help identify

the norms, and actors have perceptions about how various audiences feel about deviance.

Goode identifies different potential audiences at different levels of analysis-individual

actors, potential victims, social intimates, witnesses/bystanders, members of small

groups, societal members, formal social control officials and systems, and distant

observers. He notes that "attitudes toward and reactions to potential deviance are held

and expressed by people with vastly differing degrees of power-power to have their

views of what is right and wrong win out over those of other people" (Goode 1994, 23).

He goes on to assert that what needs to be known is "which forms of behavior and what










conditions stand a high chance of earning condemnation and punishment for the

individual" (23).

Goode identifies three dimensions that determine the likelihood of something

being labeled deviance: the numbers who are likely to punish or condemn a phenomenon,

the power of those who disapprove of the phenomenon, and the intensity of their beliefs.

Punishment or condemnation is more likely to occur if more people define something as

deviant, if they have relatively more power, and if they hold strong beliefs about the

inappropriateness of the deviance.

The centrality of the role of audiences in labeling deviance becomes more

complicated by the challenge of relativity that Goode incorporates into his approach. He

notes that audiences are relative and the "greatest amount of variation occurs from one

specific person to another" (Goode 1994, 25). The relativity in audience is compounded

by relativity in individual actors and situations. Some individuals are in better positions

to resist deviance labels. "High status individuals are allowed a great deal more leeway in

what they do and are; they aren't judged as harshly as lower-status people are, and they

have resources to deflect criticism that might be headed their way" (Goode 1994, 27).

Erikson (1962) indicates that some who engage in behavior that is labeled as deviance

can avoid being labeled as deviant individuals. Similarly, some situations are more likely

to escape labeling. "The setting makes a great deal of difference in how audiences judge

behaviors, actors, conditions, and their possessors" (Goode 1994, 28).

The settings of therapy have been examined by others, elements such as the

effects of the "fifty minute hour," therapists not providing answers to direct question but

asking questions as a response to questions they are asked, etc. (Lindner 1955, Goldman










1996, Frank 1998, Frawley-O'Dea 1998). Other major elements of the social

environment which bear upon therapists are found in legal rulings, the organizational

structure and messages of their discipline, and the media exposure of actions and attitudes

of public opinion.

One variation on relativity is potentially important to a study of deviance in

therapy. Individual therapists may know of acts which have been labeled deviant through

societal normative standards (law and ethics boards) and even know of therapists who

have been sanctioned and stigmatized for these acts (or who could be). Yet, some

therapists may be reluctant to affix the deviance label. The research explores whether

therapists distinguish between the act of deviance and the deviant actor-they may be

willing to condemn the sin but not the sinner. They may grant wide berth to many

practices and other practitioners. Therapists may be slow to judge fellow therapists since

all therapists are potentially vulnerable to errors of professional judgment and few may

want to have their own professional judgment questioned or reacted to strongly.

Moreover, therapists may be reluctant to put their occupation in a bad light. Airing even

others' dirty laundry in public (i.e., opening the therapy relationship to consideration by

other audiences such as the media) may hold implications for themselves as well as for all

therapists. The analogy would be to the "blue curtain" that insulates law enforcement and

the concomitant reluctance of police to report the deviance of fellow officers (Westley

1970; Crank 1997). The interviews will shed light on how therapists react to potential

audiences .

Changes in therapy (discussed in more detail in the next chapter) may affect how

therapists label deviance and deviant practitioners. The introduction of Rogerian therapy










stressed unconditional positive regard. As behaviorist and problem-solving therapies

became commonplace, the focus centered on current behaviors rather than intrinsic traits

or past conditions. The actors are not labeled as bad, and the behaviors are to be treated

or mitigated, not condemned. Has the ethos of therapy change enough so that therapists

do not view behaviors generally as matters of deviance--including professional

behaviors? Has a new ethos developed so that actors are not seen as deviant even if

problem behaviors are?

The study of deviance among therapists raises some questions about audiences,

actors, and situations. Although many people may condemn blatant abuses of therapy

relationships (e.g., having sex with clients), other aspects of practice may be much less

clear-cut. Victims may not be a large or powerful audience in the attribution of deviance

in therapy. As clients, they seek therapy because of various problems which are often not

concrete; treatments and outcomes are not standardized. The independent professional

judgments that therapists are expected to exercise are necessary given the uncertainty

surrounding the therapy context. Clients also have relatively less power than the

"experts" they seek out, and they are not in a good position to know about which therapy

practice will or will not help them. The uncertainty may be functional for therapists in

that members of the larger society are not in good positions to condemn various

techniques and practices that may be especially tailored to fit the particular needs of a

client. In other words, the number of potential condemners is reduced, they lack the

expertise (and hence the power) of the professionals who practice therapy, and they are on

grounds too shaky for strong condemnation.










The exalted prestige, autonomy, deference to professional judgment, and latitude

in self-regulation and judgment that have been available for psychoanalysts and other

regression therapists may be at risk. Reflection and reflectivity are undoubtedly occurring

among psychoanalysts and regression therapists as they confront changes in social

conditions described above. The labeling of parts of regression therapy as deviant has

cast a shadow on therapists who use these techniques. Since this was the main

perspective of psychiatry at the height of its professional dominance, denigrating this

practice may have contributed to some of the loss of its dominance over the other

disciplines and other, less formal types of therapy.

The issues are compounded by the norm of confidentiality in therapy

relationships. Indeed, breech of confidentiality may be one of the normative violations

that is condemned (and condemned strongly) by many people, including other therapists

and powerful social control officials. Confidentiality allows for instances of deviance

within therapy to remain secret. Moreover, "victims" of deviant therapy who think about

reporting the therapist face some constraints. Those in therapy are suspected of having

coping or mental issues, which may be stigmatizing in themselves. Their private

problems become public concerns if they report, and they may be less credibly received

than would be the professional if a dispute arises about what happened. Moreover,

therapists derive power from their formal training and their individual experience of

framing issues (which is a component of their work). They are uniquely in a position to

present a case that puts them in the best light--they can use their expertise to discredit

client behaviors and cast doubt about motives of clients making accusations.










Therapists constitute a key audience for learning about the norms and social

reaction to potentially deviant therapy practices. They may be engaging in deviant

practices, reacting to the deviance of other therapists, or adjusting their own practices

because of broader social reactions to deviant practices or practitioners.

Goode's lessons about relativity suggest that a study of deviance in therapy needs

to explore across different kinds of therapists and different situations. Therapists can

vary by type of training (e.g., social work, psychology, psychiatry), extent of training

(e.g., MSW, Ph.D., M.D.), nature of practice (e.g., solo, group, self-employed, salaried),

and nature of clientele (e.g., specialty populations like children or the elderly versus

general clienteles).

Another key audience for the study of deviance in therapy arises within the

official social control system. Some of the social reaction that is important for

understanding deviance in therapy emanates from official social control agents. Indeed,

formal social control reverses the power arrangements in ways that may affect

perspectives on deviance. Professional practices are regulated by law and by professional

groups which promulgate ethical standards for their members. However, different

states/jurisdictions can advance different laws (e.g., psychiatrists in Florida will work

with different laws from those in New York) and different professional associations can

present different standards for therapists (e.g., psychiatrists will belong to different

associations than will social workers). This contributes to the perception of the nebulous

nature of normative definitions. Given the relativity, therapists may have different

understandings about deviance in their workplaces.










Goode asserts that "it is important to identify the party [or parties] judging the

behavior or condition .. the relevant audience" (Goode 1997, 29). In addition to the

legal system which serves as an audience, the national, state, and local organizations of

therapy disciplines (see footnote 1) intervene to prevent outsiders including moral

entrepreneurs from regulating their practices [persuasive, legitimate, active, credible

figures who launch a campaign to discredit an activity (108)]. The societal norms for

therapists are prescribed or proscribed through the formal standards of ethics of each of

these therapy disciplines. Other components of the audience are the therapists who are

labeled, their clients and victims and their social intimates, other direct observers of the

act(s) judged deviant or of the labeling process, members of the mass media, members of

society who follow the process through media, and others who read or hear about the

behavior labeled deviant but are at a social distance precluding their being influenced by

the judgment in any way. Some "parties or audiences, from the participant to the

detached observer, would condemn the behavior, the condition, the actor or the possessor,

were they to come face to face with them" (28-9).

Constructionist Versus the Essentialist View of Deviance

Goode (1997) rejects an essentialist view of deviance-one which holds that

essential differences exist which can be used to categorize phenomena, including

deviance. Instead he adopts a moderate constructionism which recognizes that many

categories are social and mutable rather than derived to reflect inherent properties or

"essences." The constructionists hold that "definitions have no absolute, objective

validity; they are meaningful only within the context of the criteria spelled out by a

particular classification scheme" (Goode 1997, 34).










Constructionists expect that social conditions evolve. For example, they would

expect therapy to change and the problems therapists deal with to change. Definitions of

deviance in therapy are also expected to evolve as problems develop and norms shift.

The changes may occur at the therapist level (e.g, individual reactions and responses to

issues and vicissitudes of practicing in an otherwise changing social and physical

climates), at the mental health institutional level (e.g., imposition of revised standards and

sanctions by the therapy organizations), and/or at the inter-institutional level (e.g.,

reactions to emerging laws and to exposure by the media).

The discovery of child abuse generally (Pfohl 1977) and the ongoing discovery of

sexual child abuse created a new context and prompted change in the larger society and

among therapists. Mental health professionals spent multiple hours accessing

client/patient's memories as a first step in transforming a client/patient's dysfunctional or

unhappy life. Their present problems are rooted in past events so that memories seem to

hold the key for successful interventions. An institutional familiarity with Freudian

techniques and notions of repression may have also contributed to a concentration on

efforts to locate memories of those who had been victimized by child abuse. Regression

therapy and the search for repressed memories was de rigeur for therapy. The public

awareness and the estimated prevalence of childhood abuse suggested an explosion in

perceptions of numbers of possible victims, making it more necessary for therapy. The

techniques used to explore these memories has given rise to successful lawsuits by third-

parties who were directly affected by the therapy sessions.










Elite-Engineered Deviance?

"Defining behavior as deviant is variable with respect to the degree to which it is

spontaneous and grass-roots or organized and engineered" (Goode 1994, 56). The

literature provides little evidence of any kind of spontaneous grass-roots groundswell to

rein in deviance in therapy. Instead, the social reaction emanated from courts,

legislatures, and professional associations which were the guardians of professional

standards of ethics. The attribution of deviance, whether of particular therapists or of

treatment practices, is most manifest in changes in the ethical standards and in the

imposition of laws that affect the procedure of therapy. In other words, the definitions of

deviance played out at elite levels. The legal and professional developments occurred

during, and may have been encouraged by, an academic conflict among psychologists

about the utility and validity of work on the repression of memory (see chapter 4).

The increased attention given to repression by the media was documented in

chapter 1. The institution of media helped spark popular, legal, and therapy recognition

and interest in the changing cultural norms of therapy practices and in practitioners who

deviate from these norms. It reports salient legal issues and plays a role in making salient

the cases that reflect these issues through broad exposure. Public attention was focused

on the problems that media highlight, including the discovery of child abuse and concerns

about sexual child abuse. This attention brings other institutions into play as the examine

the issues and problems from vantage of their separate and unique perspectives.

Formal and Informal Labeling of Therapists

State and federal statutes can be used for official labeling. Federal law mandates

the reporting of suspected abuse [Child Abuse Prevention and Treatment Act (CAPTA)]








19

which was originally enacted in 1974 (P.L. 93-247) and was last reauthorized on June 25,

2003, by the Keeping Children and Families Safe Act of 2003 (P.L. 108-36)]. Many

states have similar provisions in their codes.

Formal labels emanate from court cases. The courts act as an audience which


applies deviant labels directly to therapy and therapist. These formal norms govern 1)

therapists' testimony when called as expert witnesses, 2) prohibition of use by

prosecutors of information attained by some therapy techniques which increase client

suggestibility and can create false memories, 3) mandates to report suspected abuse or

danger to self or others by therapy clients/patients, and 4) the tolling of the statute of

limitations for torts experienced when a child.

Chief among the rulings which directly apply to therapists and techniques labeled

deviant are the Tarasoff and Ramona cases. In Tarasoff v. Regents (1976) the court

mandated a therapist to report possibilities for harm by the client which are discovered in

therapy or be held liable for damages which the client causes.

Ramona v. Isabella et al. (1994) first held therapists accountable to third-party tort

suits.' The court awarded both compensatory and punitive damages.



SThe cases cited in the text are the omnibus cases relating to harm that therapists can prevent or that they
can instigate. There are many cases which have been cited in the articles concerning regression and
repression of memory that have provided precedence in suits arising from alleged damage precipitated by a
therapist. The following are a few of the more notable that involved liability to third parties damaged as a
result of deviant therapy practices:
A. Couch v. DeSilva (602 N.E.2d 286 Ohio 1991) (mishandled recovery of memory by therapist)
B. Doe v. McKay (678 N.E.2d 50 (Ill. App. Ct. 1997) (tort for loss of consortium occasioned by
therapists' actions)
C. Dillon v. Legg, 441 P.2d 912 (Cal. 1968) (en banc) (patient acknowledged misdiagnosis that could
be used by injured third party to establish liability of therapist)
D. James W. v Superior Court (93 C.D.O.S.5449 Jul 16, 1993) (denial of immunity from suit about
unfounded charges by client against a third party)
E. Mateu v. Hagen (King County Superior Court, 91-2-08053-1 Seattle) (therapist's use of age
regression, bioenergetics, psychodrama, trance work, visualization, and guided imaging was overly
suggestive)








20

In addition to the legal rulings which affect therapy, there are legal rulings which

result from changes that have occurred in the practice of therapy. Among these are those

which deal with therapists as expert witnesses and those which result from some of the

techniques of therapy disclosed as potentially aberrant by the national media [e.g., the

McMartin case of New Jersey (McMartin, Virginia, et al. v. Children's Inst., et al. 494

U.S. 1057; 110 S. Ct. 1526; 108 L. Ed. 2d 766; 1990 U.S.), the Franklin case [Franklin v.

Duncan (WL 684390 9th Cir. 1995)], and the Ingram case [Raymond v. Ingram 47 Wash.

App. 781, 737 P.2d 314 (1987)]. For example, in many jurisdictions testimony will not

be admitted that is based on information the plaintiff or prosecutor retrieved via hypnosis

or psychoactive drug treatment. Therapists whose testimony is based on knowledge

gained from these techniques will not be qualified as expert witnesses.

For this dissertation research, only those rulings which directly pertain to the

practice of therapy (Tarasoff and Ramona) were specifically raised in the interviews.

Arguably, some other cases have had a salient informal effect on therapists and the

practice of therapy. The interviews provided the opportunity for therapists to volunteer

which rulings or law affected their thinking about deviance in therapy.

The institution of mental health is also involved in formally defining deviance.

Each of the therapy disciplines, in their standards of ethical practice cited in chapter 1,

includes an organizational injunction to do no harm (primum non nocere). Basing

therapy on a false premise potentially harms the client/patient when accepting and



F. Montoya v. Bebensee (761 P.2d 285, Colorado Court of Appeals, 1988) (duty to care for harm to
third party from foreseeable false charges)
G. Tyson v. Tyson (11986 Wash.2d) (delayed discovery and latent injury cases)
H. W.C.W v. Bird (840 S.W.2d 50 1992, Texas Court of Appeals) (problems with client's testimony
after use of sodium amytal)










focusing on memory which is a product of suggestibility rather than actual events.

Increasing client/patient suggestibility is adding another impediment into his/her life.

This creates a weltanschauung which must at some point conflict with reality and serve as

a barrier to adapting to present real situations and problems--one of the main purposes of

therapy.

In addition to the harm done to the client/patient, having the client/patient act

upon findings elicited by questionable techniques to resolve a problem which did not in

actuality exist, even in the past, interferes with present interactions with others who were

included in the false memory. Third-party lawsuits can arise in situations where therapy

clients confront others as a result of the therapy that they receive.

Goode (1997) argues for a contextual construction of problems.

The contextualist constructionist's concern is mainly in understanding how
definitions of social problems are generated, sustained, taken seriously,
and acted upon; and how certain claims of seriousness are advanced by
specific agents and reacted to, or ignored, by different audiences. Goode
1997, 60.

This orientation informs the organization of the next two chapters. In Chapter 3, I

examine how the social problem of dealing with mental difficulties has been generated,

sustained (or exterminated), taken seriously, and acted upon in the past. In Chapter 4, I

examine how regression therapy and repression techniques have become defined as a

social problem, how the problem is sustained by those therapists who use the techniques,

and how others attack the techniques as needing to be exterminated or modified, and I

indicate the seriousness of this problem. After a methodology chapter, the bulk of the

remaining chapters are concerned with data on how the audience of therapists view

therapy and deviance as well as react to the labeling as a problem.














CHAPTER 3
HISTORY OF NORMALCY, DEVIANCE, AND CHANGE IN THERAPY

Therapy and Change

If the past is any guide to the future, today we can be certain of only one
thing: The day will come when people will look back at our current
medicines for schizophrenia and the stories we tell to patients about their
abnormal brain chemistry, and they will shake their heads and mutter in
disbelief. (Whitaker 2002, 291)

Organized concern for mental or emotional illnesses and therapy has existed in

America for only a little over 100 years (Napoli 1981). In 1892 the American

Psychological Association (APA) was formed, establishing a functional national

organization for therapists. While there were earlier attempts at centralization (some of

which lasted for years), only after the birth of the APA did America have a national

community of mental health specialists that has survived to the present. Since its

inception, and even though many of the therapeutic theories and methods advanced (or at

least tolerated by the APA) have later fallen out of favor,' the APA has consistently

received recognition as the dominant organization within the institution of mental health.

Distinctive eras of therapy before that unifying event are difficult to discern. The

practice of therapy did not have the organizational structure of an identifiable institution

required for tracing what has been labeled deviance as generations progressed. Indeed,

there was even less separation of physical treatments for disease and morbidity from


SA number of these previously discarded therapies are now at least marginally accepted and some members
of the American Psychological Association are protagonists of many of them. A few of these later
reappeared in modified forms--notably elements of the water-immersion therapies, electric shock therapy,
and many drug treatment therapies.










treatments of mental illness than is presently practiced. Distinguishing mental health

treatments from physical health treatments is generally impossible. The medical model of

health has predominated, and in early history was the only method in use (Ackerknecht

1955). The breadth and scope of differences between practices wielded by therapists,

then and now, compounds the difficulty in distinguishing eras. Presently, institutional

rules and guidelines do provide standards for making comparisons. There were no

institutional rules and guidelines in place before the founding of the American

Psychological Association--there were only centers for treatment, or disposal, of persons

who were having mental health problems.

The historical literature reveals how difficult it is to distinguish each historical

era. That difficulty extends to discerning which practices were considered normative.

Even today there are advocates and practitioners using many of the methodological

practices that were in place hundreds of years previously (before falling out of favor, and

in some cases being labeled deviant). Treatments still range enormously, from physical

interventions (such as administering pharmaceuticals or performing electroshock) to

interventions that include more nebulous factors (such as retrieving memories of past

events).

Despite this lack of organization among therapists of the distant past and a wide

range of tolerance for diverse types of practice today, there is clear evidence of change in

the predominant theories and methods used in therapy during credibly distinct eras of

therapy. Therapy has a history of treatments and theories which have often been reviled

or regarded unfavorably by succeeding therapist generations. What may be regarded by

later therapists as deviance in treatment practices may have been regarded as a







24

breakthrough in knowledge. Indeed, some of these practices assumed leading roles in

treating mental illness (e.g., insulin shock therapy, lobotomies, and water emersion).

Individual therapists precipitated changes in the predominant methods of treatment in

their pursuit of solutions to mental and/or emotional problems that hindered normative

(or at least functional) adaptation to troubled social surroundings and self identities.

The factors which lead to therapy shifts are historically variable and are

complicated. In each era, individual practitioners adapt to these shifts in their own ways.

Their professional roles as therapists comport to the possibilities that are in that time

socially and structurally confining while adapting not particularly to a theoretical identity

but more to the practical standards which work for their clients and for themselves.

Emergence of Modern Psychiatry, Psychology, and Social Work

In the 19th century neurology and psychiatry split into separate medical disciplines.

These two were later joined by psychology as the disciplines most concerned with mental

health. This provided the infrastructure of the late 19th and the 20th centuries for building

and organizing disciplines for the regulation of diagnosis and treatment practices.

Modern psychiatry has been described as dawning at the beginning of the 19th

century (Marmer 1994). There was a return to the Hippocratic belief in the biological

basis of mental disorders, which was attended by the rise of psychiatry as a scientifically

organized discipline with roots in neurology. This somatogenic view focused on the

belief that pathological bodily conditions and brain tissue dysfunctions were solely

responsible for mental disorder. Mental illness thus became the exclusive domain of

physicians. Heredity became the salient variable for understanding mental health issues.










Psychiatry's Emergence from Neurology

While psychiatry had roots developed from humanists like Agrippa, Pinel and

Tuke (along with a few other isolated reformers of the nineteenth century) paved the way

for the transition of psychiatry into its present form. Their voices spelled the end of

justification of punishment for the mentally ill and provided for moral treatment and cure

through humanistic techniques.

The term "neurologist" came to refer to organic physicians generally
working in hospitals. Psychiatrists took over the neurologists' old position
as the outpatient border guard of the medical profession, handling the
symptoms and diseases that seemed not quite real. .. Psychiatry began
when a group of enterprising medical reformers argued in the early
nineteenth century that madmen ought to be removed from the jurisdiction
of the legal authorities and placed under that of the medical profession.
Madmen are sick, they said; give them to us and we will cure them. A
new theory and therapy justified the shift, and private bodies and state
legislatures were soon dotting the countryside with insane asylums.
(Abbott 1988, 22)

The Entry of Psychology

By the middle of the nineteenth century almost all American psychiatrists believed

that psychological problems had physiological causes (Cockerham 1992). Conventional

medical science resisted investigating how physical symptoms could proceed from

emotional causes (rather than the other way around) until Jean-Martin Charcot presented

a paper on hypnotism to the French Academy in 1882. While advancing a treatment plan

which took into consideration factors other than anatomy and physiology, his methods

produced problems of their own. Under Charcot patients came in with problems

[psychosomatic conversion symptoms, PTSD (post traumatic stress disorder), and other

emotional responses to their unhappy lives]. He gave them a certain degree of legitimacy

(even celebrity), but:







26

He took away their dignity and their hope. They were pressed into mass
conformity, put into solitary confinement, turned into chronic, even
lifelong patients. Through hypnotic suggestion .. hysterical patients
were already becoming iatrogenic monsters. (Showalter 1997, 36-7)

Loosening of the medical model of treatment proceeded steadily but slowly

thereafter. The greatest blow to the paradigm of the medical model was the one that set

therapy on a path emphasizing psychological concepts of personality, learning, and

motivation-psychoanalysis These concepts were j oined to the technique of hypnotism,

which had been first advanced a century before by F. Anton Mesmer (who has been

deemed the father of psychotherapy by psychoanalysts) (Ackerknecht 1955). The blow

was delivered by the writings of Sigmund Freud (originally a neurologist) and his early

coauthor, Joseph Breuer (discussed below in Chapter Three). Thinking about the nature

of mental illness was revolutionized by Freud and Breuner at the end of the nineteenth

century. Their "dynamic" psychology included patients who were neurotics as the

psychotics who had traditionally been treated by psychiatry (Horwitz 2002). "Dynamic

theories posited that neuroses were continuous with normal behavior" (Horwitz 2002, 1).

At the end of the century (1896) Arthur Rufus Trego Wylie was the first American

psychologist to be employed in a clinical setting. He later became superintendent of The

Institute for the Feeble Minded in North Dakota (Street 1994).

The Entry of Social Work

Psychiatrist John Conolly in 1856 wrote "The Treatment of the Insane Without

Mechanical Restraints" in England which was responsible for the growing disfavor

accorded that method of treatment on both sides of the Atlantic (Street 1994). Dorothea

Lynde Dix, arguably one of America's greatest humanists of the nineteenth century, was








27

instrumental in exposing deplorable and brutal conditions of the mental hospitals in the

U.S. during that time. "Through her efforts she personally founded or enlarged some

thirty-two mental hospitals ." (Cockerham 1992). She was the most influential

advocate of the principle of public responsibility for the mentally ill and got the mentally

ill out of jails and poorhouses into asylums. She also documented filth, brutality, and

degrading conditions in existing hospitals (Street 1994). Ironically, the numbers of

hospitals that sprang up under her influence and the enormous increase in the numbers of

patients decimated the ratio of experienced therapists-and-staff to patients, leading these

large mental hospitals to become more custodial than treatment-oriented. Neglect and

warehousing sometimes resulted, similar to that found in the 17th century but without the

draconian measures.2

Beginning in Boston in 1877, "charity organization societies" began investigating

problems of the poor and providing visits and advice to assist them (Kane 1983). Paid

positions and educational programs for what became social work practitioners developed

from these societies. By the turn of the century, settlement houses (e.g., Jane Addams'

Hull House in Chicago and Lillian Wald's Henry Street Settlement House in New York)

began addressing the social problems associated with health conditions and health

problems.

The physician who is generally considered to be the founder of medical social

work, Richard Cabot, in the first decade of the twentieth century saw the need for people

who would act alongside and in teamwork with the physicians to bridge the gap between


SAmong the photos of Richard Avedon (1993) are pictures of the mentally ill in Southeastern Louisiana
Mental Institution in 1967. These photos document that even that recently warehousing and neglect were
found in some of the large mental ho spitals.










the world of medical practitioners and their impoverished patients (Kane 1983). At first

many of these were nurses, but in 1913 social workers were distinguished from doctors

and nurses as those whose field of study was character, human relationships, and

community life. In addition to joining hospital staff, other settings soon began seeing

social workers as staff members, such as mental health clinics, schools, juvenile courts

etc.

Social workers developed organizationally, first as The American Society of

Hospital Social Workers, founded in 1918, then in a number of other affiliations

including the omnibus National Association of Social Workers (NASW) in 1955.

Educationally, stipends were first awarded for the study of social work by the National

Institute of Mental Health in 1947.

Although the growth and development of psychoanalysis and social work into

increasingly powerful and independent organizations proceeded from the late nineteenth

and throughout the twentieth centuries, these developments by no means provided a fatal

blow to the medical model for mental health. Indeed, the medical model has become

reinvigorated with advances in drug therapy. Psychopharmacology has become a major

form of treatment. Further, the Diagnostic Statistical Manuals have provided fixed

symptomology for diagnosis, recent advances in brain area mapping have provided new

possibilities for treatment, and recent advances in genetics have raised new questions

about health in all realms of the body, emotions, and cognitive health. Additionally,

recent advances in genetics and brain imaging are only two of the promising areas for

medical interventions in mental health.







29

Variety of Therapies: The 20th Century

All in all, there are at least two hundred therapies and numerous
pseudotherapies available in contemporary Westemn society, all intended to
counteract psychological stress and behavioral abnormality. (Cockerham
1992)

By the twentieth century, despite the fact that a large number of therapists were

still receiving training in Europe, there was a different motivation for treatment in the two

continents. Europeans were more concerned with how to control their populations while

Americans were more concerned with how to increase economic productivity (Cushman

1992). Building character "through self-discipline, thrift, hard work, cleanliness and

religious instruction" became the European model for mental health while in America the

"multilayered relationship between politics and 'personal growth'" led to stresses on

personality, "the sum of personal qualities that caused one to be liked by others .. to

stand out in a crowd" (Cushman 1992, 35).

At the tumn of the century and concurrent with Freud's development of

psychoanalytic theory and the importance of confession and suggestion, Emil Kraepelin

was developing the classification system for mental illness that is still in use. From his

clinical observations he developed a threefold classification (dementia praecox, paranoia,

and manic-depressive psychosis) that is the symptomatic system that (with some

refinements and changes in terminology) still occupies much of the thought, practice, and

theory of therapists today.

The demise of spiritualism and occult phenomena was reported after the 1904 first

Congress of Experimental Psychology in Germany. It had been replaced by a scientific

approach emphasizing observed facts and explanatory theories (Street 1994). At the 1904










St. Louis World's Fair, mental health was represented with papers by psychologists on

the current state and future prospects of psychology, followed by section meetings on

General Psychology which concerned experimental, comparative, and abnormal

psychology (Street 1994).

The "new psychology" of the 1920s, psychoanalysis, had direct effects on

American life. This new psychology "represented a revolt" against the academic

psychology with phases of psychoanalysis, emphasis on endocrine glands, and, later,

behaviorism (Bumham 1988). In London at the Tavistock Clinic, psychoanalytic therapy

for indigent clients received its first client and went on to become known for work in

psychosomatic medicine, social psychiatry, and child and family therapy (Street 1994).

During the first quarter of the 20th century, psychology was staking its own

domain in the field of mental health. Its development has been examined by Napoli:

More and more, clinical psychologists found themselves in competition
with psychiatrists, poorly trained testers, and complete charlatans. .. To
win public support they were impelled to 1) stake a claim to exclusive
competence and 2) show their service had widespread application. ..
Contrasting themselves to this source of competition, applied psychology
proudly cited their own use of the scientific method, laboratory
experimentation, and statistical techniques. .. [Applied psychology's]
realm of inquiry .. was variously seen as behavior, habits, motives,
feelings, or some combination of these (30 & 31). Applied psychologists
insisted that hostile emotions and behavior were not directly produced by
the environment but grew from within the individual as a result of faulty
patterns of adjustment (39-41). Psychiatrists .. were in no position to
treat all of America's behavior problems. Their numbers were small, their
training spotty, and their view of the situation myopic. (Napoli 1981, 53)

Psychiatry was confronted with industrial psychologists and industrial sociologists

in the 1930s and to maintain its dominance in the field of mental health in the cities










changes were made. The importance of therapeutic teamwork became evident. Napoli

holds that therapeutic teamwork was case oriented:

The concept of therapeutic teamwork .. grew from the belief that every
case required a three-pronged approach. Ideally, the team captain, the
psychiatrist, provided psychotherapeutic treatment; the clinical
psychologist administered tests; and the social workers developed case
histories. In practice, however, the duties of the psychiatrist began to
merge. It became increasingly difficult to distinguish between treatment
and case history, in part because psychoanalytic psychiatry had an
intrinsically historical method and in part because social work was
adopting psychiatric theory as the conceptual foundation for its own
professional aspirations. (Napoli 1981, 54-5)

Freud did not live to see how psychoanalysis came to dominate the mental health

scene and became professionalized.

Psychoanalysis was transformed in the years from 1917 to 1940, from the
calling of a self-chosen group of avant-garde psychiatrists and neurologists
to a profession with its own institutions for training and certification,
separate from medicine and psychiatry, yet with close ties to both. The
American insistence on medical training came in part from the wish to
attain the scientific authority associated with the medical profession. ..
Psychoanalysis enjoyed an enormous, new, optimistic vogue, vastly
expanding its therapeutic domain and its influence in medical schools and
in the newly founded National Institute of Mental Health. (Hale 1995,
381-2)

Psychiatrists still headed most mental hospitals but criticisms of the historical,

clinical and philosophical grounds of psychoanalytic theory opened the door for non-

medical treatments (Hale 1995). The alienating freedoms of the industrial age had

progressed in the U.S., bringing with them "moral illiteracy, confusion, isolation,

loneliness, and self-preoccupation, leading to the need for the social practice of

psychotherapy" (Cushman 1992).

During and right after the war, there was a shuffling of accepted theories on

treatments. Inroads were made by psychologists during this period into the professional










dominance of the psychiatrists and neurologists. Medical treatment still had other

avenues for approaching mental health. In 1940, successful use of insulin shock therapy

was introduced for patients with severe mental illness (Street 1994). In 1947 psychiatrists

in Maryland announced that prefrontal lobotomy had led to the release of several patients

who had previously been diagnosed as incurable. This practice became widespread in the

1940s, but in 1950 one of the foremost practitioners, Walter Freemen, announced that he

would no longer perform lobotomies or topectomies because of their harmful aftereffects

(Street 1994). Thereafter, these procedures lost more and more favor, and were replaced

by electroshock therapy and psychopharmaceuticals, which are used today to the same

purpose for similar patients in some hospitals. Use of insulin shock, electroshock, and

lobotomies and topectomies wes reduced as drug therapies assumed ascendancy in these

severe cases of mental illness. In 1953 and 1954, Thorazine (chlorpromazine) and

Serpasil (reserpine) were approved by the U.S. Food and Drug Administration for use as

having led to remarkable progress in schizophrenics (bipolar) and some other psychotics.

The results were indeed remarkable--for a time. The problems that dopamine and

serotonin blockers have caused children and some other patients (see Whitaker 2002) is

currently being addressed by researchers, journalists, and even Congressional committees

against a well-financed pharmaceutical industry.

While psychiatrists were the primary purveyors of mental health at the start of

World War II, psychologists and social workers filled need for personnel and contributed

a non-medical, psychotherapeutic professionalism to the mental health institution. This

need led the war psychiatrists to abandon "their claim to exclusive rights in this field,

falling back to the position that they must only have overall supervision of psychiatric










patients" (Napoli 1981, 143). Behavior modification, derived from psychology's

experimentally established understanding of learning factors, became the arena of appeal

during the war years. Carl Rogers' humanistic psychology, featuring group therapy and

nondirective "insight therapy," provided a non-Freudian approach to psychotherapy

(Napoli 1981). Psychologists became even more influential when a psychological board

was created by President Truman to deal with propaganda and economic and political

activities during the Cold War (Street 1994). During these years, psychiatrists were not

the only therapists to engage in treatments which became labeled deviant. For example,

in 1951 a Seattle psychologist was convicted because he used sexual intercourse

ostensibly to cure the guilt complexes of three of his female clients (Street 1994).

In 1955 a federal commission reported that over half of the 1.5 million hospital

beds in the U.S. were used to care for people with mental illness, and declared that mental

illness was the greatest single health problem in the United States (Street 1994).

Alternatives were sought and patients were increasingly released into their communities.

"The mental hospitals released most of their patients from 1965 to 1975, and many closed

for good" (Hobson & Leonard 2001, 39). Psychoanalysis was still a potent force in

mental health and illness. In 1956 an American critic noted that more people used

psychoanalysis as an explanation of human behavior than anything else in modern times,

except the great religions (Kazin 1956). Nevertheless its dominance was waning and in

1979 it became but one of the divisions (Division 39) of the American Psychiatric

Association.

Between 1960 and 1985 nearly all the factors that had contributed to the
rise of psychoanalytic psychiatry were in part reversed: doubts grew about
the scientific validity and effectiveness of psychoanalysis; alternatives to










the psychoanalytic psychodynamic style arose; psychoanalysis lost its
identification with psychiatric reform; social conditions for psychoanalytic
practice changed; partly because of a lack of demonstrable results,
government and private funding for psychoanalytic training and research
dwindled; some psychoanalysts retreated from the new therapeutic fields
they had staked out, among them, psychosomatic medicine and the
treatment of schizophrenia. (Hale 1995, 300)

By the mid-1960s, the medical model of health and psychoanalysis was being

questioned on many fronts. Leading the attack were R.. D. Laing, Thomas Szasz, and

Emest Becker. Becker (1964, 3) insightfully argued that there was a revolution in

psychiatry due to the invasion of philosophy and the social sciences into the realm of

mental health and illness, formerly dominated by the medical view of human ills. He

argues that "mental illnesses" are "broadly culturally behavioral, rather than narrowly

medical, phenomenon." Psychoanalysts failed to make plain that the world of external

objects has to be "created" as well. Becker proposed a transactional system rather than a

completely medical or psychoanalytic one.

Increasingly, mental health professions moved toward eclectic approaches

beginning in the mid-1960s. Eclecticism emphasized "the idea that methods originating

in different schools of therapy may be combined for maximal therapeutic effectiveness"

(Amkoff & Glass 1992, 671). It signaled an openness to change.

Not surprisingly, additional therapies were developed. For example,

cognitive-behavioral therapy came of age in 1970s. It is based on establishing warm and

supportive relationships where logic, rules of evidence, and Socratic questioning (to

encourage patient to reveal, question, and correct the assumptions responsible for his/her

bleak outlook and that usually takes six to twenty weekly visits). It is preferred over drug










therapy by many therapists for dealing with mild to moderate cases of depression

(Hobson & Leonard 2001, 165-6).

The need to develop effective interventions grew in part out of an expanding need

for mental health services. Between 1970 and 1995 Horwitz (2002) estimates that each

year about 15% of the adult population of the United States sought some type of

professional treatment. Correspondingly, the number of mental health professionals

quadrupled during that time frame to meet this demand (see Center for Mental Health

Services 1996 and 1998 cited in Horwitz 2002, 4).

Education and training in therapy also changed. In 1968 the first program that

replaced the dissertation with further practical training led to a new doctor of psychology

degree (PsyD) (Napoli 1981). In 1973 this program was accredited by the American

Psychological Association as an alternative to the traditional doctorate (Napoli 1981).

"Although the PsyD program at the University of Illinois has since been discontinued, the

[Illinois program carried the force of a respected faculty in a prestigious university, a

rigorous curriculum, and an appearance of solidity that paved the way for other programs

to follow" (Paterson 1992, 836). Dissatisfaction with professional training as conducted

in traditional PhD programs continued to deepen, however, and insistence on change was

expressed in many ways. At the same time, the public need for psychological services

continued to grow (Paterson 1992). Medical dominance outside the hospital and the

dominance of psychoanalysis as the major form of diagnosis and treatment were being

challenged by psychologists and social workers especially dating from the early 1960s.

Psychologists and social workers took on new mental health roles, some of which had










previously been performed by medical personnel, after the Community Mental Health Act

of 1963. (Abbott 1988, 121).

Although the medical profession's hegemony is being challenged, it continues

especially in some areas. Not until 1974 did the first psychologists become trained and

authorized to prescribe psychoactive drugs (Street 1994). Several state psychological

associations have been instrumental in bringing to their legislators the question of

whether specially trained psychologists should be allowed to prescribe medicine.

The lessons from history indicate that therapy will continue to evolve. In the

1700s, structural factors led to a revolution in how therapy was done and who was doing

it [as noted by Foucault (1961/1965; 1973/1994) and Street (1994)]. Ideology of The

Enlightenment led to humane treatment of the 1800s (Gallagher 1980; Cushman 1992;

and Street 1994) and around the turn of the 20th century to dynamic psychiatry and

psychoanalysis (Ackerknecht 1955; Abbott 1988; Burnham 1988; Cockerham 1992;

Cushman 1992; Marmer 1994; Street 1994; Showalter 1997; and Horwitz 2002). The

rise of technology and industry for World War II culminating in the need for

psychological input led to the emergence of psychology as a major factor in mental health

and illness in the U.S. (Napoli 1981; Cushman 1992; Street 1994; and Hale 1995).

Changes in philosophy and social sciences of the 1960s and 1970s led to behaviorism,

eclecticism, ascendancy of applied psychology in mental health, and to the further decline

of medical and psychoanalytic dominance (Becker 1964).

How therapy is done continues to evolve. Recent controversies over repression

and regression therapy, especially those involving childhood sexual abuse may effect that

evolution. Labeling some practices of therapy and some therapists as deviant poses a








37

challenged that therapists and their professional organizations must manage. The

interviews conducted for this research are designed to shed light on how therapists are

managing that challenge.

The symbolic interactionist roots of labeling theory (Akers & Sellers 2004)

sensitize us to the prospect that deviance standards are negotiated. The labeling

perspective shares with conflict accounts the premise that more powerful individuals and

groups have more influence on those negotiations. Therapists are not powerless, so we

might expect them to influence how therapy and mental health are defined by lay

individuals. Therapists' own internal debates and conflicts will affect the negotiated

definitions.

The methods therapists use and advocate provide an instrumental and evolving

infrastructure for lay understanding of mental health. As the major resource for

knowledge about the latest theories and methods regarding mental health issues,

therapists have attained high status in American society. They are consulted by

individuals and organizations for guidance in attaining satisfaction and productive

achievement in individual daily life.

Besides direct methods such as openly publicizing emerging mental health

theories and stratagems,3 therapists also provide an indirect influence. Through their



SSection 5 of the American Medical Association "Principles of Medical Ethics" directs psychiatrists (and
other doctors) to "continue to study, apply, and advance scientific knowledge (and) make relevant
information available to patients, colleagues, and the public .." (The Principles of Medical Ethics With
Annotations E specially Applicable to Psychiatry, 2001ledition, http://222 .psych.org/ap amembers/ethics
opinions53101.cfm).
The preamble of the American Psychological Association Ethics Code states that psychologists "strive to
help the public in developing informed judgments and choices concerning behavior. In doing so, they
perform many roles, such as researcher, educator, diagnostician, therapist, supervisor, consultant,
administrator, social interventionist, and expert witness." (American Psychological Association, 2001,
http ://www.ap a.org/ethic s/co de20 0 2.html ).










research and experiences with a number of clients or patients, therapists discover and use

standards and coping methods for understanding what mental health is and how it can be

attained or kept. These standards and methods are assessed by the general public

according to how helpful they are perceived to be for clients or patients. When the results

lead to a better life for the clients, they are copied and used by other members of society.

Those who may have no personal contact with therapists are thus also influenced by these

standards and methods. Mental and emotional weltanschauungs4 and methods for

attaining mental health goals are shaped in accordance with these theories and these

examples.

Controversies surrounding the repression of memories and regression therapy

among therapists, their professional association, and outsiders (the public and law) create

confusion. Deviance will be negotiated and defined within this confusion. This analysis

now turns to the debate about repression and regression.


W eltanschauung: one's philosophy or conception of the universe and of life (Webster's Dictionary 1976).












CHAPTER 4
REGRESSION POLEMIC

The Debate

The debate over repressed memories and regression therapy techniques to recover

those memories provide a point of entry for examining how deviance in therapy is

constructed. The use of regression techniques to recover memories of childhood sexual

abuse is especially controversial. Articles in journals from many social science

disciplines have not only challenged or defended the techniques used to discover

repressed memories, but have also questioned whether repression itself is a valid concept

to be used in therapy (Loftus 1993; Byrd 1994; Gleaves 1994; Gold, Hughes, &

Hohnecker 1994; Olio 1994; Nelson & Simpson 1994; Goldzband 1995). Some social

scientists note that there is considerable evidence that what many people think are

memories are in fact images of events that never took place. They are false memories.

There is no corresponding empirical evidence that the phenomenon called "repression"

has any reality at all (Holmes 1991; Ofshe & Watters 1993; and Pope & Hudson 1996).

Some have criticized resultant lawsuits alleging sexual abuse based on recalled memories

since no experiments have demonstrated conclusively that memories can be repressed and

then reliably recovered (Lannings 1989; Holmes 1991; Ofshe 1992; Loftus & Rosenwald

1993; and Wright 1994).

My literature review disclosed conceptual differences as to which therapy

practices are considered deviant and confronted questions about which therapists will be








40

labeled as deviant within different therapy disciplines. This dissertation uses interviews

of recently certified or licensed therapists (since 1995, since responsibility to third parties

was ruled in 1994) to examine the construction of deviance about therapy practices and

practitioners.

Freud's Understanding of Repression

Sigmund Freud introduced the term "repression." There has been an ongoing

controversy over Sigmund Freud's understanding of repression. He supplied the first

seed of controversy in 1893 when he wrote on repression "It was a question of things that

the patient wished to forget, and therefore intentionally repressed from his conscious

thought and inhibited and suppressed" (Breuer and Freud 1893/1961, 10).

As written, this passage does not imply that repression is an unconscious mental

process. However, the passage became critical in later years due to a footnote written by

Anna Freud. In the footnote to the passage Anna Freud wrote that "the word

'intentionally' merely indicates the existence of a motive and carries no implication of

conscious intention" (Breuer and Freud 1893/1961, 10).

Today, the distinction between conscious and unconscious removal of memory

from the client's access (repression versus suppression) is of great importance. In the

legal realm, tolling a tort (i.e., determining the length of time remaining before legal

remedy can no longer be sought) is governed by the legal distinction between repressed

memories and suppressed memories (memories which have been blocked from recall as

opposed to those which the individual decides not to remember but has the ability to

remember).










Present State of the Debate

Writing in favor of the concept of repression, psychoanalyst David Calof (1993),

describes his child abuse clients as having dissociative symptoms such as sleepwalking

and memory disturbances and signs of post-traumatic stress, such as flashbacks, sleeping

disturbances and nightmares and depression or other mood disturbances. These are but a

few of the many symptoms that have been attributed to consequences of repressed

memories of CSA (childhood sexual abuse) (e.g., Bass & Davis 1988; Blume 1991;

Fredrickson 1992; and Whitfield 1995).

On the other hand, David Holmes reviewed 60 years of attempts at proving the

existence of repression. He notes:

Not only do these findings fail to provide support for the concept of
repression, but they are the opposite to what would be predicted on the
basis of repression. .. Even if repression does function in the way that
therapists who work with recovered memory suppose, is it possible to
repress repeated, long-term abuses, some of which began in infancy and
lasted well into adult years? .. Of course, without the concept of
repression, the edifice ofpsychoanalysis collapses. (Holmes 1991)

Post traumatic stress syndrome is often cited as a cause of repressed memories.

There are a number of articles in rebuttal. For example, Skow specifies that there were

thousands of Holocaust victims who remembered their stress in great detail. There are

only a few very vocal orators who make the campus circuit claiming they do not

remember (Skow 1994). Rape victims also do not repress everything. Ofshe noted that

with combat and savage rapes there is traumatic amnesia but notes that sufferers know

they have suffered the experience, but have lost the details (Ofshe 1992). Paul McHugh,

director of Department of Psychiatry and Behavioral Science at Johns Hopkins










University, observed (in Wright 1994) that rather than memories being blocked out in

cases of severe trauma, children remember them all too well.

A number of individuals who "discovered" repression of memory(ies) of CSA

have later averred that their memories were not of actual events but were a product of

therapy sessions. One survey found 22% of 630 children in cases of alleged sexual abuse

later recanted (Sorensen and Snow 1991). Whatever the reasons for this change in belief,

the presence of such a number of retractors provides support to the argument that, at the

very least, some previously, strongly believed memories of CSA are false, including those

which may be a result of deviant therapy practices (violating the ethical directive to

therapists to "above all, do no harm").

Interactive relationships, social structures, and developmental socialization are

essential elements for understanding the analysis of memories--as repressed, forgotten,

delayed, deferred, manufactured, or just false--as well as for understanding how these

concepts are constructed by therapists. In view of the increased salience of repressed

memories in discourses about therapies and the polemic over usage and validity for

therapy, this dissertation is relevant as a sociological study on the construction of

regression therapies, practices within therapy disciplines, and deviance within therapy

practice.

Construction of a New Self

Debilitating mental symptoms that persist into adulthood have been linked to

childhood sexual abuse by numerous researchers since Freud initially used the concept of

repression. The role of the therapist is to assist in the processes of deconstruction and

reconstruction rather than producing a template to match the therapist's own ideology and










experiences. Through the interaction of client and therapist, memories of childhood

physical or emotional stress or trauma are discovered. Treatment incorporates these

findings. When the memory "discovered" is one that the client may have forgotten,

perhaps for many years, emergence during therapy engenders the question of the extent to

which the memory was of actual occurrences or was produced or altered in the therapy

process.

Contexts of Therapy-Assisted Self Construction

Correlations between a number of adult symptoms and CSA have been

statistically examined by numerous social scientists. Regression theorists may suspect

and actively probe for repressed memories in clients with any symptom that shows such a

correlation (see Pope & Hudson 1996; Weene 1993; Pope & Hudson 1992; Rorty, Yager,

& Rossoto 1994; Kinzl, Traweger, Guenther, & Biebl 1994; Wooley 1994; Bordo 1993;

and Young 1993). For example, in some studies a high percentage of clients who have

bulimia also report having been sexually abused when a child. When a client admits

bulimia or exhibits symptoms of bulimia to a therapist, the therapist may suspect sexual

abuse of the client when a child and actively pursue whether this client was also so

abused. Such a therapist would suspect that the memory of that abuse may be repressed

even if not reported by the client. Among these therapists, some can and do lead the

client to a memory of an event that in actuality did not occur. They do this by techniques

promoting suggestibility which include an air of authority because of the therapists'

presumed status as "experts."

The most ardent supporters of repressed memory syndrome cite the same few

studies of bulimia and neglect to report other studies finding no or little correlation








44

between CSA and bulimia. Statistical correlation of symptoms such as bulimia with CSA

in such cases have been treated as causal. The therapist then participates with the client

from an initially questionable perspective in determining new adaptive ideologies,

attitudes, and behaviors to alleviate or eradicate the present maladaptive symptoms.

Therapists who discover memories of CSA suggest that a client's previous failure

to address his or her troubles resulted from memory repression that was due to the stress

or trauma of the abuse. Repressed memories may thus be seen as similar to a virus in the

mind. It infects the life of the client and multiplies adverse effects throughout the life

course into any of several mental or emotional symptoms of dysfunctionality. Using

symptoms as indicators of CSA, these therapists rigorously probe for repression. In doing

this, sometimes inapplicable group statistical data are applied to individual

clients--finding that statistical support that large numbers of adults with a particular

symptom were also sexually abused as children and then asserting that this means that

individual clients who exhibit that symptom were also abused.

Some memories that were allegedly repressed were in fact manufactured during

therapy and are false memories. Evidence of this can be found in the following ways:

Some clients have later recanted the alleged repression and fixed responsibility for their

earlier claim of recovered memory on their suggestibility. That the memory was indeed

manufactured rather than of an actual occurrence has been discovered in some of the

following ways: 1) from data provided by family members who document the

impossibility of an abuse occurring in the living time and context of the alleged abuse

(e.g., when the alleged perpetrator was not present during that time period or

circumstances of household life precluded such an act or acts from being undiscovered);










2) from medical examinations during the targeted time; 3) through court rulings; and 4)

from the demonstrable effects of certain discovery and treatment techniques and

procedures that increase suggestibility of the client to the point that there is little

likelihood that such a memory could be unaffected (e.g., hypnosis, drug therapies,

directed imagery, etc.).

Reactions to the Repression Debate

Pivotal cases which have led to legally instigated change in therapy grew out of

controversies over repressed memory of childhood sexual abuse. The type of therapy that

has been central in the elicitation of memories is regression therapy and the practices

which it often entails. I look at two major areas in this debate: The possibility of harm

and the centrality of the controversy over regression therapy.

Possibility of harm

Situations we define as real become real in their consequences. (W. I.
Thomas 1931/1966)

The pivotal axis of contention about regression therapy has to do with the

question of whether a client's images of childhood sexual abuse are accurate memories or

inaccurate artifacts of therapy practices. Regardless of which, the images can be real in

their consequences for the client and possibly others as well, especially if he/she is

encouraged to resolve the memory by confronting an alleged perpetrator. In many

instances effects do not stop with the mental health of the client; consequences for alleged

perpetrators are dire. They are so even if the images are merely images and not actual

memories.








46

For many therapists the strength of the beliefs of clients is a potent tool for

motivating changes in behavior, emotion, and rationality, whatever the validity of that

particular belief might be. However, over-reliance on this tool has sometimes resulted in

neglect of treatment based on the reality of present contexts. The client's state ofbeliefin

the actuality of past events can result in harmful consequences for themselves and others.

Therapists may violate the therapeutic ethical principle of doing no harm by reinforcing

and directing treatment toward an occurrence that did not happen, at least not outside of

the client's own misconception.

Centrality of the repression polemic

The dissertation explores orientations to therapy practice in three therapy

disciplines to learn how the disciplines deal with repressed memories--a concept that is

itself controversial.' The concept of "repression" as used in this research involves the

following characteristics: 1) a/some traumatic or negative events occurred to the person

in childhood, 2) memory of that/those events is blocked from recovery by normal

memory processes, 3) the memory affects the person's present behavior, and 4) the way to

cure or ease the effects of the memory is to make the event conscious and to confront it in

the present.

Some major symptoms of distress or mental illness from these unresolved

memories are called "dissociative disorders." Dissociative disorders are defined as a

class of disorders in which people lose contact with portions of their consciousness or

memory, resulting in disruptions of their sense of identity.



SSigmund Freud introduced the concept of repression of memories. His changing conception of it and the
debate that followed is detailed in Chapter 3.








47

For over 80 years therapists of different theoretical paradigms have argued about

the concept of repression and methods of elicitation. The recent expansion of the

controversy is manifested by the spiraling increase in the number of articles covering

regression therapy and childhood sexual abuse (CSA) that can be found in professional

journals which are dedicated to therapy disciplines. Professional ethics have been

reexamined in reaction to this academic outpouring.

The legal profession has also reacted to this controversy over regression therapy

and child abuse. In the last few decades there has been a large increase in legal cases

involving the terms "child abuse" and "repression of memory." Those legal issues were

reviewed in the previous chapter.

Consequences for Therapists and Clients

The question of whether repressed memories actually exist haunts regression

therapy. Finding that memories used for therapy were false memories, which were

recovered or manufactured during therapy, would open the therapist to charges of deviant

practice and would construct the new self of the client around a falsehood, a weak base at

best.

A theoretical argument could be advanced that partially accounts for the recovery

of false memories during therapy. The repressed memory of CSA (no recollection) as

opposed to one that has been suppressed (recollection that is put aside) is functional for

both the therapist and the client. First, potential gains for the therapist are examined, and

then gains for the client.

Finding repressed memories increases the control of the therapist. The client may

have come to therapy seeking advice or instruction on life techniques that they he or she










is not using, is using inefficiently, or is unaware of (i.e., methods for self-efficacy). By

focusing on a "repressed" memory, the locus of power shifts to the therapist. The client

becomes dependent on the therapist who revealed this hidden property--the memory

which is beyond the scope of self-efficacy-as the root, base, and infrastructure on which

all their problems and inadequacies can be rationalized and confronted.

Psychotherapists, particularly psychoanalysts, are taught to encourage

uninterrupted narratives, removing themselves to the background, (Holstein & Gubrium,

2000). Even in encouraging these uninterrupted narratives, common therapy elicitation

techniques (e.g., silences and turn passing) can reinforce dependence and act to disallow

the client's own perception. If the therapist is passing his/her turn with a silence, the

client may come to feel that he/she has not seen or conveyed all that is necessary the topic

and may be drawn to confabulate, or search for links that do not convey what he/she had

been trying to convey, until the therapist takes his/her turn. Dependence on the

therapist's reconstruction of accepted conversational tactics comes to dominate. The

client is likely impelled to trust that there is more to be discovered.

Whatever the therapist's intentions in using these methods, the therapist becomes

essential and preeminent in the quest for change. This perpetuates dependence on the

therapist. It is therefore in the self-interest of the therapist to find repression. Regression

therapy not only keeps discovery of self focused on a particular problem--it also serves

to keep the client dependent and in therapy for many sessions.

Therapy may necessitate a protracted period for the therapist to assimilate

information and assist the client in organizing thoughts and emotions. The therapist's

personal approach to therapy influences the content of sessions through choices of which








49

narratives to encourage. Only through a number of sessions does the client become aware

of the proclivities and understandings of his/her therapist and assimilate them in a joint

construction of the client-self. Multiple sessions are thus required.

However, if the memory has been suppressed by the client, this process is less

efficient for the therapist. The client retains a greater degree of control and self-

actualization. Since the memory has been available for the client to recall when the

situation feels right, safe, and/or comfortable, the therapist performs a different role--an

adjunct role. In this situation the therapist is a resource for the client's decisions about

where his/her life should go rather than a component that is absolutely necessary for

personal improvement. The therapist can provide the nonthreatening, comfortable

atmosphere that the client requires to decide that it is time to confront the suppressed

memories; however the therapist is not the source of a recovery of the memory to

conscious deliberation.

While finding repression increases client dependence on the therapist, the client

gains in two ways. The first gain for the client is that the repressed memory provides a

convenient scapegoat for anything not going right in life. If the memory has been

unretrievable, persons and processes other than the individual can be held to blame. Any

possible lack of self-accountability may thus be rationalized. A new starting point thus

emerges that excuses the client from responsibility for previous failed interactions and

perceived failures of his or her own self construction processes. This excuses interaction

failures and emotional and mental failures dating from the time that the memory first

became inaccessible (when the incidents occurred).










The more mundane gain is found in the legal requirement for tolling the statute of

limitations' for discovery of CSA. When the client has suppressed the memory and is

only bringing it out when in a "safe" atmosphere for recall and for confrontation, the

alleged perpetrator can be held legally accountable, in most state tort courts, for three

years after the client reaches majority (tolled after the client reaches majority, not from

the time of the incident (Hagen 1991). However, if the memory has been repressed, the

accountability is not tolled until the client "discovers" the memory or can reasonably be

expected to have discovered it, whatever his/her age at that time (Hagen 1991, and

Williams 1996).

Labeling and Imputing Victimization

On the basis of a literature review, this section of the dissertation reveals

problematic aspects of constructions of selves generated during the debate on CSA and

repressed memories. Experiencing sexual abuse has been deemed a severe psychic

trauma (Olio & Cornell 1993). Regression therapists and researchers report that sexual

abuse causes an emotional shock to the child's psyche, effacing sexual mores and causing

severe suffering (Ashton 1995; Blume 1991; Breire 1990; Herman 1992; Kihlstrom 1996;

& Terr 1994).





2 Black 's Law Dictionary defines tolling the statute as a law that interrupts the running of
a statute of limitations in certain situations, as when the defendant cannot be served with
process in the forum jurisdiction. The statue of limitations is defined as "A statute
establishing a time limit for suing in a civil case, based on the date when the claim
accrued (as when the injury occurred or was discovered). The purpose of such a statute is
to require diligent prosecution of known claims, thereby providing finality and
predictability in legal affairs and ensuring that claims will be resolved while evidence is
reasonably available and fresh" (Garner 1999).










According to the theory behind regression therapy, this shock in turn creates a

mental incapacity for coping with the events) of the abuse and causes the consequent

repression of the memory(ies). The abuse is deemed a necessary and sufficient cause of

the repression. Lenore Terr, a psychiatrist, writes that repressed memories of sexual

abuse and other traumatic memories insinuate themselves into the biological and

psychological life of a person and the memories themselves come to have lives and

transformations of their own (Terr 1994).

Adding to the argument over the effect of (a) trauma(s) experienced when a child

is the argument over whether the client should be considered a victim. The importance of

this argument revolves on the labeling process.

Calling someone a victim encourages others to see how the labeled person
has been harmed by forces beyond his or her control, simultaneously
establishing the 'fact' of injury and locating responsibility for the damage
outside the 'victim.' The discourse of 'victimization' is thus practically
situated social action that promotes practical definitions of everyday
circumstances. (Holstein & Miller 1990, 106)

Thus, authors of self-help books and some regression therapists have sometimes

become labelers. In regression therapy the labels, "victim" and victimizerr," locate the

"fact" of the harm and the resultant mental or emotional problems which may occur as

beyond the client's control. Asserting victimhood of the client shifts responsibility for

present problems from the client and to the alleged perpetrator who may have caused the

repression and resultant mental problems.

Proponents of therapy techniques which do not include regression therapy may be

seen by those who do as neglecting the primary (or original) cause of present problems.

Those other therapists, thus, may be charged by regression therapists of having blamed










the victim (the client) for problems that were in fact caused by others. A negative

consequence of the "victim" label is that victims are often blamed for their own

victimization (Ryan 1976). What is missed by such an analysis is that many of the other

therapists do not label the client as a victim at all, but as someone who should be

instructed and encouraged to take care of their present problems--to develop self-efficacy

and ability to fend off adversity.

Labeling a client as a victim of repressed memory(ies) strengthens client

dependence on the regression therapist. The use of the label "survivors") for those who

aver victimization from CSA becomes a linguistic device. This term is more capable of

activating emotionally charged views of the client and the accused perpetrator than would

be the case with more neutral labels. Use of the "survivor" label implies that the CSA

took place, for how could the client be a survivor if no act had taken place. In most cases,

for various reasons, the regression therapist does not seek to verify an actual act. Other

possible labels for the person averring repressed memories of CSA (i.e., the "accuser,"

"powerless," "memory impaired") are more direct in contextual description. For

example, a client could be described as an accuser who may have been abused when a

child and rendered powerless (at least until accusations are made), or he/she could be an

accuser with a malfunctioning memory. These other terms are sometimes referred to in

the literature on regression, but "survivor" is almost invariably the label chosen by those

authors who assert the validity of repressed memories of CSA.

Organizations and their agents make it their business to describe our lives
and experiences so that they can address, assess, and ameliorate the
challenges of daily living. In the process, they become sources of
experiential definition--purveyors of identity, so to speak. (Holstein &
Gubrium, 2000, 154)










During regression therapy, the life of the client becomes defined within a master

identity consisting of a particular "self from therapy"-a master status as CSA survivor.

In some cases this status becomes so compelling that the client becomes fixated in daily

life to the exclusion of other aspects of self. This master status may mitigate and interfere

with the formation of a more versatile self that responds to situated contexts and the

multiple organizational local cultures, which the client encounters in the flow of daily

living. Diversity of response possibilities may be circumscribed.

In this dissertation, distinctions held in different therapy disciplines on these

constructions of therapeutic labels of deviance are provided through analysis of

interviews with therapists. This qualitative analysis focuses in part on their takes on the

constructions of repression of memory, the importance of regression as a therapy tool, and

the discovery of repressed memories.














CHAPTER 5
METHODS

The research methodology is qualitative and informed by the work of Holstein and

Gubrium (1995). It uses "open interviews" and centers on active techniques rather than

highly structured questions. The active interview is "loosely directed" (29). It consists of

both subjective and objective elements. The objective element deals with what is being

volunteered and discussed. It is subjective because it affects how responses are

interpreted: "The focus and emerging data of the research project provide orientation and

framing resources for developing both the subject and his or her responses" (14-15).

The standpoint from which information is offered is continually developed
in relation to ongoing interview interaction. ... The subject becomes a
narrative resource for both the interviewer and the respondent, a guidepost
for how to ask and answer further questions. ... Challenged by the
interviewer, pointed in promising directions, and at least partially aware of
the interpretive terrain at hand, the respondent becomes a kind of
researcher in his or her own right, consulting repertoires of experience and
orientations, linking fragments into patterns, and offering 'theoretically'
coherent descriptions, accounts, and explanations. (Holstein and Gubrium
1995, 29)

The "open interview" can be "constrained by the interviewer's topical agenda,

objectives and queries" (29). Active interviewers "may suggest orientations to, and

linkages between diverse aspects of respondents' experience, adumbrating--even

inviting-interpretations that make use of particular resources, connections, and outlooks.

Interviewers may explore incompletely articulated aspects of experience, encouraging

respondents to develop topics in ways relevant to their own experience (Holstein and

Gubrium 1995, 17).










One less reactive way to suggest topics is through the use of concept cards.

Concept cards serve as the resources, connections, and outlooks which set loose

parameters for discovering orientations. Interviewees can review concept cards and pick

those that are within their frames of reference as a means to initiate the "open

interviews." The interviewer operates within this contextual framework to help draw out

information. Since an interview is unavoidably collaborative, the interviewer attempts to

keep his/her collaborative input to a minimum by advancing queries on the concepts only

through neutral probes unless asked a direct question. Interviewees may take the

concepts in the directions they choose. The interviewer's input into that process is

limited to probing for the interviewees' meanings. "Questions, prompts, comments, and

clarifications point respondents to particular topics, inviting distinctive narrative

treatments" (Holstein and Gubrium 1995, 28).

Open, active interviews are especially useful for conducting narrative analyses.

"The challenge is to identify similarities across the moments [narratives] into an

aggregate, a summation" (Riessman 1993, 13). "The stop-and-start style of oral stories of

personal experience gets pasted together into something different" (14). "In the end, the

analyst creates a metastory about what happened by telling what the interview narratives

signify, editing and reshaping what was told, and turning it into a hybrid story .. (13).

In my study, that story is the tale of the respondent's place as a therapist

(attitudinally as well as rationally) within the context of therapy practices and in

professional circles grappling with the definition of deviance. That context includes legal

and societal constraints on the negotiation involved to determine which practices are

deviant and how the line between "good" and "bad" therapy is drawn.










This qualitative approach has implications for how to select interviewees, how to

conduct interviews, how to analyze information, how to use that information to select

additional interviewees, which topics to pursue, and how to interpret the data once it has

been gathered. "Investigators must continually modify initial hypotheses about speakers'

beliefs and goals (global coherence) and recurrent themes that unify the text (themal

coherence)" (Riessman 1993, 67). The approach has implications for assessing its utility:

We can provide information that will make it possible for others to
determine the trustworthiness of our work by a) describing how the
interpretations were produced, b) making visible what we did, c)
specifying how we accomplished successive transformations, and d)
making primary data available to other researchers ... Narrative analysis
allows for systematic study of personal experience and meaning: how
events have been constructed by active subjects. (Riessman 1993, 70)

Sunbj ects/Inte rviewees/Resp o ndents

A strategic sampling approach was used in which the size of the sample and the

kinds of information sought were guided by findings from prior interviews. The original

design called for interviews with recently licensed and/or certified therapists from the

three basic occupational/therapeutic disciplines-psychiatry, psychology, and social

work. The reason for the interviews was to explore how therapists constructed deviance.

Approaches to therapy varied greatly within disciplines, indicating that during

training the therapists were exposed to a variety of techniques. Disciplinary background

did not emerge as being related to orientations to perceived deviance or about repression

of memories or the viability of regression therapy. For a study of how deviance was

constructed, there was little benefit in locating a set number of subjects from each of the

three disciplines. The sampling goal became one of identifying a diverse group of

therapists rather than a set number of therapists from different disciplines.










Potential respondents were located through public records of the Department of

Health and state licensing boards, intemet directories (e.g., National Institute of Health at

http://www.nlm.nih. gov/medlineplus/directories .html and Medicare at

http://wwwl .medicare.gov/Physician/Search/Physician~erhap ), and library files on

commencement exercises by school and discipline. Alumni associations indicated that

they would contact individual graduates to ask if they would participate, but would not

provide a list. Departments contacted did not provide lists of contact information for

graduates. Since I was concerned about the confidentiality of interviewees, I did not use

any resource that would connect a particular potential interviewee with my study.

All respondents interviewed were adults. A demographics form contained the

question of whether or not the subject was 21 years of age or older. Chronological age of

the respondents was not of paramount importance. The time period within the education

process--at the end of formal training and while engaging in a career in counseling--was

the factor of importance rather than chronological age.

Respondents were not selected on the grounds of gender, race, or ethnicity. While

some differences in respondents have been found within the literature on methods and

interactional responses, my study was not directly concerned with who was being

interviewed, other than that they were therapists. Using the data gained from this

research, future research on this topic might include a quantitative research agenda to

determine the scope of contribution of these and/or other demographic elements to

therapy practice and the construction of deviance.

Ten therapists were interviewed. The number was determined during the

interviews based on how often the therapists provided similar information. This is called










saturation. Four had backgrounds in social work; four were psychologists (one of whom

had a background in educational counseling), and two were psychiatrists. They were

practicing in two southern states. The nature of their practices varied. Most were in

private practice but some were working within other medical organizations. Other

descriptive features will be discussed when presenting the results.

Interviewing
Gaining Access

The potential respondents were first contacted with the letter reproduced in

Appendix A. Pages included with the letter were the informed consent document

(Appendix B) and an optional questionnaire to attain basic demographic data about

individual participants (Appendix C). Those contacts were followed with a phone call.

That introductory phone call followed four or five days after the letter was sent. An

example of the format of the calls is found in Appendix D.

In some ways the biggest challenge to this research stemmed from difficulties in

securing access and cooperation from potential interviewees. The challenge manifested

itself in several ways. Obtaining information on which potential interviewees could be

contacted (and how) was a difficult task, especially in regard to psychiatrists. It was

difficult to discern when some therapists received training and when they were certified

or licensed from many of the records which were consulted. One mental health counselor

did not believe that she fit the parameters because the letter of introduction referred to her

as a Doctor (she was not). She was so reluctant after that point that she was excluded. A

licensed clinical social worker stated that she did not know when she could take an hour

for the interview since she was working two jobs--at a hospital and her own private










practice--and also had two children. The psychologist whom I had thought would have

more knowledge on the areas of my research interest, due to her dissertation topic, said

she was too busy in her personal and work life to be interviewed even for just an hour.

Many of the recently trained therapists had relocated to distant sites. Their

letters were returned and they could not be contacted by phone or email. Many other

prospective interviewees would not return calls (even though an initial contact letter had

been sent to provide notice). With psychiatrists, I found that the receptionists and nurses

performed a "gatekeeping" function which disallowed contacting the psychiatrists directly

or by phone. When I personally handed a sealed letter containing the contact information

with the psychiatrist's name and asked that it be given to him, the nurse tore it open in

front of me and began reading it. With many psychiatrists, letters and phone calls were

not returned, even when I had been assured that the psychiatrist had received my letter or

notification of my phone call. I did not have this problem with the other disciplines.

Sociologically Interviewing the Interviewers of Clients

One question that had to be addressed was, "How do you get therapists to open up

to a sociologist?" Their professional function is to get others to open up to them. I

represented a different paradigm and discipline. Many therapists would be more at home

performing the role of interviewer than interviewee, and they were well-versed in the art

of interviewing and would recognize the techniques that are used to elicit information.

Therapists likely have some knowledge of the sociology as a discipline from their

out-of-discipline undergraduate courses. They do not consider deviance in the same way

as do sociologists. The interviews used communications tactics that would ensure a

common understanding of meaning. For example, use of the word "deviant" was










avoided. In sociology, "deviant" is understood to be a word that has a neutral meaning

and does not connote negative aspects.

Therapists are more often focused on dealing with deviant behavior and individual

thought processes and emotions than on grappling with larger social and legal definitions

of deviance. Their introductory sociological knowledge does not ensure that they will

appreciate this line of research. The experiences of the interviewees rests on a person-to-

person approach. This perspective brackets understanding within an individual contact

level which may have blunted realization of how a sociological approach provides an

opportunity for therapists to see themselves in relation to their work and to mental health

more generally.

One challenge was to entice the therapists to step out of their chosen role--a doer

of therapy--into persons who could relate all the knowledge they had accumulated on

therapy and doing therapy. The goal was to elicit their narratives without manipulation.

Casual conversations with therapists and others raised the prospect that the

interviews would explore topics that were extremely sensitive for some. Some responses

may be emotional or be colored by emotional feelings. Techniques could be used to

reduce that kind of reaction, but the analysis would have to incorporate the prospect. For

example, probes would have to be worded carefully to avoid emotional responses and to

mamntam rapport.

Features of the Interviews

Open interviews were conducted. All interviews were confidential. The

participants were told that they could skip areas of discussion or terminate the interview

at any time--information that also appeared on the informed consent for which they










signed and were given a signed exact copy. The interviews were tape recorded and lasted

at least 60 minutes. No interviewee decided to terminate the interview within that span

and several extended comments for several minutes thereafter. After the tape recordings

were transcribed, they were erased. In the transcription phase, any information that might

compromise the confidentiality of the participant was excluded. The transcripts were

recorded with pseudonyms rather than actual names. All records and data are kept

confidential and are controlled and protected by the investigator.

Concept card were used to introduce topics and to allow interviewees to select

priorities. My review of social science journals had provided me with relevant concepts

that therapists cover when discussing the present state of American therapy, especially

some that related to repression and regression. The topics on those cards consisted of

"Accountability, Backlash, Discovery, Epidemiology and Abuse, Labeling, Law and

Therapy, Mandated Reporting, Memory and Therapy, Primum Non Nocere (Above All

Do No Harm), Professional Dominance and Hegemony, Repression, Retractors,

Suggestibility, Survival groups, Survivors, Treatment practice, Symptoms, Syndromes,

Tolling the Statute of Limitations, Treatment Practices, and Victimhood." The concepts

were typed on 1 3/4" x 3" cards and laminated. Before giving the cards to the

interviewee, the deck was shuffled several times to show that they were in no particular

order. The interviewee was then told to select the five cards he or she would like to

discuss. By the end of the interview most or all of these concepts did get discussed.

When prompts were used, they were neutral and allowed the interviewee as much latitude

for direction of interpretation as possible. Some of those prompts are found in Appendix










Analyzing Interviews
Methods for Analyzing Data

Narrative analysis was the primary tool for analyzing the interviews. It was

supplemented by qualitative content analysis. Discourse or conversational analysis was

used after several interviews to assess whether the interviews were capturing the

information needed to analyze the construction of deviance.

Narrative analysis is used for interpreting data. Narratives are described by

Gubrium and Holstein (1997) as "accounts that offer some scheme, either implicitly or

explicitly for organizing and understanding the relation of objects and events described."

Riessman (1993) noted, "Narrative analysis--and there is no one method here--has to do

with 'how protagonists interpret things' (Bruner 1990, 51), and we can go about

systematically interpreting their interpretations." I systematically interpreted the

narratives my subjects related in their interviews by looking for elements in common with

the topics found in my literature review to be of importance for an understanding of the

labeling of some therapists and therapy practices as deviant. I also explored narratives

related to where the line was drawn between acceptable and unacceptable practices or

actions that were the basis for those labels. My rendering of the results centers on four

recurring narratives: orientations to therapy; memory, suppression, and repression;

accountability and ethics; legal issues and therapy.

Qualitative content analysis sometimes draws inferences on both the appearance

or nonappearance of attributes in messages. I used qualitative content analysis on the

data to help define the similarities and differences found on the narratives. Discourse or

conversational analysis focuses on how the interview proceeded that produced the










conversation or discourse. It attends to issues like pauses, repetitions, volume, speed,

body language, etc. This kind of analysis provides context for interpreting the narratives.

It can also be used to check to see whether the interview interaction permits the subjects'

discourse to be voiced without it being constrained by the interviewer. To make sure the

interviews were yielding the kinds of stories from the respondents which could be used

for narrative analysis, the conversations from the first two interviews were analyzed. I

found that the interviews were accessing the kind of data that I needed to perform

narrative analysis about the construction and response to deviance (see Appendix F).

Am I Getting Conversations and Narratives That I Can Use?

I transcribed the data from the first two interviews to appraise whether the

interviews were collecting relevant data for the research focus. Before the data were

collected, I had presumed that I would start by looking at the responses on the concepts,

one at a time, and compare them by disciplinary backgrounds of the interviewees (i.e.,

social workers versus psychologists versus psychiatrists). When viewing the actual data,

I realized that the concepts would have to be compared across therapists--a therapist by

therapist analysis--because each of these therapists related his/her experiences from a

unique perspective that prevailed through most of the interview. How the interviewee

responded indicated how he/she shaped the content of his/her answers about the concepts.

Each therapist in this set of interviews projected importance to certain topics to a

discernable degree, indicating that he/she was intent that I understand the nuances of

his/her point of view. That these varied from interviewee to interviewee is one of the

reasons for pursuing a qualitative approach.










The first interviewee provided a language couched in terms of moral exactitude.

The second responded with very minimal prompts in a language of competent precision.

It was clear to me that each of the interviews was a unique presentation and that an

examination of the concepts must include how they were told as well as what was told

(i.e., narrative analysis should sometimes be supplemented with conversational analysis).

Appendix F contains an example of conversational analysis drawn from my data.

The discourse analysis of the first cases also confirmed the utility of the concept

cards. The first interviewees selected three of the same concept cards: Accountability and

Ethics, Symptoms, and Treatment Practices. I had not asked them to put the concepts in

order of preference and was informed that they had not. I did not refer to the cards unless

our discourse on a topic came to an end without the topic having surfaced in the course of

the interview. This procedure allowed the conversation to flow from the initial question

on therapy into lines directed by each interviewee's interests. I first compared their

discussion of these concepts and then contrasted them in terms of therapy in general and

then as they related to the use of regression and repression.

My greatest surprise in these first interviews was that none of them recognized the

Ramona case until after I explained the Ramona case to them (to see if they were aware

of this lawsuit, but not by name). They hemmed and paused and passed speaking terms in

the conversation. They were also unfamiliar with other rulings regarding third-party law

suits. I learned that I had to approach these topics differently. Although the therapists

were not directly aware of the lawsuits, either through their training or their objectives,

they had developed stratagems that would safeguard them from that threat. These became

the point of entry for eliciting their narratives about legal issues and therapy.














CHAPTER 6
ORIENTATIONS TO THERAPY AND DEVIANCE

The therapists orient to therapy in various ways. This chapter discusses

orientation to therapy in terms of the meaning of therapy for the interviewees, and what

they think about deviance in therapy. The therapists' descriptions of their own practices

and their thoughts about therapy in general are revealed and discussed. To help order the

presentation, the interview data are grouped by the type of occupational credentials.

Therapy treatment practices that are labeled "good" or "bad" were determined by

the labels that the interviewees themselves related.33 Deviance is also determined from an

examination of the contrasts in their labels of good or bad practices and therapists.

Additionally, I examined the treatment practices of my subjects to help delineate methods

that they have found to be normative for their discipline.

The subject of treatment practices would come up from the interviewee directly or

in response to a question on what they thought about them. I used the opportunity to

question about suggestibility in general and about practices that have often been linked to

suggestibility (e.g., hypnosis, drug therapy, guided imagery, and survivor groups).





SIn probing for deviance versus normative practice I had refrained from using the word "deviance" and
had used terms like "inappropriate," "non-normative," and "questionable practices." After introducing the
concept in these terms, I would use the words "bad" or "good" while making quote marks with my hands
and stressing the words so that it was clear that I was using these words as a label of convenience to
encompass this concept. None of the therapists interviewed appeared to have a problem with this device for
saving time and one even affirmed: "We're going to label it good. .. Yeah." For fluidity in reading the
rest of the text, the quotes symbolizing the stresses made in the interviews are removed.

65










Interviews with Licensed Clinical Social Workers

Each of the licensed clinical social workers (LCSWs) was able to provide a

personal definition of therapy after thinking for a few seconds before announcing his or

hers. This is notable in that each of the LCSWs used an interjection (i.e., "hmm," "uhm,"

"I guess .. ," or "uhh") to provide extra seconds for thought before answering.

Although they did therapy every day, these therapists expressed surprise that it had been

such a long time since he or she had thought about some of the basic components of the

institution of mental health (i.e., what therapy means, what are their feelings on some of

the concepts advanced in my questioning et al.).

With the exception of the interview of LCSW Amy, there were usually fairly

defined opinions and attitudes toward these topics. Amy's interview revealed a different

aspect of treatment practice. Amy came from the most medical vantage point. Her duties

in the teaching hospital where she worked were split between assisting doctors charged

with treating physical ailments and resident psychiatrists who were embarking on therapy

careers. Her input ranged from making sure that patients had rides home after their

hospital stay to alerting the psychiatrists when she detected problems which related to the

process of mental health. She dealt with patients before they were admitted to the

hospital, through their stay in the hospital, and to adjustment difficulties encountered

subsequent to their stay.

In talking about making rounds with medical professionals (i.e.,

doctors--including psychiatrists, psychologists, and nurses), Amy related numerous

instances in which she appeared to have the goals of a prototypical social worker as

outlined in the social workers (Working Statement 1981, 6):










1. Help people enlarge their competence and increase their problem-
solving ability.

2. Help people obtain resources.

3. Make organizations responsive to people.

4. Facilitate interaction between individuals and others in their
environment.

5. Influence interactions between organizations and institutions.

6. Influence social and environmental policy.

She described therapy succinctly and with some finality in terms ofhealing:

Mike Okay, you work with several different doctors. We'll get to ask
some questions about that. It'll be interesting--the psychiatrists in
particular. But, let me ask some kind of general questions. What
is therapy for you? What does therapy mean?

Amy: Hmm. To my mind, therapy is a process by which we heal old
hurts that are interfering with our present day life.

Mike: Mental and emotional?

Amy: Probably both.

As "a patient resource manager in a teaching hospital," Amy says her function and

duties are involved in "looking for discharge planning needs, for how we can deliver

more efficient service while the patient's in the hospital." Some of the ways she does this

are quite mundane (e.g., making sure the patient has somebody to pick them up on

discharge). Some are much more complex and involved interventions [e.g., dealing with

more involved services (e.g., HMOs, insurance companies, nursing homes, referrals to

outside social workers when needed etc.)]. Others deal with complex issues involving

relationships (e.g., family, friends, associates, and employers). From her vantage point,










"the client dictates the course of therapy and if something else is being uh projected onto

them, that would be in my opinion bad, practice."

There was a long pause after I asked Amy "What are good therapy practices." So

I switched my tack and asked her what good therapy would be. Her response was in

terms of effects on the patient rather than on what a good therapist does (i.e., techniques).

I guided her to therapy practices by directly asking what a therapist should not do as I

turned to the bad therapist section of the interview. She again turned the answer to

coming from the client (she later would refer to them as patients) and made good

distinctions based on basically passive actions by the therapist to finding out where the

client is and bad practices as failing to work from the client dictates. Ironically, passivity

of the therapist is seen as "good," contrasted with the peril of bad actions when actually

doing something with the patient.

Amy: We're going to label it "good," yeah. Umm that would be where
someone is able to function either .. either more effectively or
happily in their present day, because, they've been able to resolve,
issues from the past that have been blocking them.

Mike: Okay. So mostly it's taking care of problems and symptoms that a
person has now? Okay. What is bad counseling, or bad therapy?
What are practices that shouldn't be done. What shouldn't a
person who is a counselor or therapist do?

Amy: Always begin where the client is. Not where the client isn't.
Either uh that would be forcing solution or interventions that 1) the
client doesn't need, or the client doesn't want, or the timing is not
proper for the client.

Mike: So, in other words, you're kinda telling me that a good practice
would be to listen very carefully to the .

Amy: client.

Mike: client?










Amy: Yes. The client dictates the course of therapy and if something,
else is being uh projected onto them, that would be in my opinion
bad, practice.

Mike: Okay, what's, totally unacceptable? What's the line? The person
that's gone over the line?

Amy: You mean at it's very worst?

Mike: In counseling and therapy, what would you say?

Amy: Where is the ..

Mike: "You can't do that(?)," or "You shouldn't do that(?)." Well .
"You can 't do that.

Amy: Well, either telling the client what his problem is before he's been
able to figure that out for himself--if it's even true.

Mike: Um hmm

Amy: Or imposing an intervention that's immoral or unethical or, not
something that the client is willing to really go along with.

Mike: What would one of those interventions be?

Amy: Umm. perhaps suggesting sex therapy for um a problem which
the therapist is like directly involved. I mean, that is the high end.
Immoral and unethical.

Mike: So basically sex with the client or

Amy: Right .. for his own good.

The use of pauses, turn passing, and insistence on extreme clarity in the questions

illustrate Amy's discomfort with the area of good and bad practices. When I asked

directly what the line between good and bad practice would be, she answered first by

reasserting her insistence that not directing the client is being good (even when it proves

to be in the right direction) and then by defining bad as forcing interventions on the client,










immoral or unethical interventions, and at last she gave having sex with the client as one

of the bad therapy practices (interventions)

The LCSW, Will, spoke of therapy as a process that gets one past obstacles from

the past which are impacting the client and preventing him/her from becoming fully alive.

Mike: Usually the first thing that I ask is kind of general: "What is
therapy?" and "What do you consider therapy to be?"

Will: Uhh. Therapy is a process by which people, examine uh past
events in their lives that may be impacting their lives now. Their
ability to function, their behaviors uh their thought processes and
their moods, uh their emotional world and uh to where they can get
some clarity, move past some things, move past these obstacles and
be more fully alive.

Will was the most independent of the LCSWs. His practice often involved third-

party referrals and one of his groups included a clinical psychologists. For the most part,

Will was an "independent contractor" and provided counseling and therapy in a very

similar manner to that revealed by my clinical psychologist interviewees.

When asked about substandard treatment practices, Will keyed on suggestibility.

He stated that he does not do hypnosis or dream therapy but had done some guided

imagery (one of the techniques that risks increasing client suggestibility) but preferred to

do conversation therapy to change cognitive makeup.

Will: The suggestibility, how you lead the questioning. I mean that's a
big thing in child, child abuse cases as well, you know. Who's
doing the interviewing. That's why they have to tape everything
now, because that the questions are leading. If you're talking
about, you know, all this hypnotherapy, and again, what are you
dealing with to start off with, you know, what is the (?)itic? If
you've got a therapist, a psychi>: you know, even a psychiatrist in
this. .. Who is> has a certain framework, is looking for certain
things. uh it's, you know, you can, you can go find anything. And
if you run up against, you know .. ? Some types of personality
disorders are there everywhere.










Will also expressed concern about the mental health of some of the people who

were being graduated from social work universities.

Will: I mean, I looked around my class at [university] and I said '50% of
these people oughtn't to be practicing social work.' Five years. ..
And I don't know if that's true or not. but there were some people
in there who, uh had to be weeded out. Very needy type of people.
I've seen it happen at [different university] where they they've had
to> where on their internships, people would stand up and say, this
person is not appropriate to do this work.

Mike: Umhm.

Will: You know. Straight "A" student and everything, but she's, she's
crazy as a loon.

Will at first brushed aside the question of the line between good and bad practice

as being subjective before I assured him that I understood the subjectivity of the question,

but that was what I wanted--his subjective thoughts on the topic. He then spoke of

failure to achieve positive results, therapists with agendas other than the mental health of

the client, and confidentiality before returning to not releasing the patient when the

therapy is not working.

Mike: I want to ask one question. What is the line between good practice
and bad practice? Who are they. How do we determine, bad
therapists and good therapists? Should something be done about
the bad ones.

Will: You know even that is a subjective thing. You know it's not like a
litmus test.

Mike: I know it's subjective, and you're the one.

Will: Huh?

Mike: I know it's subjective and I'm asking you.

Will: Uh, uh, yeah, yeah. I would think that if (snort laugh) their
patients get sicker (laughs).










Mike: If their patients get sicker, if they do harm--primum non nocere?

Will: They .. yeah. In uh man uh .

Mike: What's a bad therapist? Have you met any bad therapists?

Will: Oh yeah. They're people whose uh, Their agendas are more
important than their patients or that it's it's uh, confidentiality >

Mike: We didn't get to talk about confidentiality.

Will: > and that stuff. Uh. Well I'm more interested in the clinical kind
of things than the .. you know. I think that the confidentiality
thing, it's it's very important of course. But it's like. .. Now it's
bally to the hip of things. It's ballyhooed way beyond uh .. you
know, I mean it's it's it's it's. .. That's somehow, that's gotten to
be a poke. It's like things in hospitals. A lot of the paper work,
regs, and the things that you have to do, are all designed by people
who don't do that work. [Will then talked about administration and
unnecessary regulations before getting back to bad therapists] ..
Yeah. Cause a lot of people. I mean, you get people in here come
into therapy, and there's not going to be improvement. You know?
I mean, and you see that all the time too.

Mike: And so, you would want to get rid of them or just keep them?

Will: Yeah, just yeah, "Well this is not working."

The two other LCSWs, Betty and Larry, both related the object of therapy to be

freedom from something that the client is stuck in rather than healed from or got through

an obstacle. For them, the therapist helps to move the client out of the place where he/she

is stuck.

The focus of Betty' s responses did not appear to come from a particular American

perspective. This LCSW included an intercultural standpoint in understanding and

treatment of clients. She talked of therapy as an experience of growth that client and

therapist are both going through. She spoke of the therapist in the third person as if the

therapy is "out there someplace" to be discovered through the interaction of the therapist










and the client. This Oriental concept of "releasing" the self into mental health involved

an interaction of two selves--that of the therapist as well as of the client.

Mike: What do you think therapy is? What's it mean to you?

Betty: I guess. .. Therapy for me personally or for my clients or both?

Mike: What does it mean to you.

Betty: Therapy is .. its just an opportunity where two or more people get
together and umm and growth is going to happen somebody is
going to learn insightful things about themselves. You know, stuff
about themselves and umm is going to learn about things, how it
relates to them and how it makes them feel and how it makes them
be and behave in the world and what changes they want to make
and therapy helps them bring those leeriness to the forefront to help
them grow .. from whatever awareness they are learning. So that
to me is what therapy is.

Mike: And so a therapist would be .. ?

Betty: Like a change agent

Mike: A change agent?

Betty: Yeah somebody who just helps someone move forward out of
whatever's happening with them and move out of that because
they're stuck or ..

Betty jumped right from my question of what a good therapist would be to

therapist skills (communications and listening) and therapist morality and ethics (honest

and open). When I asked what a bad therapist would be, she answered, "a therapist who,

for their own growth and development uses the patient for that." After reassuring her of

confidentiality (that I would make sure that her identity as interviewee would be known

by no one but me), I asked her if she had know such a therapist. She related the

following, which amplified her position on bad therapists:










Betty: Okay, well not anyone locally but when I lived in [state] there was
one person who um dated their patient and the patient had money
and influence and all other kinds of other things. And I think it was
just purely for their own getting out there and meeting people that
they could also treat and whatever and um but, so I would say a
bad therapist is someone who dates their patients or who sleeps
with their patients or who um who talks about their patients, breaks
confidentiality um without anybody, you know, other than a mentor
or something. You know?

Mike: Right

Betty: But there sometimes needs to be some help with a consultant or
whatever. So a bad therapist would be one who doesn't take care
of themselves and who um and who is not in good form for their
patients, who is not healthy and whose not modeling behavior that
is, that is .

Mike: What do you mean by healthy?

Betty: Umm Somebody who's not drunk at night and hung over in the
morning and can barely focus on the patient the next day.
Someone who doesn't exercise and sleep well so they're groggy
and sleepy and not thinking very well. um, You know? Someone
who just in general doesn't take good care of themselves um and so
they can't be fully present to their patient

The LCSW, Larry, stressed the importance of a religious standpoint. He described

therapy in terms being a guide in his relationship with clients.

Mike: Okay. The first thing is what is therapy for you? What does
therapy mean?

Larry: Uhmm. Boy, I guess I'm taking normal people that have to be .
happen to be stuck in one of life's transitions and sort of providing
a safe place for them to work through that and try to get them to a
better place.

Mike: Right. Right .. there's no right (laughs) answer for me. It's your
answer and-

Larry: I could talk for an hour but an hour is all you got, so. ..


Mike: Yeah. That's fine.










Larry: I guess coming from my perspective there's a lot of attachment
therein, basically, someone who can help a person become
anchored in their .. in that they are a person of value and often go
back and explore previous things or previous events where they
have not felt that. So it's .. transference is probably a key thing
in my approach to therapy.

Larry noted that he took the questions on "what is therapy" and "what makes a

good (or bad) therapist" for granted. After seeing pauses, I decided to change the order of

the question and asked about bad therapists first. Larry then answered the question as to

what a good therapist does--basically to play a supportive role. He begins his sessions

with an eight page introductory form that primarily provides questions to reveal

expectations of the client and to let the client know the psychological approach he takes

as a therapist. He related good practices to be those that provide unconditional, positive

regard to affirm the values of the client. His practice provides a secure place to explore

the gap between psychological and spiritual realms. He did this primarily through

"discussion."

Mike: Would it be easier to say what makes a bad therapist, an
unacceptable therapist?

Larry: (Inhales) I'm probably influenced a lot, by Carl Rogers on the
whole, issues of unconditional, positive regard. A therapist has to.
.. A person wants to get from where they are--to some other
state other than where they are right now, and that involves
influence and yet a realization that I don't know their world
completely. So a good therapist is somebody that affirms the value
of a person, so that that's a settled matter, and they can explore
other things that might be a little more threatening to them in any
other context.

We discussed authoritarian relationships often requested by clients and then I

returned the conversation to the topic of bad therapists. In the following section Larry

talks of a particular therapist who was involved sexually with a client.










Mike: Okay. Let's go to what's a bad therapist, what makes. .. This
kind of emotional thing. Have you known people that you
considered to be bad therapists, and what was there about them that
made them a bad therapist? And if not, what would make a person,
you would say, a bad therapist?

Larry: Most of what I get is self-reports of clients' experiences without the
without a therapist. Yeah, certainly you get into the extreme.I
have indeed conferred in a therapist that entered into a sexual
relationship with a client.

Mike: And you said .. ?

Larry: I inherited that client, so something at that extreme, uhhm. Often
it's more in the area of, probably, the use and abuse of influence,
having an agenda for how they need that person to ., what
direction they needed that person to go in. So. Ahh, they've
usually been in areas pertaining to power and areas pertaining to
transference.

He then spoke of abuse of influence and then used his early experience as a

therapist to point out the trap some therapist may fall into (letting their own emotional

needs lead them into pressuring the client to outcomes) to those which may be more for

the therapist's own benefit than that of the client. He then spoke disparagingly of

therapists who abandon the client when help is still needed.

Overview of How LCSWs Define Therapy Practices and Therapists

While I decided to ask about "the line" between good and bad therapy practices at

an early point in all the therapy interviews, I also returned to "the line" at the end of all

my interviews. In many cases, psychologists and psychiatrists as well as the social

workers added to their statements. With the exception of social worker Will, the

therapists were all asked about good and bad therapists very early in the interview. The

flow of Will's interview precluded my asking until near the end. Whether it was an

element of the process of the interview or some other factor (i.e., we had talked about










sexual abuse of children before this topic was asked about), LCSW Will was the only one

of the clinical social workers who did not mention that therapists who have sex with

clients, present or former, are bad therapists.

Each of the therapists had several persons who were resources whom he/she could

call upon for support and to help him/her maintain good treatment practices. Amy had the

medical staff at the hospital and several social workers that she called upon for

specialized service for patients. Larry met weekly with another social worker, a

psychologist, and a nutritionist. He also spoke of contacts with clerics who were one of

his resources for new clients and in at least one instance had provided counseling

assistance. Will shared an office with a psychologist (alternate day occupancy) in a clinic

which included other clinical social workers and psychologists. He also conducted a

mental health group with a psychologist at another location. Betty was supported by

other students and instructors at the clinic where she worked and where she was getting a

degree in acupuncture. She also had contact with massage therapists and other alternative

health specialists (mental as well as physical).

While my literature review had been rife with expostulations and defenses on

what traits a bad therapist has, and often these were contrasted with good therapists, I was

surprised to discover that the interviewed therapists did not have such formulated

opinions. After I discovered this in an early interview, I rephrased my question and asked

about good practices as opposed to bad ones. At that point I left open the definition of

"practices" (i.e., whether I was asking about how offices were run or what techniques

would be labeled bad or good). I was interested in both, but I wanted to find out which

ones each therapist would preference in their initial answer. Finally, when asking about










practices, I included that I was interested in finding out what was the line between

practices that were labeled good or bad. Each of the changes I made in presenting these

topics brought more immediate responses and appeared to reach areas which had more

saliency for the interviewees.

LCSW Amy did list some of her roles as a resource case manager, but only Betty

spoke of good therapists as those who had definable skills (which she enumerated) when

she talked of the necessity of maintaining professionalism [my term]. Amy strongly

stressed the importance of being aware of and following the dictates of the client in

deciding on interventions; Larry spoke of providing a supportive role; and Will said that

it is important for the therapist to help in solving the client's problems and stopping the

therapy sessions when they are no longer producing positive results.

When talking about bad therapists, all spoke of the fault of giving precedence to

the therapists own agendas and/or needs over those of the clients. Betty and Will spoke

of the importance of maintaining confidentiality. Amy's definition of bad therapy

practice was that it is the opposite of the definition of good therapy--not following the

dictates of the client/patient-therapy processes must involve and spring from the client.

For Larry, the paramount difference from statements of the others was in emphasizing the

importance of continuing the therapy support, and not abandoning the client prematurely.

While Larry advised caution in not letting the patient go too soon, Will advised caution in

not letting the patient go soon enough.

The social workers who had been interviewed were essentially trained to assist in

the practical concerns of their client/patients. To become Licensed Clinical Social

Workers they also had been required to pass a national examination. Three of the










LCSWs were occupying primary therapist roles and the other was performing roles and

tasks within a teaching hospital. These tasks involved supporting doctors charged with

physical problems and supporting the psychiatrists who were often residents assigned to

the hospital. One aspect of her support took the form of alerting medical personnel to the

mental health needs of the patient for coping with the world external to the hospital

environment as well as within it.

All of the LCSWs had support people to assist in their practice as needed. Those

in private practices performed functions described similarly to those of other primary

therapists. They acted as the primary mental health resource for their clients on a one-on-

one basis and led mental health group sessions. Each of their offices was in a clinic

which contained other therapists and available support personnel.

Two of the LCSWs oriented to therapy related that clients were mired in situations

and conceptual binds that were affecting his/her mental health. Another was concerned

with blockages restraining the client from mental health. The fourth was oriented to

treating mental illness as an injury and herself as a component of the healing process.

The LCSWs in private practices all used brief therapy consisting of only a few therapy

sessions. Each had treated clients in group therapy sessions as well as individually.

Along with Will, Amy and Betty noted that character flaws were additional

barriers to good practice. All had, in at least one instance in their careers, experienced the

actions of a licensed clinical social worker that they labeled "crazy." In each of these

cases, they were appalled that such a person could be licensed. Since this research is

concerned with the labeling of practices as deviant or normative and leaves questions of










character for others to pursue, the interviewer did not probe for details or seek other

instances of character flaws, which are not directly proscribed by professional ethics or

the law.

The LCSWs correlated bad therapy with doing harm to the client (i.e., primum

non nocere). For Amy sexual abuse of patients by the therapist, cultivating extreme

dependency on the therapist, and manipulation (even when it results in a good outcome

for the patient) were the things that harm patients. Larry discussed harm that came from

counter-transference. Will and Betty more directly related harm to not being sensitive

("present") for the client/patient. All of the social worker interviewees advocated some

kind of constraint by licensing boards although the form that this might take varied,

greatly.

To get to actual therapy techniques, I had noted that my literature review had

brought up the practices of hypnosis, drug therapy, and guided imagery and, in turn, asked

what did each think about those practices. Will had used guided imagery at some times in

his practice, but he preferred to use talk. He strongly cautioned that use of these

techniques raise the issue of suggestibility and that use of them opens the therapist to

accusations of managing the client rather than helping them solve their problems. None

of the others had used any of these techniques. Betty and Amy also were concerned about

suggestibility in relation to these techniques but accepted that they were used by others.

Larry's theoretical perspective precluded use of hypnosis or guided imagery. Betty was

particularly concerned about the over-prescription of psychotropic drugs but like the rest

said that they were useful in some instances.










Interviews with Psychologists and an Educational Counselor

The clinical psychologists and the educational counselor spoke of using a

cognitive-behavioral perspective on therapy. All, however, were eclectic in their

selection of particular approaches and goals. These were tailored to the context of the

therapy sessions and the content of the social an physical environment of a particular

client.

Rick, a psychologist, got several of his clients from referrals by clergy. He

differentiated between an ideal type of therapy and the way therapy is practiced.

Nevertheless, his theoretical perspective was very similar to the other psychologists but

focused more on fitting client selection according to his religious framework. He did not

believe that there was a conflict between his religious beliefs and his theoretical training

but did give examples of times when his religious beliefs had affected client selection. At

first, he appeared taken aback by my probe about therapy. He chose to reframe my

question "What is therapy?" into "What therapy should be?" He answered that it should

be a way of producing wanted and healthy changes in life.

Rick: In essence, therapy I believe, not to get too Clintonian, but I guess
part of the reason I'm having trouble answering your question is it
depends on what you mean by 'is.' So I'm going to answer instead,
"What therapy should be." Therapy for me should be, a, mode by
which a professional assists, someone in, producing wanted and
health changes in life[?].

When I asked how he (a therapist) does that, he discussed theoreticians from the

cognitive behavioral perspective and then a theoretician from the solution oriented

approach. In the therapeutic discipline blank on the demographic data form he had










written "'predominantly co gnitive-b ehavioral, informed by other appro aches, including

solution oriented."

Hypnosis was a technique that Rick had used to help a client do things that the

client wanted to do but had resistance to other therapy techniques. Rick remarked that he

had some training in hypnosis and the client had suggested trying it. Rick did not find it

to be effective. He said that with more training he would consider using it in the future

for changing expectations, but not for changing personalities.

Rick: It's that 'hope' concept. "I can't stop smoking, I can't stop this,"
or "I can't get along with my wife." "Yes you can!" [laugh] You
know?

Mike: Yeah

Rick: And if that ends up being a tool that somehow, [raps on table] the
ritual and all that of it, uh tends to be more convincing than my just
saying, "Well if you try this technique .. ." Then it's something
used for positive value and a gain and service--fine!, It's a valid
therapy. Uh there's a cliche for that. But [laughs]. Uh, in that
context, I could see using it. My belief in hypnosis as being .. a
thing. Uh it was some type of, you know, quasi-magical thing that
really has a lot of effect on its own. It's limited. But I do know
that people, uh are convinced and sold on ideas of different ways,
and if hypnosis can be used in a way of, of increasing their,
expectation of change, buying into that suggestibility, sobeit. .. I
don't use it. I guess what I'm trying to maintain here and make
clear here is that I don't have an absolute prohibition against the
idea, if I thought it would be helpful to do. I just haven't found a
case where it is.

Rick did not use guided imagery about memories but he did use imagery in

relaxation techniques, "imagining themselves." He did not use pharmacology because it

was not available to him. He did see it as a tool helpful for therapy, depending how it is


used, but did not go into detail as to when it is misused.










Rick was very succinct in his statement about when a therapist has done bad

practice: "You're going too far, when, you lose track of who the therapy is suppose to be

about. It's not about you, it's about them."

When I asked Rick what makes for a good therapist, he first responded with

personal traits that a therapist should have and then working with the clients instead of

trying to.Ax them and finally respect for their values. Rick was the therapist who rejected

potential clients on the basis of his own values. Therefore part of his approach involved

his ability to show the client that he shares their values.

Rick .. [exhale]. Well certain obvious things-intelligence, uh uh
insight, understanding, study--all that kind of good stuff. Uh, but I
think the basic, uh, Respect for your clients as as a partner in the
process. Uh, you're not,Jixing them. If you view it that way,
you're going to be far too uh aggressive, and you can either .. can
push them in directions that they, they don't want to go. uh You're
kind of helping them fix themselves. so a kind of respect for them,
and uh, which includes uh, a respect for their values. Kind of goes
back to the question about, How do you build the trust. uh you
know, where possible, kind of showing you know that you share
their values. uh

Mike: yeah

Rick:: Just part of how I end up getting a lot of referrals.

Bad therapists are defined as ones who have their own agendas and "wants

everybody to fit into their mold." He thought that everyone has his/her own world

outlook and philosophy, but therapists should make theirs "up front," "so that they can

know whether they (clients) match you and find somebody else if they don't." Rick's

religious outlook and ideology were very important for him.

Rick: I don't pretend to be unbiased. uh I'm in favor of, faith and values
and strong marriages and that kind of stuff and if you want
somebody who's gonna, tell you how to get out of your marriage










without any guilt.> I can recommend you to a few other therapists.
You don't want to be working with me.

Being "up front" and selecting clients with similar values were the way Rick

avoided being a bad therapist and having his personal agenda affect his clients. "Agenda"

for Rick had three components: philosophical (melding professional and religious ethics);

financial (e.g., keeping somebody in therapy when they really don't need to be); and

emotional (e.g., inappropriate relationships). The interview flowed into the authority that

a therapists represent and the need to listen to how the clients talk about their and

problems. These are examined for logical errors and fallacies that the client is telling him

or herself and, as a therapist, Rick would focus on solutions for the client.

Rick's practice was slow at the moment. He did not accept clients from HMOs

and clients were responsible for dealing with insurance companies. He said he would

work with clients with insurance, but required them to pay up-front and collect the

insurance remuneration themselves. Since he did not collect fees from third parties, he

did not feel that he needed to spend much time on diagnosis. He would go straight to

problem solution. If a diagnosis was needed by the client for insurance purposes, Rick

would consult the DSM IV. When I asked what was the line between good and bad

therapy. He said, "good therapy is about them, bad therapy is about you."

Karen, Ph.D. in educational counseling, defined therapy in term of the privileged

responsibility of helping balance the clients' feeling and "head" aspects. She referred to

"solution focused therapy," but indicated it was an insufficient label for the type therapy

she did. In addition to focusing on problems that the client was presently having, she

added that her work was eclectic and involved helping people get balanced in their lives










by working on "the feeling side of them," not justt in their head all the time." Karen also

described therapy as a privileged position with responsibilities.

Karen: Well it's a very privileged position I have in terms of .. in terms
of people trusting me with their stories and with their issues and
their problems and concerns and helping them believe that there is
a way to live a better life, be truer to themselves, live in--I'm
trying--harmony and community better, be at more at peace with
themselves, make changes that they want in their lives.


Ethics was the key to good treatment practices for educational counselor Karen, a

Ph.D. in educational counseling. She also mentioned respecting the confidentiality of the

client to the extent legally possible. Karen talked about ethics and laws throughout the

interview and sometimes it seemed that she was waiting for me to express something to

give her a cue as to what her answer should be.

Approach to therapy and techniques were not so important to Karen as living up

to professional ethics. She felt that different approaches which might be inappropriate or

ineffective for a particular therapist might work for another. This was the moment I

chose to ask about the Ramona case (amplified in Chapter 9). I concluded a short

synopsis of the case by noting some of the practices that were discussed in the case and

noted: "They used certain practices--hypnosis, Sodium Pentothal, directed imagery and

uh a lot of things that had to do with suggestibility. Do you use any of those in your

practice?"

Karen: (Laughing) Right, right. No I don't do hypnotherapy and directed
imagery. I'm not sure what you mean by the term. Let me put it
this way, is your question what do I do about repressed memories?

Mike: Yeah that, should do.










Karen: Ye(laughs)ah, uh I atypically, everything's individual. I mean that
there's not one thing I do in my life, probably, that I do in the same
way every time--not even how I brush my teeth. So, I do believe
that people can repress memories. I think it's a phenomenon, I just
accept it as such. Do I work, to pull those out of people? I don't. I
think they are .

Mike: You don't probe?

Karen: I may ask them some questions and I'll test, I'll watch reactions,
I'll listen to words, I'll, you know, watch, you know.

Mike: But you don't open it up?

Karen: Let's see do I open it up? If it's appropriate. Am l a sleuth about
them? No. No, there's a reason that they're sort of latent and I
think it can be harmful. I mean, if it's relevant I work with it, but.


After stating that she did not use any of those techniques, she assumed that I was

asking about how she approached repressed memories. She believed that people can

repress memories and believed that repressed memories can be harmful. Karen would

ask some questions about the memories if the client brought them up, but would not

probe for them. She showed some uncertainty about the relevance of these memories for

diagnosis and/or treatment by ending her statement on their relevance with a subjunctive

"if" and the open-ended qualifier "but. .."

Of all the therapists I interviewed, Karen was most guarded in her answers. As

the interview went on, she would volunteer information. In the early stage of the

interview she would use stalling tactics such as repeating the question as if she had not

heard it, laughter, and long pauses as if passing her turn to speak, even to respond to the

question. One example is that she took a comparatively extremely long time to select five










cards from the concept cards. She reacted to the cards as if they were a test. Finally she

indicated her quandary:

Karen: I know what I am going to do, just decided what I am going to do
with these. [A few words were accidently erased from the tape] .
process it and one of the things that get sorted are people with tests
like these are quick to make judgments or they think about the
possibilities forever. (Karen laughs) I know. I know, but I'm just
thinking. .. You've got someone who's gonna try to think like,
"Well if I put these, then what will that mean." Rather than "Oh
this, this, this, this."

She was also judicious in defining a good therapist. The following is an example:

Mike: Okay, what makes for a good therapist?

Karen: Well, lots of things. (laugh)

Mike: What's number one?

Karen: Yeah, what's number one?

Mike: What is the one thing you would say if that person doesn't do that
thing, then they're not a good therapist.

Karen: To be ethical.

Mike: To be ethical?

Karen: Yeah, cause I think. .. Take ten therapists with the same client.
We can approach things ten different ways and then we can all be
good or we can all be horrible. (laugh).

For Karen, following the dictates of the law and the ethics of the profession

determine if the therapist is good or bad. She indicated that she hoped that the legality

and professional ethics would be the same in a particular case, but the final determinant

of the line between good and bad practice was "the law! "

The other psychologists, Gail and Zoe, spoke from an educational perspective.

This was discernible by the text of their discussions as well as from the fact that Gail was










involved with children with problems often regarding intellectual barriers and that Zoe

was primarily involved with students at a university. Throughout their interviews, they

would demonstrate facility in the transmission of knowledge--what they knew about a

subject. This perspective is associated with the educational system more so than with one

of the other institutions.

Gail said. "I don't really feel like I have a certain orientation toward therapy."

During other elements of the interview, I would pose a question and she would give

remarkably detailed and inclusive answers that were obviously not memorized but

internalized-illustrating a firm understanding of the topics. Her answer for this question

appeared to be less formed and more in the process of being thought out as she spoke it.

This is notable in the uncharacteristically uneven flow of the answer illustrated by the

second part of this exchange:

Mike: In, your words, what is therapy? What do therapists do?

Gail: I think therapists work with people to consider situations that are
creating some sort of stress or unhappiness and explore options for
making changes, so that they can feel better.

Mike: Where do you fit in therapy?

Gail: I really, it's hard, I'm kinda eclectic. I guess that more uhm .
Sometimes ., Depending on the problem, you know .. this
depends on the problem, so like your, your typical behavioral kinds
of things .. or your anxiety kinds of things. I'm more cognitive
behavioral. If it's a relationship issue--I'm more interpersonal. If
it's more of something like, uhm your recurrent problematic
patterns, like you know, someone who's got more of a personality
disorder (which I really don't see much here now, but I use
to)-uhm I might do more of a mixive, interpersonal and insight
oriented kind of work.










From answers to this and other questions, it became apparent that for Gail therapy

is primarily what a therapist does. A therapist works with people and explores options for

making changes so that they can feel better. She had not put an answer in the blank of the

demographic form which was for Theoretical Perspective, but she described herself as

eclectic in her approach to therapy during the interview.

Good treatment practices for Gail were those which provide interventions. For

her, interventions are "suggestions" that are made for the clients and with their input.

Gail: Treatment practices would mean: what kinda interventions are
your gonna put in place, what kind of suggestions are you going to
make to parents, or things that you are going to suggest to kids or
what sorts of options are available to them for getting the needs
met. Because we are a multidisciplinary setting, I really think that
treatment practices is having a wide range of things that patients
have access to.

Mike: What types of interventions do you do or do you suggest or. ..
What do you do?

Gail: Well, a lot of times we're going to work on things that improve
communication, or things that will improve expectations, behavior
and discipline at home, and we're kind of just making some things
clear that haven't been, and helping kids to understand what's
going on that's creating behavior problems and what kinds of
incentives and consequences are available when they make
different kinds of choices. A lot of times parents are coming
because they're having a difficult time managing their
temperament and their child. So, knowing about the treatments we
have like things that they can get from censoring litter treatment
and all possible help with medication. We also talk about the
options they have and their feelings about pushing, or not.

Rather than speak of specific treatment practices or techniques, Gail related them

to the unspecified ways used for clarifying causes, incentives and consequences available

for choice about clients' problems and that are used to work on improving the clients

abilities in communication, expectations, and behavior. While she did not provide any










information on guided imagery or hypnosis, she was very much in favor of her clinic's

biomedical connection and its multi-faceted approach to the practice of therapy. She

went into detail in describing that:

Gail: This is a, you know, biochemically, medical facility, and I'm very
much in support of it. I do think, that it's uh, probably over-
prescribed at times, and I think -

Mike: Here, or .just in general

Gail: umhm, I don't think here. I think that in general. I think it has
been carelessly prescribed or I should maybe even say carelessly
monitored. I feel like, by the time a patient here, has been
prescribed medication, we've done a pretty exhaustive assessment,
and uh, we're getting information from families and parents and
our intensive zone and observations, and seeing them multiple
times and so I feel pretty confident. I also think when we prescribe
medication, we do follow-up assessment, we get teacher feedback,
we get parent feedback, and we have parents keep journals. and so
on, I think when, when we're doing it, it's a- I think sometimes
people use it as a way to treat, for instance, behavioral problems,
and while a lot of kids have behavioral problems, medication is not
gonna address them. Uhm, you need a multidisciplinary approach
and, for a lot of the kids that have the disruptive behaviors, they
need .. they need their own strategies, they need medication, they
need to leamn arousal techniques (which is a big piece that I've
learned from our occupational therapist that they provide the kids)
just learning how to modulate your own arousal level .. for
different situations, to rev yourself up or rev yourself down.

Gail: So, It's very interesting [the study of arousal techniques]. I mean,
and a lot of the kids we work with have a learning disability, have
attention difficulties that are secondary to having learning
disabilities because when you're working, when you're in an area
where you're already .. stressed, and you have to work extra hard
to keep up with everyone else, your stamina is gonna be less at the
end of the day than the other kids that didn't have to work as hard,
and that's gonna create attention problems. And so if you can, you
know, boost your system by having medication, it's gonna make
the learning easier. And I'm very much in support of that. But I
do think, sometimes, that a fifteen minute interview might be all
that a, physician needs to give someone medication.