Crime, stupidity and responsibility among mental health professionals

I in no way want to promote the Church of Scientology nor am I in the fan club of Dr. Thomas Szasz.

I don’t have much to say about Scientology other than the fact that it gets pretty annoying to be accused of being a Scientologist simply because I question the validity of a diagnostic category like Attention Deficit Disorder and maybe I’ve suggested that giving amphetamines to young children might not be the best solution to this non-disease.

On the other hand, I could say a lot about Szasz who is something like the father of the anti-psychiatry movement.  I certainly think that he has done a lot of good by questioning the assumptions and practices in the mental health field going all the way back to the 1950’s.  Unfortunately, his discourse and that of his anti-psychiatry disciples is just as ideological and lacking in factuality as the worst drivel coming out of NAMI and from pharmaceutical marketers and the APA for that matter.  But, we’ll save that discussion for a later post.

Today, I just wanted to share about their Psychiatric Crimes Database, a rogues' gallery of badly behaved mental health professionals.  It makes for a, maybe not exactly fun, but perhaps amusing at times and otherwise disturbing read.  It is part of a website presented to the world by the Citizens’ Commission on Human Rights (CCHR).  CCHR is a joint effort by Szasz and the Scientologists dating back to 1969.  Its mission is to ”investigate and expose psychiatric violations of human rights and to clean up the field of mental healing.”

They claim to have aided in increasing prosecutions of mental health professionals of all kinds and to have promoted improved ethical and legal standards in the industry.  As to the later of these claims, I cannot vouch for the activities of CCHR itself, but I can say from my experience in mental health that the consistent pressure from the psychiatric survivor and anti-psychiatry movements, which have at least symbolic if not real leadership and impetus from Szasz, have had an actual and positive impact in the industry by increasing awareness and respect for things like informed consent and patient/client choice.  Yet, that being said, I do have to question what they seem to want to imply about themselves and the industry with their database.

Carrie Denbow, social worker, had her license suspended, according to the CCHR site, due to accusations she had sexual relations with a minor client in a motel room with two other students while drinking and smoking marijuana.  The client was an adolescent to whom she was providing counseling.  It is further alleged that Ms. Denbow took the client to her office three or four times a week where she performed oral sex followed by intercourse.  It is also alleged she broke confidence by seeking relationship advice from her minor client's peers.  Ms. Denbow was let go from her job in 2009.

The Psychiatirc Crimes Database is, very simply, a list of prosecutions and licensing censures against mental health professionals.  It appears to be updated quite frequently; there are eleven items in the database for January of 2011.  If CCHR had a role in any of these investigations, it is not evident and seems unlikely.  It appears to simply be a list of items gathered from the news and public records.  Items span a gambit of crimes and ethical violations.  Just in the last couple of months we see everything from a psychologist having his license placed on probation due to DUI to a psychiatrist charged with attempted murder for stabbing a patient twice in the chest with a sword.

My non-scientific cursory look at the database leads me to the conclusion that the most common category is the big no-no of sexual relationships between providers and clients, in some cases with minor clients.  This appears to be followed by billing and documentational faults leading to charges of fraud.  A third category is providing excessive prescriptions of controlled substances, sometimes for a payoff, sometimes without medical examination (as in being handed out in a public park in one case).  Otherwise, items are a miscellany of misdemeanors, violations and serious crimes.

The website explains its purpose:

The following database is being presented as a public interest service to law enforcement agencies, health care fraud investigators, immigration offices, international police agencies, medical and psychological licensing boards, and the general public.

And claims to impact larger issues:

Many psychiatrists have an intimate knowledge of criminality-one which has nothing to do with the professions involvement in the expert witness field.

• Between $20 billion and $40 billion is defrauded by the American psychiatric industry in any given year.

• At least 10% of psychiatrists admit to sexually abusing their patients: In America, that's at least 4,500 rapes and, internationally, more than 15,000 rapes.

• Psychiatrists, psychologists and psychotherapists have the dubious distinction of having laws specifically designed to curtail their tendency to commit sex crimes against those in their charge.

• A 1992 study of Medicaid and Medicare insurance fraud in the U.S. showed psychiatry to have the worst track record of all medical disciplines.

They don’t indicate how they came up with the specific numbers (e.g., 10% of psychiatrists admit to sexually abusing patients), but it is also true that both Szasz and the Scientologists share an overall denouncement of the very concept of mental illness and this database has to be seen as part of their larger pogrom against all things psychiatric.

Psychiatrist Douglas Rank who, according to CCHR, was charged with stabbing a woman in the chest twice with a sword in front of his office.  The wounds were life-threatening, but she survived after hospitalization.   She was apparently both his patient and in a "personal relationship" with him.  Rank was sentenced to 15 years after plea bargaining down from attempted murder to first-degree assault.  He had previously been investigated for over medicating and having sex with a patient.

Speaking to that implied intent, I have to feel that simply listing every kind of crime and stupid behavior of individual mental health providers cannot be taken as a condemnation of the industry as a whole.  There is plenty of room to criticize the mental health field and all of its tenuous assumptions and cherished beliefs, but, in my opinion, the fact that a particular California psychologist had his license placed on a probationary status, for instance, according to the CCHR site, because he was found awakening from unconsciousness in a department store after hours with a pocket full of methamphetamine, has no real bearing on the field of mental health other than the fact that it is peopled by human beings who are capable of addictions, errors, criminality and stupidity as humans are in any profession.  

Furthermore, the fact that professionals are censured, placed on probation, suspended and prosecuted, if anything, indicates that the industry does in fact have good safeguards and oversight by which to protect consumers and the public.

Yet, the database does have an impact on the reader, and if you haven’t yet, I suggest every one take a look at it who has an interest in mental health whether as a provider, consumer, family member or interested bystander.  If nothing else, it serves as a reminder that it is always a good idea to be cautious and do a little research before accepting a particular professional as the mechanic of your mind, so to speak.

Psychiatric Crimes Database

Borderline Personality Disorder, Crime, and Responsibility

On the topic of mental disorders and responsibility—of late, I’ve been hearing several therapists repeat a couple things that bother me:

1) Borderline Personality Disorder is just as serious as Schizophrenia and sufferers of BPD should be given just as much clinical attention and services.

I have to say, no, BPD is not the same as schizophrenia and should not in fact be treated the in the same manner.  Should medical professionals be told they need to treat sunburn the same way they treat cancer?  I think not.  Furthermore, I don’t know why we treat so many people whose primary presenting problem is BPD in the public mental health system intended for people with severe disabilities.  The bulk of the empirical research seems to show that BPD is best treated in the community with an established and effective therapy such as Dialectical Behavioral Therapy or similar.  Placing people with BPD in residential facilities for the severely disabled will only be detrimental for both the client and everyone else who lives or works at the facility.

2)  People with BPD who behave manipulatively should not be blamed or expected to change because their behavior is avolitional.

I will agree that “blaming” the client is in no way helpful, nor will expecting someone with BPD to instantly change result in anything but frustration.  However, it is simply false to say that someone with BPD has no ability to modulate mood or behavior.  No human behavior short of reflexes or seizures are avolitional.  Making false statements of this kind, even in apparent defense of people with serious disorders, only serves to increase the divide in understanding.  It also takes away from the agency and empowerment of the client that we are trying to help.  Someone with BPD is not helpless to change.  Change can happen with trust and support as long as there is a real desire in the person to make a change.  Setting clear but respectful limits helps too, because we all know that, like it or not, life has limits.  It is not at all helpful to give the BPD patient the message that anything they do is okay just because they have a diagnosis.  Such a message can be devastatingly harmful.

It might help to illustrate this issue.  Take a look at this excerpt from a recent news article (well, it's news-ish, I guess, it's from The Sun):

A WOMAN has been jailed for cruelly imprisoning three young children in a disgusting room without clothes, food or water.

Jan. 25, 2011.  Sick Daniella Henderson left the youngsters in the squalid conditions and their ordeal only ended when the kids were seen hanging out of a window desperate for help.

When police arrived at the house they found the bedroom they had been left in all day stank of urine, had no beds or furniture and had a bucket as a toilet.

The grandfather of one of the children today slammed sick Henderson's 15-month jail term as too lenient. . . .

Penny Moreland, defending, said: "Most people will find this shocking and distressing. This has not borne out of pure malice or badness.

"She was deteriorating mentally and has a borderline personality disorder [sic]."

The defense attorney here is presenting what a certain ilk of therapists are trying to put out there, that someone with BPD cannot be held responsible for their behavior. I would say, yes, it is distressing.  The defense states that the behavior was not malice or badness and seems to imply that the behavior cannot be malice or badness as long as the behavior is “explained” by a mental health disorder, in this case BPD.  It seems to be an underlying tacit assumption that the categories of malicious behavior and symptomatic behavior are mutually exclusive. At the risk of blaming people with BPD for their own behaviors, I have to question the validity of this assumed dichotomy.  Is it possible that someone’s behavior might be driven by BPD and that person is acting with malice?

Yet another opinion on mental illness, violence, and responsibility

I am hesitant to add to the din about mental illness and violence in the wake of Jared Loughner, but I’d like to make a few small points on the topic.

First of all, I have to say, I find it a little creepy that someone describing himself as a forensic psychologist, would so quickly put up a full website, complete with domain name, dedicated to this suddenly infamous young man: loughner.info

It feels a little exploitative, but probably not anymore than traditional journalism I suppose. The posts seem thoughtful and informative in any case.

But, to the real point, the consensus seems to be that our Mr. Loughner was coming down with a nasty case of schizophrenia. As more details come out, the more this seems likely. I wouldn’t dispute it, but I'm not going to diagnose him via media reports, either.  Still, I think it's fair to acknowledge there is a mental health component and this ties into larger social concerns about mental illness, danger and responsibility. 

The next questions are, (1) what then is the personal/moral responsibility of a person with mental illness in regard to their behaviors, and (2) are people with schizophrenia dangerous?

As to the first, well, maybe it’s a question for the philosophers, but that won’t stop the lawyers and pundits from opining. I won’t bother to answer such an expansive question myself, but I do want to make note of the fact there is a very large population of people with schizophrenia who suffer from paranoid delusions who chose not to act out violently toward others. This interesting fact touches on both of the above mentioned questions, I think. From my own experience, I’ve known quite a few individuals who believed very strongly that they were being persecuted by specific others in some way and in some cases the belief systems included threats to their lives. Very often this involves poison but there can be any number of creative delusory devices.

So why is it that people who believe they are being poisoned, attacked and persecuted, are so often non-violent even in the face of an overwhelming belief that their own life is being threatened?

This is something like a key question and the answer(s) touch on both personal responsibility and risk assessment. But, this question tends to get overshadowed in the immediate aftermath of a spectacular psychiatric failure as we saw recently in Tucson and not so long ago at Virginia Tech.

The somewhat simplistic explanation is that most people who suffer from schizophrenia have an intact moral capacity and it is only a small subset of people with schizophrenia who also fit an anti-social profile in which there is a lack of compassion or concern for others. I do think this is true in a general sense even if the categories of schizophrenia and anti-social personality suffer from fuzzy boundaries and arbitrariness.

The other important clinical factor is severity of delusions (along with other symptoms). For someone with schizophrenia, delusions seem to follow a sort of hydraulic principle. That is, as the severity of symptoms fluctuate, there is a shift in the psychic pressure of the delusional system (metaphorically speaking). As an episode increases in severity, the delusions shift in two ways, (1) strength of belief, and (2) amount of mental time and energy given over to ruminating on the delusions. With increasing severity there is an intensifying obsessional quality in the person and an increasingly aggressive reaction to reality checks or questioning of the delusory beliefs. Severity comes into play with violence and responsibility because the greater the severity of the symptoms, the harder it is for the individual to ignore the direction of delusory thought and the harder it is for the person to receive any form of feedback or external redirection.

There can be a number of ameliorating factors however. One factor, in some cases, is life experience. After going through a number of episodes, some individuals learn from very difficult experiences (homelessness, hospitalization, loss of family support, etc.) that their beliefs can be problematic and with time this can aid an individual in developing coping and self-management skills. The reverse is also true, that a young person who is first developing schizophrenia does not have the benefit of those life experiences and the first emergence of delusory beliefs can have a seductive, intoxicating quality and are very difficult to challenge from the outside.

Aside from clinical analysis, I think it is very important to know that people with schizophrenia are individuals. I do not mean this as a slogan, but in a very real way. As overwhelming as the effects of schizophrenia may appear to be on the personality, it does not in fact do away with it. People living with psychosis and schizophrenia continue to hold and express values and morals and a full range of human motivations both good and bad, just like the rest of us. More so than any other label in mental health, the term “schizophrenia” too often overshadows the person.

These kind of catastrophic events, as in Tucson, tend to trigger the latent fears in the public and inevitably lead to calls for greater controls on the mentally ill and stronger commitment laws to allow the mental health system to more easily intervene with involuntarily measures. All this puts the focus on the illness while de-emphasizing personal volition. In this round, by and large, I think the media response has been a little better informed than after Virginia Tech and mostly I see calls for increased mental health services, which is a safe and reasonable position to take, although, I think people need to be better informed about the limits of what mental health services can do. Simply throwing more money at the problem is not necessarily going to help, and there is a good chance the resources will be diverted to other people and other agendas.

Even where a wide array of mental health services are available, the people who need them most often have no interest in them (while there are plenty of other people who don't really need all that care but are willing to accept social security checks and get all kinds of counseling--but that's a whole different story). There really is no way to force therapy and treatment on someone who absolutely doesn't want it, not unless they can be placed under civil commitment, and that is determined by presentation of immediate and believable danger to self or others. Assessing danger has elements of best and customary practice, but in the end it is educated guesswork based on past history, stated intentions and a range of known risk factors. How do you know their history? Well, unless you get past clinical data, it comes down to what the client is able or willing to tell you. For someone who doesn't have an established history, assessing danger is quite tricky and there is a certain amount of intuition and personal judgment involved. There simply are no guarantees or simple solutions.

Is that Thorazine in the Baby's Bottle?

One of the most disturbing trends in mental health today is the increasing use of powerful antipsychotic medication to treat behavioral problems in children, even very young children. According to a 2009 report by the Food and Drug Administration, there are 500,000 children in the United States being administered regular doses of antipsychotics. Medicaid data shows public health monies spent on antipsychotic drugs for children exceeding $30 million in New Jersey and topping $90 million in Texas. It is a trend that has built relentlessly for the past ten years and continues unabated.

I find the use of these drugs on children to be appalling almost beyond words. Having worked as a mental health professional for many years, I am well acquainted with these medications. This class of drugs, sometimes referred to as neuroleptics, are major tranquilizers and are primarily used and intended for controlling hallucinations and delusions in cases of psychosis and schizophrenia. For an adult with severe schizophrenia, these medications may be a glimmer of hope, but it is always a difficult risk-benefit analysis because there are potentially severe side effects and reactions. Depending on the individual, these medications can cause tremors, involuntary spasms and movements, severe sedation, muscles of the face become rigid, and loss of pleasure sensation, just to name a few. Permanent neurological damage can occur in the form of tardive dyskenisia, and sudden death can occur from a reaction called neuroleptic malignancy syndrome. With newer forms of antipsychotics, these type of side effects are less frequent and less severe, but continue to be a risk depending on the reaction of the individual’s body. However, newer, “atypical,” antipsychotics present new dangers to the patient, metabolic changes that result in a dramatic increase in the instances and severity of diabetes and heart disease. The result is that adults on antipsychotic medications have a life span that is 20 years shorter then the average person.

We know these medications have the potential to cause permanent harm to an adult’s brain, but they are still used because it is considered by many to be worth the risks to control just some of the symptoms of debilitating disorders, and, except in the most severe cases, where a person’s legal rights have been taken away due to impairment, it is ultimately up to the patient to decide whether or not to take that risk.

What then will these medications do to a child’s developing brain? The jury is out, but it can’t be a good thing. Who makes the decision and why? Certainly not the child who will live the rest of his or her life with the consequences of that decision.

The New York Times ran a recent article on the subject, highlighting the case of one child who was started on an antipsychotic at 18 months old. This helps to highlight the human side of this tragedy:

At 18 months, Kyle Warren started taking a daily antipsychotic drug on the orders of a pediatrician trying to quell the boy’s severe temper tantrums.

Thus began a troubled toddler’s journey from one doctor to another, from one diagnosis to another, involving even more drugs. Autism, bipolar disorder, hyperactivity, insomnia, oppositional defiant disorder. The boy’s daily pill regimen multiplied: the antipsychotic Risperdal, the antidepressant Prozac, two sleeping medicines and one for attention-deficit disorder. All by the time he was 3.

He was sedated, drooling and overweight from the side effects of the antipsychotic medicine. Although his mother, Brandy Warren, had been at her “wit’s end” when she resorted to the drug treatment, she began to worry about Kyle’s altered personality. “All I had was a medicated little boy,” Ms. Warren said. “I didn’t have my son. It’s like, you’d look into his eyes and you would just see just blankness.”

Today, 6-year-old Kyle is in his fourth week of first grade, scoring high marks on his first tests. He is rambunctious and much thinner. Weaned off the drugs through a program affiliated with Tulane University that is aimed at helping low-income families whose children have mental health problems, Kyle now laughs easily and teases his family.

Ms. Warren and Kyle’s new doctors point to his remarkable progress — and a more common diagnosis for children of attention-deficit hyperactivity disorder — as proof that he should have never been prescribed such powerful drugs in the first place.

As to what’s driving this latest treatment fad?  I think there are a number of factors.  The easiest and most popular target is Big Pharma.  The pharmaceutical industry has the largest profit margin of any major industry, and do you know what their most profitable line of drugs are?  Yes, that’s right, antipsychotics.  This class of drugs brought in a staggering $14.6 billion in 2009.  Antipsychotics are marketed as heavily as any other product line, and the marketers are always looking for new markets.  Antipsychotics have been marketed for depression, for instance, and they are actively promoted to pediatricians for use on children, but, for the most part, marketing efforts keep within the limits set by the FDA and the risk-benefit decisions made industry lawyers.  The FDA approved Risperdal for use on children as young as 5, but most antipsychotics are only approved for children 10 or older.

Yet, in spite of the FDA guidelines, these drugs are being given to much younger children. Who then is to blame? The other popular targets of finger pointing are the parents (and, I would add, teachers and childcare workers). Perhaps it is helped along by marketing campaigns, but the fact is, parents are increasingly choosing to pathologize and medicate their children in lieu of other, more traditional, parenting strategies. Childcare and educational professionals add to the stampede by pressuring parents to go to the doctor when the child’s behavior puts a strain on the professional. I think we can objectively state, unequivocally, the nature of childhood needs and behaviors has not changed in recent generations, yet more and more parents go to their pediatricians insisting there is something wrong with their child and demanding some pill they can give the kid to fix the problem. Parents just want to do right by their child, I’m sure, but they fail when the don’t take the time to research what they are doing and the possible consequences.

The final responsibility, however, rests on the shoulders of the professionals who prescribe these medications. Physicians are free to prescribe off label use of drugs and are under no legal obligation to stay within FDA approved guidelines, and some physicians seem more then willing to exercise this discretion in spite of the very serious risks they are exposing the child to. Regardless of shameless marketing by drug manufacturers and the irrational pressures of frustrated parents, the physician is supposed to be the final gate keeper and is responsible to safeguarding the health and wellbeing of the young patients. Physicians who push antipsychotics on children clearly fail in their responsibilities.

The issue is further complicated by shifting diagnostic categories. Schizophrenia is a disorder of adulthood. Age of onset is typically late adolescence or early adulthood. There is no defined criteria and very little in the way of scientific data to justify giving this diagnosis to younger children, yet we are seeing it, now, younger and younger, usually tied to a prescription. Another expanding diagnosis is bipolar. This disorder is very loosely defined and as a result, unscrupulous or simply confused professionals can see it everywhere. It too used to be a disorder of adulthood but has mushroomed as a child diagnosis in the last decade. The other big diagnosis linked to antipsychotics is autism. This is a very serious and real childhood disorder and children who suffer from this take a lot of care and present a lot of challenges. However, the autism diagnosis has become hugely popular and its working definition has expanded infinitely. As in the case of Kyle Warren, just about any child can get the diagnosis at this point. It is now virtually meaningless, yet it is the justification for giving these very serious drugs to young children.

The big picture is we have an expanding culture of psychopathology in which more and more facets of human behavior are being defined as disorders and sicknesses. This extends even to the point of defining childhood tantrums as a sickness that we have to treat with a powerful drug. The pathologization of childhood started probably in the 1980’s with attention deficit disorder and this became hugely popular in the 1990’s. In the first decade of the new millennium, we saw a significant expansion of clinical depression, bipolar and even schizophrenia into younger and younger populations with related drug therapies. Additionally the autism diagnosis has been opened up into a “spectrum” disorder so now parents of children with any kind of perceived interpersonal or behavioral challenges can have an autism label slapped on ‘em at bargain basement prices.

The bottom line is that young children are being harmed by antipsychotic drug treatment and it’s no laughing matter. The trend line is very disturbing. I hope I am not one of a few lone voices in the wilderness. Is anybody listening?

Talk Therapy with a Forked Tongue

Therapy's Delusions: The Myth of the Unconscious and the Exploitation of Today's Walking Worried
by Ethan Watters and Richard Ofshe

The Goodread review:

In this clearheaded and courageous book, Ethan Watters and Richard Ofshe expose the pseudoscience behind the twentieth century's most enduring myth - Freud's theory of the psychodynamic mind. Despite the lack of credible evidence for a powerful unconscious that controls our behavior, a huge number of therapists continue to base their practice on the idea that only they can uncover their patients' unconscious motivations, luring thousands of Americans, from the mildly demoralized to the seriously ill, down dangerous and arbitrary paths of treatment. . . . This book is a call to action for reforming the poorly regulated mental health profession, so that no more patients are misled by a myth that has held sway over American minds for far too long

Finally someone is willing to come out and say it.  Much of what passes as psychotherapy is not based in empirical science and is quite often unhelpful or even worse.  This book is a wry yet disturbing romp through the cultural history of psychoanalysis from its birth out of the forehead of Freud, through it’s explosive captivation of the American pop psyche, and finally up to the present day accumulation of psychotherapy methods (the intellectual grandchildren of Freud’s) that are trademarked, patented and hocked to practitioners at carnival-like trade shows.  It is a must read for anyone who has questioned the Great Oz of the Ego/Id/Superego Trinity and wants to know who the man behind the curtain is.

While there has been a virtual Gatling Gun of  criticism of the biomedical model from psychosocial adherents, there has been very little in recent memory in the way of criticism of psychotherapy.  In that sense, Therapy’s Delusions is a breath of fresh air.  My only gripe with Watters and Ofshe is their implicit assumption that the biomedical model is more objective and has more to offer consumers of mental health.  While both theoretical arenas contain elements of empirical knowledge, they are also both driven by ideology and consumer-capitalism.  It is quite well known now that the pharmaceutical industry drives bio-psychiatry forward as a commercial enterprise.  The authors fail the test of objectivity by ignoring this plain fact.  However, they have done us a service by highlighting the equally disturbing but lesser known fact that psychosocial based therapy is also a capitalist endeavor made up of many entrepreneurs and businesses both large and small.  Every peddler of treatment models and every practitioner of psychotherapy has a profit motive hidden, undeclared, under the surface of their brand.

What’s wrong with that, you ask, it’s the American Way, is it not?  Yes, it is.  And it is not so wrong except that it is denied and hidden.  It is lurking in the id of the mental health industry, you might say.  Hidden from view, who can say when and how often the profit motive trumps the best interest of consumers of mental health care?  Don’t expect a straight answer from your therapist, especially if their house is underwater, as we say these days.

Parasitism as Psychotherapy

There is a lot of literature and professional discourse in the area of transference and counter-transference.  It is a staple of clinical supervision and represents some core concepts relevant to quite a few therapeutic models.  Anyone providing, or claiming to provide, psychotherapy must be aware of, and have at least a modicum of training on these core concepts.

So, why is it then, in the public mental health system, there is so much confusion and ignorance on such basic concepts?  Is it because graduate counseling and social work schools are vocational factory farms intended to get people in, take their money, then move ‘em out with their rubber stamp degrees?  Is it because the public mental health system attracts mediocre and failed therapists (I don’t think so because private therapists are hardly any better)?  Is it because of the confusing eclectic din of contradictory theories and “evidence based” practices that make it impossible for directors, clinical supervisors, and therapists alike to develop any kind of coherent vision of what they are doing?  Is it simply due to lack of oversight and supervision that individual professionals gradually drift into their own personal comfort zones, un-self-aware, and motivated by their own emotional needs?

Do I sound too harsh a critic?

I see it every single day in the field.  Every day.  The same dramas get played out endlessly with every possible variation, yet always the same.  The client with the borderline personality or complex PTSD or dysfunctional patterns of meeting their needs, whatever you want to label it, it plays out the same anyway.

On the one hand you have professionals who are frustrated at being manipulated and lied to by their client; cynical at dealing with clients who have no interest in working on their  issues or getting better but seem to only want to suck as much as they can out of the mental health system; and angry at colleagues who blame them while covering up, making excuses, and enabling the client’s manipulations and anti-social behaviors.

On the other hand you have professionals who, with great self-importance, take up the cause of these poor misunderstood individuals.  Somehow these professionals develop a shameless belief in their own “special” ability to connect and understand.  They quickly conclude and profess that all the client’s problems stem from the negative judgments of others, including judgmental mental health professionals.  They seem to believe that the “cure” is to empathize and sympathize with their client, while never questioning their client’s beliefs or behaviors.

I have news for you.  If you find yourself falling into one of these camps, you need to stop what you are doing and step back to find some objectivity.  Psych 101:  if you are emotionally enmeshed or reacting strongly to your client, you are not going to be able to provide any kind of real therapy.  And that is exactly how it plays out.  Clients who get this kind of dual reaction/enmeshment treatment don’t get better.  The reactors just play out the role of perpetrator, thus reinforcing the client’s belief in their own victimhood and allowing the client to dodge any responsibility for their own behavior.  The enablers do just that, they cover up for their client and enable them to continue with their dysfunction.

The enmeshed enablers are probably the worst of the two, simply because they will continue the “therapeutic” relationship for years and years and years regardless of the complete lack of progress.  What develops is a sort of emotionally symbiotic parasitism that’s paid for by Medicaid.

On the one side of the symbiotic relationship is a client whose dysfunction has led them to get all of their emotional needs met through therapy and the mental health system.  In other words, therapy is an end in itself.  The negative and positive relationships they develop with professionals feeds their emotional need for drama and attention and emotional enmeshment.  There is no desire for actual improvement.

On the reverse side of the symbiotic relationship is a professional who is hungry for attention and recognition and a feeling of efficacy.  As long as the therapist stays on the client’s good side by joining them in their denials, rationalizations, and reification of their victimhood, the client will return the favor by singing the therapist’s praises and generally playing to their ego.  The bigger the ego of the therapist, the more susceptible to this they seem to be.  These arrogant professionals believe they are somehow immune to counter-transference and ignore clinical best practices.  The result is they feed their client’s pathology without end and seem to be oblivious to the fact that their client never gets better.  It doesn’t seem to matter because both client and professional are getting their emotional needs met by the relationship and Medicaid pays for it all without question.

There does not seem to be any end in sight to this pattern.  It has been a major problem in the mental health system since it was first identified in the mid 20^th Century.  But in spite of the mountain of literature and treatment guidelines, professionals continue to make the same mistakes time and time again.  How can a therapist help a client face their hard-to-face issues when the therapist isn’t willing or able to face their own issues and seriously look at how their counter-transference impacts their efficacy?

Therapist Types: The Confrontationalist

These are the overbearing I-have-all-the-answers counselors.  They listen only long enough to figure out what you need to be told.  The bulk of the counseling is directive and educational.  The direction might come from a defined theoretical perspective or it is often simply a hodge-podge of common sense and non-sense.

This is still the industry standard in drug and alcohol counseling where 12-step provides the material for indoctrination.  Input from clients is allowed so long as it follows the prescribed 12-step path.  Any wayward or contradictory beliefs expressed by the client about their own life and motivations are met with staunch correction from the counselor.  Independent thought is labeled intellectualization, rationalization, denial, “escape into health,” and such.

There are also Confrontationalists in mental health counseling.  The temperament and relationship is similar to the 12-step based counselor, but the content may be different.  Confrontationalists may impose a medical model or use reality therapy or any number of different approaches, but it is always delivered in a confrontational and directive manner.

Confrontationalists are the tough-love counselors who may tell you that you’re the boss but the unspoken message is: “My way or the highway.”  If you deviate, you feel like you are being corrected.  Any insight you express about your own inner life is squashed and replaced by common adage dressed up as psychological theory.

The Confrontationalist Symptom List

• Loud or authoritative tone of voice
• Interrupts
• Talks-down-to
• Educates
• Directs
• Poor listening skills
• Imposes a model of therapy regardless of whether it fits the clients needs
• If the client is argumentative he or she is re-educated or may be booted from therapy.