Clinical Update, September 2007 Turning Love for Movies into Fun, Learning and CE Credits "If one person came home from the movie theater, just one, and saw somebody screaming at empty air on the street corner and related to them differently with understanding, then we would have done our job."    --Akiva Goldsman (screenwriter of A Beautiful Mind) Movies have been widely used for therapeutic and educational purposes. Lately the popular literature, academic articles and dissertations have increasingly focused on the use of movies in psychotherapy. We now have four online courses that use the movies to address the topics of ethics, boundaries, DSM and, of course, cinema therapy.  These courses are offered as a 20 CE credit Movie Lover's Package at http://www.zurinstitute.com/moviesce.html. Films are particularly well-suited as an adjunct tool in therapy and at depicting  psychological phenomena and ethical dilemmas because: The combination of images, music, dialogue, lighting, camera angles, and sound effects in a film mimic thoughts and feelings that occur in our consciousness. The viewer experiences what a character sees and feels. Movies have become the great storehouse for the images that populate the collective unconscious. Many consider movies to be the most influential form of mass communication, because the spectator enters a form of trance, a state of absorption, concentration, and attention, engrossed in the story and the plight of the characters. The camera carries viewers into each scene. Because they perceive events from the inside as if surrounded by the characters in the film, the characters do not have to describe their feelings. Absorbing information through film descriptions brings an entertaining element into the therapeutic or learning process. When we enjoy ourselves, we become emotionally engaged. We heal, grow, and learn more easily and effectively. The diagnosis of mental disorders and the discussion of ethical and legal themes is usually taught using written or oral techniques and material, although using this material can be dry and tedious. Our attention is more engaged when movies are used as a teaching tool, because of our affective response to the vicarious identification with movie characters.  Because popular movies sometimes distort or exaggerate diagnostic symptoms or behaviors in therapeutic settings, they provide material for fruitful discussions and, at times, produce extra learning material. Without concerns about confidentiality, we become privy to a character’s inner thoughts, feelings, and motivations for illustrative “case discussions”. The following four courses are available as a package at http://www.zurinstitute.com/moviesce.html 1.   Cinema Therapy teaches how to use movies effectively in clinical work. 2.   DSM: Diagnoses Seen in Movies deepens your understanding for the DSM by discussing pathologies of film characters. 3.   Therapeutic Boundaries in Films discusses issues, i.e. dual relationships, self-disclosure, gifts, etc. 4.   Therapeutic Ethics in Movies explores ethical questions in general by contemplating ethical dilemmas that are portrayed in popular movies.  Clinical Update, August 2007 End of Life Issues: Facing and Managing Death, Dying and Beyond Our online course on End of Life Issues is available at http://www.zurinstitute.com/endoflifecourse.html. As I was preparing to send out today's Clinical Update, synchronistically, it came to my attention that Costco is selling all kinds of coffins. "The Lady of Guadalupe Casket " goes for $924.99, "The Mother Casket" for $1,299.99, and "In God's Care Casket" sells for only $924.94.  (Rushed orders are available for an extra fee, sorry, no returns.) Obviously, as the Baby Boomers inevitably face their parents' and their own deaths attitudes and commerce are drastically changing in regard to death and dying. In the United States, it is said that there are two great fears rarely spoken of in polite company: Death and insanity. Insanity can be avoided and treated. Death makes no room for either avoidance or treatment. We all die and there is no cure. Most of us stay away from the dying and the specter of death until a family member, dear friend or neighbor gets terminally ill or suffers from a fatal accident. Then there we are, usually totally unprepared the first time. Since Elisabeth Kubler-Ross' groundbreaking work in 1969 on death and dying, there has been much more research done on end-of-life physical, psychological and social processes. Dr. Kevorkian and the tragic case of Terry Schiavo have also brought the question of "How do we die?" into the forefront of our awareness. Some of the issues, which demand attention include the following:   Medical Science can prolong life almost indefinitely leaving us faced with ethical and moral dilemmas that, heretofore, were not before us. People just died without the heroic, extreme, extraordinary measures taken to keep them alive. People are paying much more attention to how we die and want to have some control over how they end their life. Death is certain. Dying is not a beautiful or romantic process and may even be repulsive. The dying and their wishes are frequently ignored rather than recognized. We want to know what death is, but cannot truly understand it beyond the fleeting "near-death" experiences reported by a few. By the year 2050, people over 85 are expected to make up 24% of older persons and 5%, numbering over 19 million, of the entire population in the United States. Currently, three-quarters of those people who die yearly are older adults. Older adults want information about advance directives, palliative and hospice care and how to die comfortably at home. Most older adults fear pain, being alone when they die and that their wishes will be ignored by health practitioners. There are many ways to die: Natural death of old age, accidents, suicide, homicide, incurable disease, deaths surrounding birth and war, terrorism and execution. Family members are increasingly becoming the frontline caregivers for their older parents or other relatives. Consequently, they are also the primary caregivers during the dying process. What do caregivers (professional, paraprofessional and family) need to know? Curative care is disease-specific and restorative in principle. Palliative care is symptom-oriented and supportive in nature. Hospice care is an extension of palliative care and focuses on preparing, at all levels (physical, social, emotional, spiritual and economic), for death. There many questions associated with death and dying, most of which cannot be answered. These include: "How long will the patient live?" "Can the patient die at home?" "When will professional assistance be used, if at all?" "How can one recognize that death is near?" "What are the signs that death is imminent?" "How does one know for certain that the person has died?" Some of the issues considered by caregivers as death approaches include whether or not to engage or stop extraordinary lifesaving measures, whether to make plans for assisted or non-assisted suicide, whether or not to stop feeding or hydration, and whether or not to make substantial changes in a will or the disposition of the estate. No two people suffer bereavement in the same way. Grief begins before the person dies and even the dying person grieves. The circumstances of death, the age of the dying person and our relationship with that person all influence bereavement. Grief is an intense, bewildering and convoluted experience, filled with a plethora of emotions that can last a long time. Culture and ethnicity greatly impact the decisions and rituals associated with death and dying. When caregivers or providers are culturally different from a dying person or the family, there may be barriers to communication and understanding. Terminal illness, the prolongation of life in the very old, the administration of curative, palliative and, finally, hospice care, and how death occurs are fraught with profound and serious moral and ethical considerations, among them assisted suicide and euthanasia. Caregivers and providers must have an understanding of all of these issues and terms in order to be effective and helpful in the process. The Karen Ann Quinlan case many years ago and the more recent Terry Schiavo case demonstrate that these ethical and moral considerations and consequent decisions are filled with personal pain, questioning, doubt, outrage, indignation and social disagreement and divisiveness. Euthanasia is a medical treatment in the Netherlands and Belgium and assisted suicide is a medical treatment in the Netherlands, Belgium and Oregon. In the United Kingdom, the British Medical Association’s ethics committee in May 2006 recommended that doctors end the lives of some patients “swiftly, humanely and without guilt”. Advance planning for the dying can be a complex process. Having working knowledge of “advance directives”, “living wills”, “durable power of attorney for health care”, and the “protective medical decisions document” is imperative for a clinician who spends time with dying clients. Beyond the legal matters, clinicians have to have clarity regarding their own ethical, moral, and spiritual biases. Most of the world’s spiritual traditions, Jewish, Hindu, Islam, Christian, Jain, Sikh, Buddhist, Taoist, Native American and Indigenous religions, Maya, Animist, Humanist, Agnostic, Atheist and other more obscure beliefs concern themselves with what happens before death, at death and after death. Some say that there is no soul or afterlife. Nevertheless, we are time-space creatures; that is to say, since we are here now, we were always going to be here and when we die, we will always have been in our particular space-time. Catholic faith strives to grow a civilization of love in the middle of a culture of death and says that there are two extremes to be avoided: Deliberate ending of life actively or passively; that is, lethal injection or withholding care with the intention of causing death or to prolong life at all costs not realizing that death is not always a defeat, but the end of the natural process of life. Central to Buddhist teachings about life and death is the concept of impermanence. Form is emptiness and emptiness is form. Death is everywhere all the time and all things pass away. The Tibetan Book of the Dead, or The Great Liberation by Hearing in the Intermediate States, reveals the secrets of enlightened living and life after death. The first complete English translation was recently published in 2006. Clinical Update, August 2007 Google Factor: Therapists' Self-Disclosure on the Web Our online course on Self-Disclosure is available at http://www.zurinstitute.com/selfdisclosurecourse.html Traditionally, the professional literature has discussed three types of self-disclosure: 1. Deliberate self-disclosure includes therapists intentionally disclosing, to clients, personal information about their marital status, spiritual orientation, music preferences, political affiliation, etc.  Deliberate self-disclosure also includes information posted by the therapist on their own, and other, Web sites. 2.    Unavoidable self-disclosure includes a wide range of possibilities, such as the therapist's gender, age, physical attributes, disabilities, visible tattoos, obesity, manner of dress, wedding rings, etc. Therapists, who practice in small or rural communities or on college campuses, encounter additional significant unavoidable self-disclosure. 3.    Accidental self-disclosure occurs when there are incidental-unplanned encounters outside the office, or spontaneous verbal or non-verbal reactions. 4. Deliberate but unintentional disclosure occurs when therapists post certain information online. One example is when therapists post information online about their clients while neither getting releases nor adequately concealing their clients’ identities. Other deliberate but unintentional types of disclosures are when therapists condone fraud and illegal activities on the Internet. (For more information on this issue, go to Dr. Riolo’s web page at http://www.youradvocateonline.com.) What And How Clients May Find Information About Their Therapists: In the past, intrusive clients were known to have searched and found their therapist’s home address, marital status or who deliberately, or criminally, stalked their therapists.  The meaning of stalking has radically expanded with the introduction of Internet Search Engines such as Google, and thousands of for-fee services that would find almost anything a client might desire to know about their therapist. What clients can find using a simple Google search to locate online information not deliberately posted by the therapist:  Home address, home or unlisted phone numbers, a personal e-mail address. Licensing Board’s sanctions or complaints. Family members, family trees, or sexual orientation. Volunteer activities and community involvement. Professional activities and membership in professional organizations. Political affiliation and political petitions signed. With a click of a (Google) mouse clients can find their therapists' writings on a variety of Web sites and personal blogs and therapists' own blogs. Other clients’ and peoples’ writings’ about the therapist on a variety of Web sites and personal blogs. These include ex-clients’ complaints, grievances, grouses, cavils, quibbles, grumbles; charging accusations, criticism; IF YOU ARE NOT SURE WHAT ELSE CLIENTS CAN FIND ABOUT YOU, GO TO GOOGLE AND ENTER YOUR NAME.   Ways in which clients can join social networks and find very personal info about their therapists: With a click of a mouse clients can join online social networks, such as Tribe.net, MySpace.com and Facebook.com. Ways in which clients can join social networks, such as Facebook or MySpace, and find personal information about their therapists: a) Clients can "friend" their therapists online, and gain access to all sorts of information, including relationship status, religious views, hobbies and even favorite songs. b) Clients can also read their therapists' blogs, if their therapists use their real names.  Other clients are able to find the identity behind the screenname; those savvy in research may have little trouble at all.  IF YOU WANT TO FIND OUT HOW EASY IT IS TO JOIN SUCH SOCIAL NETWORKS AND FIND INFORMATION ABOUT PEOPLE, JOIN ONE OR TWO AND SEE FOR YOURSELF. What information clients can obtain about their therapists by paying for specialized online background checks: Financial information, including credit reports, debts, liens, Bankruptcies, etc. Criminal records. Small claims civil judgments. Past and present law suites. Marriages and divorces; including divorce records and allegations of domestic violence or molestation. Ownership of property and businesses. Tax information, such as taxes paid and tax liens. Cell phone records, including a 10-year history with available listed phone numbers! IF YOU DO NOT BELIEVE THIS, SIMPLY GO TO GOOGLE AND TYPE “BACKGROUND CHECK” AND SEE WHAT COMES UP. Ways that clients can locate information online about their therapists’ professional lives and what their therapist are posting on listservs and in chatrooms: Clients can often join professional listservs and chatrooms with rather simple pseudo-names.  Often no one checks. On many listservs anyone can join.  This information is then given, from these open sites, to “invitation only” listservs.  Although there may be a registration form required, often all that is requested is: name, business name, address, phone number, E-mail address, and area of practice.  The information is rarely checked for honesty or accuracy.    It is rare that more than 10% of list members post with any regularity and some never do. So therapists, at best, have no information regarding the remaining 90% of people on the list. To make it even easier to learn about someone who posts on lists, some list owners/ moderators insist that one also post one’s name, credentials and location, i.e., city and state, as a signature.  That, of course, would make it easier to Google someone. Some listserv moderators invite participants to present cases online. As a result, clients who deceptively join such listservs, may be privy to information about the therapists’ other clients, and perhaps the details of their own treatment.  Even when the listserv’s moderator appropriately disguises the identity of the client, the clients may recognize themselves in the details, as they also might if someone they know is in treatment with the same therapist. Clients, who join such listservs, may detect information regarding their therapist, illegally or unethically, committing insurance fraud, charging high co-pays, etc. In short clients can learn lot about a particular therapist, as well as the private information of his or her clients, from their comments on listservs. This information, accurate, or inaccurate, may be available indefinitely. Reflections on clients’ search for information regarding their therapists and differences between: Curiosity: Clients’ curiosity about their therapists when they Google them or check their therapists’ professional web site. This search may yield professional orientation of therapists, training, etc. Due diligence or thorough search: Clients who are more seriously looking for information about their therapists. This “due diligence” or thorough approach may include searching the licensing board’s web site to see if their potential therapist had any complaints filed against him or her. It is important to honor clients’ wishes to learn about the people whom they wish to trust and learn from and not to confuse due diligence search with intrusive search. Intrusive search: Clients may ‘push the envelope’ and intrusively search for information about their therapists. They may search for home address or to identify martial status or family members, etc. This may also include disguising one’s identity and joining social networks, listservs, etc., in order to find information about therapists; paying for an online service which legally gathers information about the therapist that is not readily available online. This may include divorce or other court records that are considered public records. Illegal search: Hiring online services, which illegally gather information about the therapist. Such information may include cell phone records and tax records. Note about therapists searching for information about their clients: The above four categories are equally applied to therapists’ ways of finding out information about their clients. Therapists may be generally curious about their clients and try a simple quick Google search to see if anything significant is revealed. If therapists are concerned about their clients, they may search more carefully on issues of criminality, litigious situations, such as past board complaints or lawsuits. Of course, the intrusive and illegal searches are applied to therapists as they do to clients. An example is when a therapist, who is willing to run a bill and carry a debt, may choose to run a credit check on the client with the client’s permission. What therapists should pay attention to when it comes to Internet disclosure: Assume that EVERYTHING that you post online, whether it is on your own web site, private or public blogs, listserves, online bulletin boards, chats, social networks, etc may be read by your clients. Be very careful in discussing case studies online and make sure that you either get permission from the client to discuss it, or make sure that identifying information is removed or changed.  In HIPAA terminology make sure you 'de-identify' your clients' identity. Be aware that your clients may read what you have posted as advice to other therapists in consultation regarding their own cases. Your clients may then draw conclusions based upon what you proposed, or even take the information personally. If you find out that a client or potential client has acted in an intrusive manner in regard to online searching, think about the clinical, ethical and legal ramifications, document your concern, respond appropriately, and, if necessary, seek consultation. Google yourself periodically so you are aware of what your clients may be privy to.  Google yourself using different combinations of name and degree, such as "Mark Smith, Ph.D.," "M. Smith, Ph.D.," "Dr. Smith," etc. If , in your search, you find private information about yourself that you do not want to be public, or misinformation that you want to correct,  find out whether you can have it removed. If the information was obtained or posted illegally or is defamatory, it is more likely that the therapist can remove this information by contacting the web site master and the server who either take the information off line or shut off the web site all together. However, if the therapists put the information online themselves, it may be harder to remove. Clinical Update, August 2007 DSM: Diagnoses Seen in Movies Learning about the DSM with fun and the movies or What can movies teach us about diagnosis? Movies are particularly well suited to depict psychological phenomena. The combination of images, music, dialogue, lighting, camera angles, and sound effects in a film mimic thoughts and feelings that occur in our consciousness. Since characters in many popular films portray persons who live with mental disorders, these depictions offer a unique learning opportunity. A new online course on the DSM: Diagnoses Seen in Movies at: http://www.zurinstitute.com/dsmandmoviescourse.html Following are a few examples of how movies illuminate the multifaceted nature of mental disorders and can help us use the DSM for effective treatment planning, and communicating with colleagues as well as with insurance companies. A Beautiful Mind offers a powerful opportunity to understand Schizophrenia. As Good As it Gets demonstrates almost every possible symptom of Obsessive Compulsive Disorder. Analyze This introduces Panic Disorder and in a humorous fashion. Annie Hall illuminates Anxiety Disorder. Mr. Jones offers the opportunity to learn about many aspects of Bipolar Disorder as well as about the differences between this disorder and Schizophrenia. Mad Love depicts a character with symptoms of Cyclothymic Disorder. Girl Interrupted invites us to discus Major Depression and the complexities of differential diagnosis. The Hospital offers an opportunity to learn about Dysthymic Disorder. In Country depicts a Vietnam War veteran with severe Posttraumatic Stress Disorder. Affliction demonstrates Alcohol Abuse and Dependence. Blow portrays Cocaine Abuse and Dependence. Play Misty for Me helps us understand Borderline Personality Disorder. Wall Street depicts Narcissistic Personality Disorder. Dying to Dance illumines Anorexia. Freeway II: Confessions of a Trickbaby demonstrates Bulimia. Brassed Off illustrates Adjustment Disorder. Clinical Update, July 2007 Cybersex Addiction & Internet Infidelity Our online course on Cybersex Addiction & Internet Infidelity is available at http://www.zurinstitute.com/cybersexcourse.html Cybersex addiction and Internet infidelity are the two most common forms of Internet addiction. Clinicians are seeing a growing number of clients addicted to Internet pornography or couples experiencing trouble because of online affairs. This course shows you specialized techniques in treating these new clinical problems. This course reviews the signs of Internet infidelity, how they develop, and how they differ from offline affairs. You will also learn specialized counseling techniques to help couples improve communication and repair broken trust after an online affair. As Internet sexuality is evolving as quickly as the technology itself, this course shows therapists how to diagnose cybersex addiction, the risk factors involved, the stages of development, and advanced techniques in treatment. Here are some of the most common facts about cybersex addiction and Internet infidelity. With the multitude and abundance of sexually explicit material online, addiction to online pornography has become the crack cocaine of the Internet. Internet Porn Statistics showed there are about 4.2 million pornographic websites constituting 12 % of the total websites. The pornographic pages constitute 372 million hits and daily pornographic search engine requests range to 68 million or 25 % of total search engine requests. Beyond online pornography, users can engage in sexually explicit adult chat rooms. Fantasy role-play rooms exist online with names like, “Hot Sex” “Bondage” or “Black Men for White Women”. With this type of access, cyberspace allows people to dabble, experiment, and explore sexual feelings and indulge in private fantasies unique to the online environment. Online sex is unique and qualitatively different than other forms of sexual behavior. The addict’s preoccupation with sexual arousal stems from his or her own imagination and fantasy history that once unlocked can be difficult to put back inside the bottle. Cybersex addiction can be hidden by overt signs of depression and anxiety, masking how much a client spends online. Therapists often overlook the symptoms of Internet addiction such that the disorder goes undetected, making related problems worsen. Over 60% of cybersex addicts have not previously suffered from a history of sexually addictive behavior until they discovered the Internet. Among many online addicts, cybersex is perceived as the ultimate safe sex method to fulfill sexual urges without fear of disease such as AIDS or herpes. Cybersex addiction can lead to divorce, marital separation, and job loss. Among couples, cybersex addiction and Internet infidelity are leading causes of divorce. Internet infidelity can impact older adults as well as new couples and cause the same kind of pain and devastation as if the affair occurred in the physical world. Treatment for cybersex addiction utilizes cognitive-behavioral techniques specialized to meet the needs of moderating appropriate computer use with a focus on abstinence from problematic online applications. This new 4 credit CE course will teach you How to diagnose and screen for cybersex addiction. How cybersex addiction impacts individuals and couples. How to identify the warning signs of Internet infidelity. How to work with couples after an online affair. How online sex differs from other forms of sexually addictive behavior. How cybersex can be a healthy way for individuals to explore new forms of their sexuality. How online sex can unlock new or hidden sexual fantasies. How to apply behavioral therapy for symptom management with cybersex- addicted clients. How to apply cognitive-therapy to treat cybersex-addicted clients. How to moderate a client’s computer use and manage relapse. How to access self-help resources for clients addicted to the Internet. Clinical Update, May 2007 Depression: The Therapist's Toolkit Our new 9 CE credit online course on Depression is available at http://zurinstitute.com/depressioncourse.html Depression: The Therapist's Toolkit Depression, the most common mood disorder, probably affects a majority of people who seek psychotherapy--whether they come in for depression or not. Therapists who have only one or two treatments in their toolkit will successfully treat only about 2/3 of their depressed clients. Depression in children: how it looks different than adult depression. Is combination therapy--meds plus therapy--really the best treatment for depression? A wider variety of therapies and non-pharmacological treatments than ever before have been proven effective for treating depression. Successful therapists match the best treatment to each individual depressed client. Therefore, it follows that the therapists most successful at treating depression will have the widest repertoire of treatments and ideas. Pregnant women and new mothers are often at increased risk for depression. Research has shown that, at times, it is hard to distinguish antidepressant withdrawal from the return of depression. They can seem the same with unfortunate and even disastrous consequences for your clients. Depression is also caused by situational factors, such as external threat and stress, racism, pace of life and many other environmental factors.  Depression can be rooted in people's inability to deal with existential issues, such as grief and lack of meaning, or in people experiencing a spiritual void. To escape depression, expert suggest, get out of the head and into the gym. As a biopsychosocial disorder, depression has many different causes and symptoms. Learn about them from behavioral, psychodynamic, existential and biological perspectives. Research has shown that relationship-based and psychodynamic therapies work as well as CBT. This course will teach you to The different approaches to the etiology and treatment of depression. To distinguish antidepressant withdrawal from the return of depression as they can seem the same, and to read pharmaceutical research without being misled. How effective are antidepressants? How do you weigh the risks and benefits of antidepressants? What's the story on omega-3 (fish oil) and St. John's wort? Should you use cognitive therapy, behavioral therapy or cognitive behavioral therapy? Or none of them. How new mothers' depression affects their infants. How to access and use self-help resources for your depressed clients. Clinical Update, May 2007 Bipolar Disorder: The Disorder, Its Treatments and Alternative Views Bipolar disorder is also known as bipolar affective disorder and manic depression.  Like diabetes or heart disease, Bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.  It is a disorder that brings up the question, "Is it possible to have too much of a good thing?" The experience of mania raises interesting questions about whether positive emotions, such as joy or exuberance, can be pushed to extremes where they lose their adaptive or prosocial qualities.  Intriguingly, Bipolar is linked with exceptional creativity during periods of good functioning. Dr. Jamison, in An Unquiet Mind, called it "an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering..." Our new  7 CE credit online course on Bipolar Disorder, Bipolar Disorder: The Disorder, Its Treatments and Alternative Views, is available at: http://zurinstitute.com/bipolarcourse.html. Bipolar -- Recap: Bipolar disorder, also known as manic-depressive illness, causes unusual shifts in a person's mood, energy and ability to function. People on the "high" side of bipolar disorder may feel on top of things, productive, sociable and self-confident. Many people have described the "high" of hypomania as feeling better than at any other time in their lives, but the feelings are exaggerated. They often cannot understand why anyone would call their experience abnormal or part of a disorder. There is no cure for Bipolar disorder, and the best pharmacological treatments often are not very effective because of problems with adherence and compliance. Different from the normal ups and downs that everyone goes through, the symptoms of Bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. Like other mental illnesses, Bipolar disorder cannot yet be identified physiologically, for example, through a blood test or a brain scan. Therefore, a diagnosis of Bipolar disorder is made on the basis of symptoms, course of illness and history. Bipolar disorder can be treated, and people with this illness can lead full and productive lives.  Medications are considered mood stabilizers if they have two properties: They provide relief from acute episodes of mania or depression or prevent them from occurring; and they do not worsen depression or mania or lead to increased cycling. Lithium and Depakote have been shown to fulfill this definition.  Other meds were originally developed as anticonvulsants for the control of epilepsy. Other available medications that are undergoing research as promising mood stabilizers include several new anticonvulsants and the newer, "atypical" antipsychotics. More than 2 million Americans in any given year have Bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. More than half of adults affected with Bipolar disorder had their mood disorder begin at age 16 or younger. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Bipolar I refers to a condition in which people have experienced one or more episodes of mania. Though an episode of depression is not necessary for a diagnosis of Bipolar I, most people who have bipolar I will have episodes of both mania and depression. Bipolar II refers to a condition in which people have had at least one hypomanic episode. The diagnosis in general and the rate of the disorder for children, as with ADHD, is highly debatable. Signs and symptoms of mania (or a manic episode) include: increased energy, activity and restlessness; excessively high, overly good, euphoric mood; extreme irritability; racing thoughts and talking very fast, jumping from one idea to another; distractibility, can't concentrate; little sleep needed; unrealistic beliefs in one's abilities and powers; poor judgment; spending sprees; increased sexual drive; abuse of drugs, particularly cocaine, alcohol and sleeping medications; provocative, intrusive or aggressive behavior; denial that anything is wrong. A mild to moderate level of mania is called hypomania. This may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus, even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment hypomania can become severe mania in some people or can switch into depression. Episodes of mania and depression typically recur across the life span. Between episodes most people with bipolar disorder are free of symptoms, but as many as one-third have some residual symptoms. "Pills do not come with skills," and psychoeducation and psychotherapy are important ways of building positive skills to improve relationships, promote academic and vocational success, and produce better coping mechanisms and quality of life. Cognitive behavioral therapy helps people with Bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness. Psychoeducation involves teaching people with Bipolar disorder about the illness, its treatment and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation is often helpful for family members. Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms. Clinical Update, April 2007 Boundaries and the Movies: Learning about Therapeutic Boundaries through Movies Our new (second) 6 CE credit online course on Ethics & Movies, Boundaries and the Movies: Learning about therapeutic Boundaries through Movies, is available at: http://www.zurinstitute.com/boundariesandmoviescourse.html Course fulfills the Law and Ethics Requirement. Themes in movies have long shown a fascination with therapeutic boundaries.  While many movies portray therapists as wacky, greedy and sexually predatory, many other movies deal sensitively with the everyday therapeutic and clinical complexities that we face. Following are a few examples of how movies illuminate ethical complexities and can help us navigate through them in our practices. Antwone Fisher illuminates the therapist's need for flexibility regarding treatment decisions, the value of inviting a patient to a family dinner or calling a patient "son." Good Will Hunting stimulates a rather heated discussion on the ethical complexities of the use of language, physical touch, getting in one's face, sessions outside the office and many other therapeutic boundaries.  Gross Point Blank demonstrates how important it is to inform clients about limits of confidentiality as early as is feasible in the therapeutic relationship.  It also reminds us that sometimes clients can easily instill fear in us, therapists.  The myth of the therapist's omnipotence is challenged. Deconstructing Harry hilariously illuminates for us the potential hazards of the home office. Dressed to Kill invites us to explore the complexities of gift giving and how gifts, which are formulated as a planned intervention, can be ethically appropriate and therapeutically valuable. What About Bob? reminds us how important it is to set boundaries with an overbearing and highly intrusive (but funny) client. The movie shows us how to try to deal with our anger, and to being intruded upon, in the best possible ways. Ordinary People invites us to consider how decisions about the therapist's physical proximity to his client can support a treatment goal. Prince of Tides teaches us about the ethics of sexual relationships with a client's brother. Basic Instinct illustrates the fact that some clients, in some situations, can gain significant power over their therapist with whom they have sexual relationships. Prime demonstrates the surprises and messes that are often unavoidable in our practices.  It proves that dual relationships do not occur only in rural communities and how risk-benefit analysis and consultation can help navigate complicated and unexpected clinical situations.  Frances exemplifies how the inappropriate use of language can lead to a boundary violation.  K-Pax illuminates the importance of consultation and collateral information in understanding the client.  It also demonstrates how physically restraining a client may be necessary to protect the client from him/herself or others. Stay brings up the question of sexual relationships with former clients. It shows how long after termination it is appropriate to get involved and the kind of situation one should never, sexually, get involved in with former clients. The first Ethics-Movies I covers: Confidentiality, Self-Disclosure, Touch, Dual Relationships and Out-Of-Office Experiences (i.e., home visits, in-vivo exposures, attending a wedding, incidental encounters, etc.) and is available at http://www.zurinstitute.com/moviesethicscourse.html The new Ethics-Movies II covers: Informed Consent, Gifts, Home Office, Clothing, Language, Humor and Silence, Proximity and Distance between therapist and client, and, finally, Sexual Relations, and is available at http://www.zurinstitute.com/boundariesandmoviescourse.html   Clinical Update, April 2007 Supervision II: Advanced Topics, Ethics & Law A new (second) 6 CE credit online course on Clinical Supervision is available at: http://www.zurinstitute.com/supervisionadvcourse.html Course fulfills BOTH the Supervision and the Law and Ethics Requirements On Supervision and Mentoring: Some form of supervision, mentoring, or apprenticeship exists in most fields.  Historically, it has been the elders who have provided training and guidance to those with less experience. Whether this mentoring is for the skilled craftsperson (Blacksmiths, Musicians, Jewelers, Carpenters) or professional (Financial Advisors, Psychotherapists, Physicians), this form of assistance enhances both the individual and the community at large.  However, attention to the process of clinical supervision as a distinct area of inquiry is relatively new. Many movies depict different types of profound mentoring relationships. They include, Full proof monk, Seabiscuit, Star wars, The Guardian, Billy Elliot, Dead Poet Society, Harry Potter, Officer & Gentleman, Lord of the Rings, Zoro, The Emperor's Club or The Last Samurai.  (Future course on supervision will focus on mentoring relationships in the movies.) Supervision is defined as the collaborative relationship that exists between a clinician of advanced education and experience and a clinician who is less experienced and often unlicensed. Within the supervisory relationship, the senior, or supervising, clinician is responsible for the oversight, management, evaluation and clinical liability of the junior clinician, or trainee. The primary goals for supervision are: 1. To prepare the trainee to practice independently 2. To advance the status of the trainee from Novice to Master 3. To ensure the safety of the general public by performing consistent and comprehensive evaluation of the trainee The Purpose of supervision is to provide the trainee with: - Education - Training in: Nature of the profession; Theoretical understanding; Research and how to evaluate it; Critical Thinking; and Enhancement of clinical skills - Corrections or revisions of any poor clinical habits, misconceptions, or therapeutic techniques - Professional skills: Networking, Marketing - Burnout prevention strategies - Ethical risk management strategies - Clinical "container" that limits risk for the consumers - Professional growth Supervision increases comfort and confidence in the trainee The process of supervision can enable the trainee to identify his/her strengths and weaknesses, as well as ways to perform optimally As gatekeepers to the profession, it is imperative that the supervisory relationship be educational & evaluative Unfortunately, it is very challenging to assess the effectiveness of clinical supervision! This intermediate-advanced course on Clinical Supervision will teach clinicians to: Identify optimal qualities and skills in both supervisor and supervisee Select a personal style for supervision Enhance creativity as a supervisor Manage challenging people and situations in the supervision process Demonstrate ethically-driven decision-making skills The new 6 CE credit course on Supervision II is at http://www.zurinstitute.com/supervisionadvcourse.html. The original, more basic, 6 CE credit Supervision I course is at http://www.zurinstitute.com/clinicalsupervisioncourse.html. Clinical Update, March 2007 Schizophrenia: Analysis of the Disorder, its Treatment and...its Detractors For a 6 CE credit online course on Schizophrenia: click here. Schizophrenia has been one the most puzzling, disturbing and fascinating mental illnesses of all time, which affects nearly one percent of Americans. Historically, individuals with Schizophrenia were thought to have "split personalities."  Eventually, clinicians came to recognize clear differences between Schizophrenia and Dissociative Identity Disorder.  Now, those in the general population have an even clearer understanding of the nature of Schizophrenia as a result of exposure to films such as "A Beautiful Mind," "Clean, Shaven" and "The Fisher King." Even with improved awareness in both clinical and general populations, there is still active debate about the illness and its diagnosis and treatment.  For my view of the "Village" and Community of Care go to http://www.zurinstitute.com/villageformentallyill.html.   Schizophrenia -- Recap: Schizophrenia is a chronic, severe and disabling brain disorder that affects about one percent of Americans. While schizophrenia occurs in 1 percent of the general population, it is seen in 10 percent of people with a first-degree relative who has the disease. Research has shown that schizophrenia affects men and women equally and occurs at similar rates in all ethnic groups around the world. The modern term, "Schizophrenia," comes from the Greek word "shjzofre'neja," meaning "split mind." Despite misunderstanding by much of our population, schizophrenia is neither "split personality" nor "multiple personality." Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect and sense of self. Due to the disabling "voices" that many schizophrenic people hear, it can be very difficult for them to maintain a job or even manage consistent self-care. As such, the burden on their families and society is significant. The National Institutes of Health says the total costs of the illness approach $30 billion to $65 billion annually. Individuals with schizophrenia may experience positive, negative or cognitive symptoms, all of which can inhibit normal function. Psychotic symptoms (such as hallucinations and delusions) usually emerge in men in their late teens and early 20s and in women in their mid 20s to early 30s. They seldom occur after age 45 and only rarely before puberty. While many of the older antipsychotic medications, such as Thorazine, were associated with adverse side effects, such as Tardive Diskinesia (TD), there are many antipsychotics available today that have far fewer side effects. TD is primarily characterized by random movements in the tongue, lips or jaw, as well as facial grimacing, movements of arms, legs, fingers and toes, or even swaying movements of the trunk or hips. TD can be quite embarrassing to the affected patient when in public. The movements disappear during sleep. They can be mild, moderate or severe. Some of the atypical antipsychotics currently in use include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). Each has a unique side effect profile, but in general, these medications are better tolerated than the earlier drugs. The risk of suicide amongst those with schizophrenia is far higher than in the general population.  And, while Clozaril is associated with several serious side effects, it is one of the only anti-psychotics that effectively reduces the risk of suicide in schizophrenic patients. Some of the atypical antipsychotics can be administered by injection, reducing the risk that the patient will "forget" their daily or twice daily medications. A study in the New England Journal of Medicine found that 74% of the patients in the study discontinued antipsychotic medication before the end of their treatment due to inefficacy, intolerable side effects or other reasons. One FDA Public Health Advisory warned that elderly patients with behavioral disturbances who were being treated with atypical antipsychotics ran a significantly higher risk for death than folks not being treated with antipsychotics. Studies out of the United Kingdom suggest that CBT can be an effective tool for diminishing delusions, as well as for reducing the experience of voices in those with schizophrenia. There are numerous studies suggesting that patients treated with neuroleptics receive more hospitalization than those not treated with neuroleptics.  Contemporary researchers and clinicians regard recovery from schizophrenia not only as the cessation of symptoms but also as the development of new meaning and purpose as one grows beyond the catastrophe of mental illness.  While there is no known cure for schizophrenia, the recovery model provides new hope for those with this disease. Facilities that provide psychosocial rehabilitation provide patients with work and social skills training, education about their disease and why medications are important, symptom management and, often, therapy for dealing with the trauma of having schizophrenia.  There are nearly 4,000 such facilities across the country. In the words of R.D. Laing, "Madness need not be all breakdown. It may also be breakthrough. It is potential liberation and renewal as well as enslavement and existential death." Szasz continues to fight for the normalization of schizophrenia, perceiving the symptom profile of those diagnosed and labeled with schizophrenia as an illness of fit between individual and environment.  According to Szasz, these individuals are coping in the way that they have learned to manage their environments, and they do not have "brain disease" as many scientists have suggested. The new 6 CE credit online course on Schizophrenia will enable you to: Define schizophrenia and describe symptoms generally associated with it. Outline the basic etiology of schizophrenia. Identify the classic and contemporary treatments for schizophrenia. Discuss alternative views of schizophrenia and critique current ideas and interventions. Compare and contrast pharmaceutical and non-pharmaceutical interventions.   Clinical Update, March 2007 Touch in Therapy: Advanced Course and Recent Developments For an Advanced Course on Touch in Psychotherapy (Level II) for 6 CE Credits (fulfills Law & Ethics Requirement): http://www.zurinstitute.com/touchadvcourse.html We have been told by ethics experts, attorneys, continuing education instructors and supervisors never to touch our clients beyond a handshake.  Touch has been increasingly perceived as a risk management issue to be avoided rather than as one of the most powerful ways to connect with and heal our clients.  The paranoid notion that non-sexual touch is likely to lead to a sexual relationship, is countered by greater understanding of the importance of touch for human connection and bonding and in reducing stress, anxiety and depression. In spite of a half century of extensive knowledge on the emotional, relational, physiological and behavioral benefits of touch, many therapists still shy away from appropriate non-sexual touch due to fear of boards, attorneys and lack of training.  Even though most therapists touch their clients by patting them on the back, holding a hand or giving an appropriate hug at the end of sessions, they do not write or talk much about it.  The good news is that more clinicians are open to looking at the benefits of touch.  Even though US culture tends to sexualize all forms of touch, clinicians are increasingly aware of the importance of touch with those who are depressed, anxious and stressed, as well as with children and women who were sexually abused. Our New-Advanced Course on Touch (at http://www.zurinstitute.com/touchadvcourse.html) consists of the following articles: TOUCH AND THE STANDARD OF CARE:  This is one of the first articles to  describe how clinically appropriate touch clearly falls within the standard of care in psychotherapy and counseling.  This includes ritualistic or socially acceptable gestures, such as a handshake or hug, conversational markers, such as a touch of the hand or a consoling or reassuring, grounding touch.  Then there is body psychotherapy or somatic therapy touch, such as Reichian Therapy, Bioenergetics, Somatic Experiencing, Hakomi and Rubenfeld systems, that also clearly fall within the standard of care.  The article articulates measures one should take to document, when to obtain consent, and how to assess the affect and effectiveness of touch in therapy. THE MEANING OF TOUCH FOR THE THERAPEUTIC RELATIONSHIPS. BY JAMES FOSSHAGE, Ph.D.: This is a truly ground breaking article, which articulates the many ways that touch can be used in psychodynamic and other psychotherapies.  It emphasizes the importance of touch for therapeutic alliance and how touch increases trust and openness between therapists and clients.  Dr. Fosshage discusses the clinical use of touch not only in Psychodynamically oriented therapies but also with women who have been abused and other populations and modalities. FROM FELT-SENSE TO FELT-SELF:  NEUROAFFECTIVE TOUCH AND THE RELATIONAL MATRIX BY ALINE LAPIERRE, Psy.D., with an introduction by Allan N. Schore, Ph.D.: Dr. LaPierre discusses recent neurobiological research indicating that critical levels of tactile input of a specific quality and emotional content in early postnatal life are important for normal brain maturation.  Based on her argument against Field and other researchers, she discusses the importance of touch for human development and its role in the therapeutic environment, including Psychodynamic oriented therapies. She summarizes her short article with, "From this perspective, the touch taboo and resulting touch illiteracy limit our psychotherapeutic horizons and rob us of effective, perhaps critical, forms of clinical reparative interventions and interactive couple and caregiver education." ABOUT THE ETHICS OF PROFESSIONAL TOUCH, BY COURTENAY YOUNG: The author, Courtenay Young, is the President of the European Association for Body-Psychotherapy (EABP) and is a leading authority on the topic of the ethical and clinical aspects of therapeutic touch.  He extensively covers the ethical and clinical aspects of touch in therapy as very few other articles do. ETHICAL AND LEGAL ASPECTS OF TOUCH IN PSYCHOTHERAPY: Provides a review of the codes of ethics on touch, an ethical decision-making process and a summary of legal aspects in regard to touch in therapy. Clinical Update, March 2007 Child Abuse: Identification and intervention For an online course on Child Abuse for 9 CE Credits (also fulfills Child Abuse Requirement): Click here. Child Abuse Quick Fact-Sheet: More than 2.5 million cases of child abuse and neglect are reported each year. Of these, 35 percent involve physical abuse, 15 percent involve sexual abuse and 50 percent involve neglect. One in four girls and one in eight boys will be sexually abused before they are 18 years old. About one in 20 children is physically abused each year. Child neglect can include physical neglect (withholding food, clothing, shelter or other physical necessities), emotional neglect (withholding love, comfort or affection) or medical neglect (withholding needed medical care). Unlike the commonly held belief, not all abuse victims have severe reactions or display dysfunction as adults. Usually, the younger the child, the longer the abuse continues and the closer the child's relationship with the abuser, the more serious the emotional damage will be. The immediate effects of shaking a baby, which is a common form of child abuse in infants, can include vomiting, concussion, respiratory distress, seizures and death. Long-term consequences can include blindness, learning disabilities, mental retardation, cerebral palsy or paralysis. Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form properly, resulting in impaired physical, mental and emotional development. In other cases, the stress of chronic abuse causes a "hyperarousal" response by certain areas of the brain, which may result in hyperactivity, sleep disturbances and anxiety, as well as increased vulnerability to post-traumatic stress disorder, attention deficit/hyperactivity disorder, conduct disorder and learning and memory difficulties. A study of 700 children, who had been in foster care for 1 year, found that more than one-quarter of the children had some kind of recurring physical or mental health problem (U.S. Department of Health and Human Services, 2003). A National Institute of Justice study indicated that being abused or neglected as a child increased the likelihood of arrest as a juvenile by 59 percent. Abuse and neglect increased the likelihood of adult criminal behavior by 28 percent and violent crime by 30 percent. Update on California Child Abuse and Reporting Act (CANRA): http://www.leginfo.ca.gov/cgi-bin/displaycode?section=pen&group;=11001-12000&file;=11164-11174.3 The online Child Abuse (9 CE credit) course (at http://www.zurinstitute.com/childabusecourse.html) will: Present statistics, demographics and prevalence of child abuse. Provide facts and dispel myths regarding offender and victim traits, characteristics and dynamics. Present the signs and sequelae of sexual abuse and identify the consequences and effects of child abuse. Identify effective assessment, investigation and interventions Present the laws for reporting child abuse in different states and provide a list of resources for clients, the general public and clinicians. Clinical Update, February 2007 De-Mythifying Therapeutic Boundaries: From fear and ignorance to clinical integrity and effective therapy Review Dr. Zur's book, Boundaries in Psychotherapy, and order at http://www.zurinstitute.com/boundariesbook.html For a Home Study course (10 CE credits) that is based on Dr. Zur's book, Boundaries in Psychotherapy, and fulfills the ethics requirement at http://www.zurinstitute.com/homestudy.html#boundaries For an Online course that is based on Dr. Zur's book, Boundaries in Psychotherapy: http://www.zurinstitute.com/boundariesbookcourse.html We have been repeatedly told in graduate school and CE ethics and risk management seminars never to touch beyond a handshake, avoid gifts, do not engage in bartering or leave the office with a client and, of course, avoid dual relationships like the plague.  In our hearts most of us therapists know that a hug and supportive touch can often connect and heal more than words, and a gift may also speaks louder than words.  We also know that a home visit can give us more clinical data than clients report to us. Those who live in small communities know that dual relationships are a normal part of the rich interwoven fabric of small communities, such as church, synagogue, college campus, rural or small town, gay and lesbian, ethnic minority communities, etc. Regardless of what risk management or ethical experts tell us, there are NO ethical guidelines or state laws that prohibit non-sexual, clinically appropriate touch, appropriate gift exchange, clinically driven self-disclosure or non-exploitative dual relationships. Therapeutic Boundaries -- Recap: Boundaries in psychotherapy refer to issues of self-disclosure, physical touch, gifts, bartering, activities outside the office (home or hospital visits, attending clients' weddings or school plays, lunch with anorectic client, adventure therapy, etc.), incidental encounters, social and other non-therapeutic contacts and various forms of dual relationships.  Boundary crossings and boundary violations generally refer to any deviation from traditional, strict, 'only in the office,' emotionally distant forms of therapy.  Basically, they may all be seen as a departure from the traditional psychoanalytic or risk management approaches. Boundary violations in therapy are different from boundary crossings. While boundary violations by therapists are harmful to their patients, boundary crossings can be clinically very helpful. Harmful boundary violations typically occur when therapists and patients are engaged in exploitative dual relationships, such as sexual contact with clients or exploitative business relationships. Helpful Boundary crossings can be an integral part of well-formulated treatment plans or evidence-based treatment plans.  Examples are, giving a supportive hug to a grieving client, accepting a small termination gift, flying in an airplane with a patient who suffers from a fear of flying, bartering with a cash-poor farmer, lending a book or CD to a client, making a home visit to a bed-ridden patient, attending a wedding, confirmation or Bar Mitzvah, going to see a client performing in a show, going for a walk with a depressed patient or accompanying a patient to a dreaded but important doctor's appointment. Ethics codes of all major psychotherapy professional associations (e.g., APA, NASW, ACA, CAMFT, NBCC) do NOT prohibit boundary crossings, only boundary violations. Therapeutic orientations, such as humanistic, behavioral, cognitive, family systems, feminist or group therapy, often endorse boundary crossings as part of effective treatment. Different cultures have different expectations, customs and values and therefore judge the appropriateness of boundary crossings differently. Communally oriented cultures, such as Latino, Native American or Jewish, are more likely to frown upon the rigid implementation of boundaries in therapy. Not all boundary crossings constitute dual relationships. Making a home visit, going on a hike, attending a client's wedding and many other 'out-of-office' experiences are boundary crossings, which do not necessarily constitute dual relationships. There is a prevalent and unfounded belief about the 'slippery slope,' which claims that minor boundary crossings inevitably lead to boundary violations and sexual relationships. This illogical approach is based on the 'snow ball' effect. It falsely predicts that the giving of a simple gift likely ends up in a business relationship, therapist's self-disclosure becomes an intricate social relationship and a non-sexual hug turns into a sexual relationship. Dual Relationships in Psychotherapy Dual relationships, or multiple relationships, in psychotherapy refer to any situation where multiple roles exist between a therapist and a client.  Examples are when the client is also a  student, friend, family member, employee or business associate of the therapist. Non-sexual and non-exploitative dual relationships are neither unethical nor illegal nor below the standard of care. Sexual dual relationships with current or recently terminated clients are always unethical and often illegal. Dual relationships are often unavoidable in rural and small communities, the military, forensic settings, church communities and among gays and lesbians, the deaf, people with AIDS, Hispanic, African American and many other minorities. Non-sexual dual relationships do not necessarily lead to exploitation, sex or harm.  The opposite is often true.  Appropriate and healthy dual relationships can prevent exploitation & sex rather than lead to it. None of the major ethical guidelines mandate a blanket avoidance of dual relationships.  All guidelines do is to prohibit sexual dual relationships with current or recently terminated clients, as well as prohibit exploitation and harm of clients. There are several types of dual relationships: Social, business, professional, communal, etc. Dual relationships can also be concurrent or sequential, avoidable, unavoidable or mandated, and can be simple or complex or intricate. Clinical and Ethical Recommendations The appropriate meaning and applicability of boundaries can only be understood within the context in which therapy takes place. The context of therapy consists of the following four components: Client factors (e.g., culture, age, gender, history of trauma or abuse, presenting problem); Setting factors (e.g., outpatient vs. inpatient, solo practice vs. group practice, home office vs medical building, rural vs urban); Therapy factors (e.g., individual vs. family vs. group therapy, psychoanalysis vs. humanistic vs. body psychotherapy); Therapeutic relationship factors (i.e., nature of therapeutic alliance; phase in therapy); Therapist factors (e.g., culture, age, gender, clinical experience, training). Develop a clear treatment plan, which is based on client's problems, needs, personality, situation, venue, environment and culture.  Intervene with your clients according to their needs and not according to any dogma. Some treatment plans may necessitate boundary crossings; however, in other situations they should be ruled out.  Make sure you know the difference. Conduct a risk benefit analysis before crossing boundaries.  Remember that inaction, such as rigid avoidance of boundary crossing, may also have significant drawbacks for clients and the therapeutic process. In planning to cross a boundary or enter into a dual relationship you must take into consideration the welfare of the client, effectiveness of treatment, avoidance of harm and exploitation, conflict of interest and the impairment of clinical judgment. Do not let fear of lawsuits, licensing boards or attorneys determine your treatment plans or clinical interventions.  Do not let dogmatic thinking affect your critical thinking.  Act with competence and integrity while minimizing risk by following these guidelines. Remember that you are being paid to provide help, not to practice risk management.  Do not enter into sexual relations with a current or recently terminated client. Consult with informed and open minded experts in complex cases and document the consultations. Attend to and be aware of your own needs and biases through consultations, peer supervision, therapy, etc. Discuss with your clients the complexity, richness, potential benefits, drawbacks and likely risks that may arise due to boundary crossings and dual relationships.  When appropriate, share with them your risk benefit analysis. Boundary crossings with certain clients, such as those with borderline personality disorders or those who are acutely paranoid, are not usually recommended as they more often benefit from a structured and well-defined therapeutic environment. Make sure that, when appropriate, your office policies include the risks & benefits of boundary crossings and dual relationships, and that they are explained, read and signed by your clients prior to treatment. Make sure your clinical records document includes consultations, substantiation of your conclusions, potential risks and benefits of specific interventions and the discussion of these issues with your client. At the heart of all ethical guidelines is the mandate that you act on your client's behalf and avoid harm.  That means you must do what is helpful including, when appropriate, crossing boundaries and engaging in dual relationships. Clinical Update, February 2007 Female Batterers: Male Victims -- The Hidden Side of Domestic Violence For an online course on Female Batterers for 4 CE Credits, Click Here.  We have just completed a course which offers a fresh look and a new perspective on a topic that's hard for most of us to approach: Women who are violent in their intimate relationships.  Despite what the general population may believe, research has begun to identify a growing trend of women as victimizers in their relationships.  It is very hard to consider the idea of women's violence.   Some of the objections to this idea are: This is blaming the victim; Women hit only in self-defense; We should not ignore thousands of years of oppression of women and the whole social context of patriarchy and men's power and control over women; Discussing women's violence diminishes the responsibility of men's violence; Women are inherently peaceful, they will turn to violence only in self-defense.  However, we believe that ignoring the problem of female batterers is likely to  increase the danger to the women themselves and to have a terrible effect on the children.  Facing the problem is obvious the first step in the process of preventing violence and healing for the family. Following is a short summary of the facts and complexities involved with female battering: Approximately 835,000 men are battered each year by their partners. Men are less likely to report domestic violence by their female partners due to shame, machismo, fear of humiliation by police and male peers, and even fear of retaliation by their perpetrators. While many women who commit Intimate Partner Violence are simply defending themselves against assaults by their partners, as many as 80% of women who murder their husbands have histories of violence and often have extensive criminal records. Recent research suggests that women may commit domestic violence because they think they can "get away with it." Research has identified that on many occasions women who feel unheard in their relationship may commit violent acts to get their partner's attention. * According to recent research, men do not perceive violent acts committed against them by female partners as "domestic violence."   Individuals use whatever form of violence proves most effective for them: men, with greater physical strength, use direct physical violence, while women are more likely to use weapons in their violent acts against their partners.  From a Social Policy perspective it is important to recognize that while there may be equal acts of violence by men and women against one another, there may be heightened danger for women who commit even minor acts of violence due to the potential for retaliation.  By inducing shame, as often proscribed in the popular Duluth Model, male perpetrators can be prompted to greater feelings of rage rather than increased feelings of empathy for their victims.  In many states couples therapy is prohibited for men who have been involved in domestic violence, even though women have been actively involved in the violence.  This may result in greater danger to women. Family Systems Theory has been useful as it emphasizes the mutual contribution of the partners and interprets mutual effects of violence in the relationship, eliminating assigning fault or negative consequence for any single party in a relationship. Domestic violence is a problem that exists for the couple. It is a system of violence rather than the men's problem.   It is a social and familial problem and should be attended to at that level. Clinical Update, January 2007 Postmodernism and Psychotherapy: What Postmodern is and How it Relates to Psychotherapy This Clinical Update will shed some light on the mystery of what is postmodernism.  Postmodernism is the latest buzzword that has forever changed the world and the way we understand it. The reasons why clients seek psychological help and how they understand their life challenges are different than they were in "modern" times. The practice of psychotherapy and counseling needs to change with the times in order to remain relevant; however, many clinicians find postmodernism elusive and difficult to understand. This new course on Postmodernism and Psychotherapy: Understanding the Essentials for 6 CE credits (at http://zurinstitute.com/postmoderncourse.html) helps make postmodernism and its influence understandable and relevant to the clinical practice. Quick Look at Postmodernism: Postmodernism is not so much a separate theoretical orientation as it is a trend, which can be seen in a number of approaches to psychology. Postmodernism impacts the reason why clients enter therapy and counseling as well as how they understand their problems. Postmodernism has important relevance for how therapy is developed, practiced and evaluated. Postmodernism reflects changes in the way people understand knowledge or truth, including knowledge about psychological health and therapy. Postmodernism emphasizes the importance of pluralism and diversity along with the need for dialogue. Personal stories, narratives or subjective experiences is valued over objective knowledge in postmodern theory. Postmodernism recognizes that what is best or healthiest for one person may not be for another; each person has the right to define what is healthy for him/herself. Claims for objective or universal truth are viewed with suspicion in postmodern theory. The Course (at http://zurinstitute.com/postmoderncourse.html) reviews the following elements: An overview of premodernism, modernism and postmodernism Common misunderstandings about postmodernism The importance of interdisciplinary dialogue for postmodern psychology and therapy The impact of postmodern times on the client's presenting issues Dangers and limitations of postmodernism Conceptions of the self in postmodern theory and its relevance for therapy Postmodern approaches to psychotherapy including narrative, humanistic, existential and contemporary psychoanalysis Postmodernism and critical psychology Diversity Issues and Pluralism Postmodern perspectives on religious and spiritual issues in psychotherapy  Evaluating therapy effectiveness and appropriateness from a postmodern perspective Understanding the different approaches to psychotherapy from a postmodern worldview Applying postmodernism to psychotherapy and counseling Postmodern Ethics, psychotherapy and counseling Clinical Update, January 2007 Sport Psychology: An emerging and exciting specialty Sport psychology is the study of athletes' behavior and the psychological influences on performance. Its scope also covers a broad spectrum of subject areas ranging from exercise as a psychotherapeutic modality to motor learning. Especially of interest to human services practitioners and coaches is the application of sport psychology for the purpose of evaluating athletes, predicting, monitoring, documenting and analyzing psychological performance during training; and competition, as well as engaging in mental training interventions, to enhance performance. For an online course on Sport Psychology for 4 CE Credits, Click Here  The course was developed by one to the top experts in the field, Roland A. Carlstedt, Ph.D., Chairman of the American Board of Sport Psychology. Subject areas in Applied Sport Psychology Foundations of sport performance: motor learning and output, cognitive processing, intensity, attention. Improving performance through mental training. Working with athletes,  teams,  coaches and sport organizations. Monitoring athletes during training and competition. Tactile learning: using motor learning principles to facilitate technical performance. Assessing athletes: predicting performance, evaluating psychological performance. Normative databases of neurocognitive and psychophysiological (mind-body) functioning. Online (Internet-based) athlete testing. Psychological scouting athletes for professional and college sports. Psychological performance statistics: quantifying the mental game. Intervention amenability and compliance: what works and for whom and how often. Intervention efficacy testing: to what extent does a method work. Biofeedback and Neurofeedback with Athletes: potent emerging interventions. Heart Rate Variability Monitoring, Assessment and Biofeedback. Clinical sport psychological interventions: exercise psychotherapy. Psychopathology in athletes. Integrating sport psychology into the clinical practice. Participants in this new Sport Psychology course will learn about: Motor Learning: understanding the interplay among psychological, neuropsychophysiological and motor learning in mediating peak technical performance. Getting in the game, your bridge to athletes, coaches and teams. Cognitive Factors: discovering how cognition influences motor learning, attention, task-performance. Knowledge about what makes an athlete tick; it's not just about doing sport psychology but also understanding how and why things happen. Psychophysiology of Sport: learning how mind-body measures influence performance and how they can be monitored prior to and during actual competition to better study the effects of differential subliminal brain-mind-psychological processes that can facilitate or hinder peak performance. Bringing the mental game to life with user-friendly technology and methods. Primary Higher Order Factors: exposure to three emerging psychological factors and behaviors that have been found to explain more of the variance in the performance equation than ALL psychological factors in previous research. Assessment of Athletes: review of issues, perspectives and conventional approaches to the evaluation of athletes. Evaluation of Psychological Performance: learn about psychological performance statistics that help quantify athlete performance during training and competition. Taking sport psychology out of the office -- a very valuable tool that will help make you a coaches best friend. Review of the Literature: a presentation and synopsis of research that is relevant to applied sport psychology. Overview of Interventions: gain insight into the most commonly used mental training methods in sport psychology including visualization and cognitive techniques; relevant research and theoretical underpinnings; mind-body dynamics. Integrative Evidence-Based Athlete Assessment and Interventions: The Carlstedt Protocol: learn about the first systematized science-based approach to comprehensive athlete evaluation and mental training. Certification in Sport Psychology: learn about the American Board of Sport Psychology Certified, Master Certified Consultant and Board Certified Sport Psychologist, Visiting Fellowship and Internship programs (distance-based with mentored/supervised applied practicum and final project).  Participants in this course (at http://zurinstitute.com/sportpsychologycourse.html) will be entitled to a 15% discount on the tuition fee toward training and certification in sport psychology through the American Board of Sport Psychology (ABSP). Clinical Update, December 2006 Cultural Diversity A new online course on Cultural Diversity for 6 CE Credits at: http://www.zurinstitute.com/diversitycourse.html The importance of multicultural competence is indisputable in light of the following facts: "We are fast becoming a multicultural, multiracial, and multilingual society.  The recently released 2000 U.S. Census reveals that within several short decades persons of color will become a numerical majority." Those same Year 2000 Census results indicated that: Over 50% of the state of California is composed of minority groups. Over 30% of New York City is internationally born. Approximately 70% of the District of Columbia is African American. Close to 37% of San Francisco is Asian American. Nearly 70% of Miami is Latino. Increasing diversity is the result of greater immigration of ethnic minorities and the higher birth rates among the minority populations when compared to their Caucasian counterparts. According to Census data, approximately 45% of public school students are people of color. Racism can directly impact the health status for persons of color and result in decreased life span and susceptibility to illness. Racial/ethnic minority groups have less access to health care. The nature of services is woefully inadequate; they are more likely to be medically uninsured; and the services provided are often inferior and more likely to result in the death of racial/ethnic minority clients. Clinicians, like the rest of the population, are not immune from inheriting the biases, stereotypes and values of the larger society. And, try as they might to avoid doing so, they may unintentionally act out these biases in the treatment of their clients of color. Our course is an attempt to proactively respond to Wing Sue's (2003) reminder that, "Culture-specific mental health treatments consistent with the cultural values and life experiences of a particular group may prove more effective than conventional forms of treatments."   Clinical Update, November 2006 Eating Disorders: A clinician's guide A new online course on Eating Disorders for 4 CE Credits at: http://www.zurinstitute.com/eatingcourse.html "I am the poet of the Body, and I am the poet of the Soul Seeing, hearing, feeling, are miracles, and each part and tag of me is a miracle. Divine am I, inside and out, and I make holy whatever I touch. The scent of these arm-pits is aroma finer than prayer. I dote on myself, there is a lot of me and all so luscious."                                       Walt Whitman How many women do you know today that would speak in such reverent tones of their bodies? Not many! This course is meant to educate people on eating disorders, on body image and the influence of the media on women of all ages.  We are experiencing an epidemic in disordered eating in this country with almost 2/3 of Americans being overweight or obese and at least 5% of Americans struggling with anorexia or bulimia.   As professionals, it is incumbent upon us to learn as much as we can about these deadly disorders.  It is imperative that we know how to recognize an eating disorder and then know enough to at least make an appropriate referral. Approximately 7 million girls and women, and approximately 1 million boys and men will struggle with eating disorders this year. Eating disorders have the highest mortality rate of any DSM diagnosis. Anorexia nervosa is the leading cause of death in adolescent girls, with bulimia nervosa a close second. 19% of college aged women in America are bulimic although as many as 33% of young women in this age group will experiment with eating disordered behaviors. 10% of all persons with eating disorders are male. 81% of 10 year-olds are afraid of being fat. 91% of women recently surveyed on a college campus had attempted to control their weight through dieting. 80% of American women are dissatisfied with their appearance, which is indicative of a cultural condition.  When surveyed, a group of young women were asked: Would you rather be maimed in an automobile accident, experience the loss of a good friend, flunk out of school, lose all your hair or be fat?  The overwhelming response was that they would rather have any of the above situations happen to them than be fat. We are truly experiencing an epidemic of disordered eating and body image in our culture.  The question becomes, "Now that we are aware, what do we do?"  The first step must be education. Clinical Update, October 2006 Cognitive Behavioral Therapy: Nuts & Bolts A new online course geared to help you refresh your skills and/or add Cognitive Behavioral Therapy (CBT) to your toolbox.  Cognitive Behavioral Therapy - Nuts and Bolts: Online course for 4 CE credits is at: http://zurinstitute.com/cbtcourse.html. Whether you've been in practice two years or twenty, you've certainly had the opportunity to consult with clients that seemed mired in their own mind-waste.  Weeks, months, sometimes even years of psychotherapy do not seem to move these clients towards greater health, clarity, insight or joy. Enter CBT: One of the most practiced therapeutic skill sets today.  Combining the theories and techniques of founding fathers such as Ellis, Beck, Watson and Skinner, CBT enables clinicians to move past those cognitive blocks and distortions to accompany clients towards improved mental and physical health. Unlike psychoanalytic therapies that focus on the intrapsychic root of a person's issues, CBT practitioners believe that changing thought patterns result in long lasting emotional, behavioral and cognitive changes CBT is one of the most widely known and used brief therapies utilized for symptom reduction. It is a highly effective tool for resolving negative self-talk that may support ineffective, inappropriate and, sometimes, even dangerous behavior.  As a field, CBT now encompasses therapies based on the work of such greats as: Aaron Beck, Albert Ellis, Maxie C. Maultsby, Jr., Aldo Pucci, Jeffrey Young, Marsha Linehan, Daniel Meichenbaum and David Burns. CBT is relatively simple to learn and utilize and can be provided by a wide variety of clinicians and professionals across many settings. Because the therapist him/herself is not primary to successful intervention, CBT can be practiced by a wide range of clinicians and clients. CBT can be used effectively to treat depression, anxiety, panic, Obsessive Compulsive Disorder, Post-Traumatic Stress Disorder, chronic illness, fatigue and more! If you've been wondering about CBT and its efficacy and would like to add CBT to you toolbox of interventions, then this course is for you! This course will: Review the history and foundations of Cognitive Behavioral Therapy Identify and describe various interventions associated with CBT List disorders that can be treated with CBT Explore the benefits of combined pharmaceutical/ CBT treatment Summarize the contemporary trends in the field of CBT Clinical Update, September 2006 Disposing Clinical Records in California Forward this important information of the upcoming changes to fellow California psychologists, MFTs and LCSWs. California Psychologists: Rev up the Shredders -- New Record Keeping Regulations for California Psychologists Beginning January 1, 2007, all licensed psychologists in California must retain a patient's health service records for a minimum of seven (7) years from the patient's discharge date or seven years after a minor patient reaches the age of eighteen. California Governor, Arnold Schwarzenegger, signed AB 2257 on July 20, 2006. This provides much needed clarity, as prior to the passage and signing of AB 2257, state law did not address the issue of record retention by psychologists in independent practice. The new requirement represents a minimum requirement for the length of time psychologists must retain mental health records.  The implication is that each case must be considered individually to determine if there is a reasonable basis for retaining the records longer. Private practitioners are allowed to retain their records for a longer period, if they wish or are required to. The new law means that on January 1, 2007, California psychologists can dispose, preferably by shredding or incineration, records of adult clients whose treatments were terminated prior to December 31, 1999.   The new requirement is consistent with current practice for California's heath facilities, such as licensed clinics, nursing facilities, adult day health care facilities, intermediate care facilities and skilled nursing homes.  Florida, New Jersey and Oregon have equivalent record retention requirements of seven years minimum from last appointment or date of service.  Texas has a longer retention of records with a minimum of ten years and an additional ten years after the patient turns eighteen. Until January 1, 2007, California psychologists should continue to retain full records for three years after completion of planned services or after the last date of contact.  Full or summary records are to be retained for an additional twelve years.  The record may be disposed of no sooner than fifteen years after completion of planned services or after the date of the last contact, whichever is later.  In the case of minors, the records shall be kept at least one year after the minor has reached the age of 18, but in no case less than seven years. Please note that there may be forensic or other reasons to keep records longer. California MFTs and LCSWs:  No Changes to Existing Laws The recommendation for record keeping for California MFTs and LCSWs: Taking into consideration §4982.05, Enforcement Status Limitation code, and the changes instituted in 2004, the recommendations are: Records created by marriage, family and child counselors and social workers should be preserved for a minimum of ten (10) years following the discharge of the patient. That means that California MFTs and LCSWs can dispose, preferably by shredding or incineration, records of adult clients whose treatments were terminated prior to October, 1996.  Records of un-emancipated minors should be kept one year after the minor has reached the age of majority but in no event less then 10 years. Please note that there may be forensic or other reasons to keep records longer. Contact BBS, CAMFT or CA-NASW for updates and verification. For an Online Course on Record Keeping, which fulfills the law and ethics requirement and includes 53 Clinical Forms, go to: http://zurinstitute.com/recordkeepingcourse.html. Clinical Update, September 2006 To Zip or Not to Zip? Self-Disclosure in Psychotherapy How much should I self-disclose to my clients? To whom should I self-disclose? When should I disclose? What should never be disclosed? Can I get into trouble for disclosing too much? These questions and many others are answered in this Clinical Update and in much more detail in our Self-Disclosure online course for 4 CE credits. SELF-DISCLOSURE IN PSYCHOTHERAPY: A RECAP Self-disclosure has been one of the most misunderstood constructs in psychotherapy. Somehow the traditional psychoanalytic notion of neutrality and anonymity along with rigid risk-management advice have dominated our thinking on the issue. It overshadows sound and proven behavioral and cognitive-behavioral interventions, such as modeling and the emphasis of humanistic, feminist or group psychotherapy on authentic relationships. At its most basic, therapist self-disclosure may be defined as the revelation of personal rather than professional information about the therapist to the client. When therapist disclosure goes beyond the standard professional disclosure of name, credentials, office address, fees, office policies, etc., it becomes self-disclosure. There is a commonly held belief that self-disclosure is what we tell our clients. In fact there are many forms of self-disclosure, which involve the way we walk, talk, greet, discuss issues, spontaneously react to our clients, dress or decorate our offices, and how we answer or do not answer their questions. Since the 1990s we have witnessed a cultural shift where celebrities and politicians, such as Oprah Winfrey, Elizabeth Taylor or Bill Clinton, have accustomed the public to intimate and detailed confessions on national TV. At the same time, Oprah, Dr. Phil and endless realty shows have promoted extreme and often bizarre self-disclosure by people on TV in front of millions of strangers. As a result, modern consumers feel entitled to access all kinds of information about their therapists. With the click of a button they can turn to medical boards, federal medical data banks and a vast array of resources that are ready to provide private information about their therapists. Of course, they can Goggle us and find all kinds of information that we had no idea was even available to the public. Appropriate and clinically driven self-disclosures are carried out for the clinical benefit of the client. Many disclosures are simply unavoidable. Inappropriate self-disclosures are those that are done primarily for the benefit of the therapist, clinically counter-indicated, burdens the client with unnecessary information or creates a role reversal where a client, inappropriately, takes care of the therapist. TYPES OF SELF-DISCLOSURE There are four different types of self-disclosure: 1. Deliberate self-disclosure refers to the therapist's intentional, verbal or non-verbal disclosure of personal information. It applies to verbal information shared by the therapist and also to deliberate actions, such a placing a certain family photo in the office or making a sigh in response to the client. There are two types of deliberate self-disclosure: Self-revealing, which is the disclosure of information by therapist about themselves, and self-involving, which involves therapist's personal reactions to client and to occurrences during sessions. 2. Unavoidable self-disclosure includes a wide range of possibilities, such as therapist's gender, age and physics, place of practice, tone of voice, pregnancy, foreign or any accent, stuttering, visible tattoos, obesity and many forms of disability, such as paralysis, blindness, deafness or an apparent limp. Therapists also reveal themselves by their manner of dress, hairstyle, use of make-up, jewelry, perfume or after shave, facial hair, wedding or engagement rings, or the wearing of a cross, Star of David or any other symbol. Therapists who practice from their homes disclose extensive information, such as economic status, information about the family and pets, sometimes information about sexual orientation, hobbies, habits, neighbors, community and much more. Therapists who practice in small or rural communities must all contend with extensive self-disclosure of their personal lives by virtue of the setting. Non-verbal cues or body language (i.e., a raised eyebrow or flinch) are also sources of self-disclosure that are not always under the therapist's full control. Even not answering the client's questions about the therapist's personal life is considered a form of self-disclosure. 3. Accidental self-disclosure occurs when there are spontaneous or unconscious verbal or non-verbal reactions during a session. Also included are unplanned meetings outside the office. 4. A client's deliberate actions are potentially rich sources that can reveal personal information about the therapist. Of course, the prime example is in the movie, What About Bob? A client can initiate inquiries about their therapist by conducting a simple Web search. Such searches can reveal a wide range of professional and personal information, such as family history, family tree, volunteer activities, criminal records, community and recreational involvement, political affiliations and much more. Therapists' online biographies or professional resumes may also reveal significant information about the therapist. A client's deliberate spying on their therapist can reveal a significant amount of private and personal information. SELF-DISCLOSURE & THERAPEUTIC ORIENTATIONS The attitude towards therapeutic self-disclosure is closely related to the therapist's primary theoretical orientation. Behavioral, cognitive and cognitive-behavioral therapies have emphasized the importance of modeling, reinforcement and normalizing in therapy and view self-disclosure as an effective vehicle to enhance these techniques. Humanistic and existential psychotherapies have always emphasized the importance of self-disclosure in enhancing authentic therapeutic alliance, the most important factor in predicting clinical outcome. Traditional analysts have followed Freud's instructions to serve as a mirror and a blank screen for the client, freeing the client to project their own feelings and thoughts onto the rather neutral therapist. Neutrality, abstinence and anonymity, according to traditional analytic theory, are the foundations for transference analysis. In contrast, the interpersonal focus of several modern psychodynamic psychotherapies has emphasized the importance of self-disclosure in relational and intersubjective perspectives. Family therapy, Ericksonian therapy and Adlerian therapy use it for the purposes of modeling and therapeutic alliance. Group psychotherapy is another orientation that has stressed the importance of self-disclosure. Feminist therapy values therapist self-disclosure for its role in fostering a more egalitarian relationship and solidarity between therapist and client, promoting client empowerment and allowing the client to make informed decisions in choosing women-therapists as role model. Self-help based therapies use self-disclosure extensively. Narrative therapy also places a high value on what they call therapists' transparency SELF-DISCLOSURE WITH DIFFERENT POPULATIONS Therapists working with different populations have different rationales for self-disclosure: Self Help and 12 Step Programs are the most common use of self-disclosure, such as Alcoholics Anonymous, Narcotics Anonymous, Over-Eaters Anonymous and other self-help and peer-support models. Children and those with a diminished capacity for abstract thought often benefit from more direct answers to questions requiring self-disclosure. Adolescents are often resistant to therapy as they frequently see adult therapists as authority figures and extensions of their parents. Religious and spiritual based therapies: Self-disclosure has a unique importance for therapists working psychotherapeutically with patients who hold particular religious or spiritual beliefs. These clients often ask therapists questions about their spiritual orientations and values as part of the interview process. Gay and lesbian clients present one the most convincing arguments for self-disclosure. Self-disclosure is a very important issue as it relates to the key issue of being "out." War veterans with PTSD have often been cited as a group of clients with which self-disclosure seems clinically important. Minorities are often more comfortable with therapists who self-disclose or were observed or perceived by clients as coming from the same or a similar minority group. TO ZIP OR NOT TO ZIP? Be aware of the wide range of types and forms of self-disclosure and their potential impact on clients. Do not focus only on verbal and intentional forms of self-disclosure. National surveys have consistently shown that most therapists are involved in some form of intentional self-disclosure. Deliberate self-disclosure generally should be geared for clinical-therapeutic purposes and for the client's benefit. Self-disclosure should not aim to primarily satisfy the therapist's needs, pride or ego. Excessive or inappropriate self-disclosure may create a situation where the client is no longer the focus of treatment or where the client perceives a need to take care of the therapist. As with any decision regarding boundary crossing, the decision to self-disclose is based first and foremost on the welfare of the client. Almost all professional codes of ethics do not address directly the issue of self-disclosure. Intentional and deliberate self-disclosure is made under the general moral and ethical principles of Beneficence and Nonmaleficence - therapists intervene in ways that are intended to benefit their clients and avoid harm to them. When self-disclosure is unavoidable, as often is the case in small communities, therapists must evaluate whether such exposure is likely to benefit, interfere, have impact or effect the therapeutic process in any way. Therapists who are engaged with significant or systematic self-disclosure should document or explain their clinical rationale in the clinical records. As with any other intervention, deliberate self-disclosure should be determined by the client's factors (i.e., presenting problem, history, gender, culture, age, mental capacity); therapist's theoretical orientation; therapist's culture and comfort with self-disclosure; and the setting of therapy (i.e., home office, military base, small town). ^^Top of Page Clinical Update, July 2006 Beauty: Does the Mirror Really Know Who's the Fairest? For an online course on Beauty: Click here. Dr. Sage DeBeixedon, my coauthor of the course on beauty wrote: Most of us are old enough to remember Beverly Hills 90210 with high school co-eds engaging in every day drama, each and every one looking like a star while doing so.  I went to the real life version of that high school, and the script seemed to mirror my experience week after week.  The parents of my peers were movie moguls and directors, producers, writers and celebrities.  A significant portion of time and money was invested in maintaining the beautiful façade, through starvation diets, colon cleanses, weekly massages and strenuous physical regimes. I came from European farmers.  I can work hard, am very intelligent and am pleasant to look at. My parents put every dime they had to move us out of the rough neighborhood and into the "right" life.  I scholarshipped my way into school and wore hand-me-down uniforms.  Fitting in with the beautiful people wasn't an option.  Decades later I still work hard, think clearly and am still pleasant to look at.  Some even think me beautiful. But when I look back, I now realize that the beauty I saw in myself, even then, was far more accurate than the beauty sought after by my peers. Throughout time there have been many conceptualizations of beauty.  From each different field of study and from every different culture and perspective, beauty can be given unique description and definition.  In our new course on Beauty, theories of beauty are reviewed and the impacts of these culturally-held perceptions are identified.  Pathological pursuits and consequences of beauty are addressed as well.  So you think beauty is in the eye of the beholder? Think again. According to new research from the University of Exeter in Great Britain, the preference for pretty faces over ugly ones is embedded in our brains from the moment of birth and possibly prior to birth.  This research and other studies suggest evidence for evolutionary design in how we perceive beauty.  Similarly, research has also shown that good-looking boys and girls have a much bigger advantage in life than previously realized, the reason given is because we are all genetically programmed to love a pretty face.  Scientific tests with new-born babies have revealed that they have an instinctive fascination for men and women who look like Hollywood film stars - and an in-built prejudice against more "ordinary"-looking adults.  Research has shown that if you have attractive individuals, people judge them to be more honest, trustworthy and better in terms of time-keeping -- any positive attributes are more likely to be associated with such attractive individuals. There's no doubt that attractive people tend to do better in life than less-attractive people.  Apparently, nobody ever said evolution was supposed to be fair. Naomi Wolf, author of The Beauty Myth, notes, "The American Anorexia and Bulimia Association states that anorexia and bulimia strike a million American women every year... Each year 150,000 American women die of anorexia." It is estimated that one woman student in five is anorexic. Cosmetic surgeons are having a field day with women seeking out the knife for every conceivable flaw. The Beauty Myth preaches that normal, round, healthy women's bodies are too fat; that cushy, soft women's flesh is really cellulite; that women with small breasts aren't sexy; that women lacking the "perfect" face aren't attractive; that a woman over 30, who shows signs of life on her face, is ugly." "When women evaluate their physical attractiveness, they compare themselves with an idealized standard of beauty, such as a fashion model," says Richard Robins, professor of psychology at the University of California, Davis. "In contrast, when both men and women evaluate their intelligence, they do not compare themselves to Einstein, but rather to a more mundane standard." Women who undergo breast enhancement surgery may be more likely to commit suicide than those who don't, according to a study published in British Medical Journal. A survey of female undergraduate students found that about 15 percent of the women met criteria for signs of anorexia or bulimia, body dissatisfaction, a drive for thinness, perfectionism and a sense of personal ineffectiveness. Research has shown that magazine reading and television viewing, especially exposure to thinness-depicting and thinness-promoting media, significantly predict symptoms of women's eating disorders. Women who frequently read fitness magazines, for reasons other than interest in fitness and dieting, display greater signs of disordered eating than women who rarely read them at all. Further, reading fashion magazines in particular is significantly related to a woman's drive for thinness and her dissatisfaction with her body, although magazine reading, in general, has little effect on body dissatisfaction. Harrison says that the relationship between mass media consumption and symptoms of women's eating disorders appears to be stronger for magazine reading than for television viewing. However, watching "thin" shows is a consistent predictor of a woman's drive for thinness and viewing "heavy" shows is significantly related to body dissatisfaction. Research indicates that lesbian and heterosexual women view their bodies very differently. The reason is that lesbian women studied emphasized the importance of being a 'whole' person, balancing a healthy body with healthy personality. A Few Quotes: Beauty is in the eye of the beholder and it may be necessary from time to time to give a stupid or misinformed beholder a black eye.  Miss Piggy People are like stained-glass windows. They sparkle and shine when the sun is out, but when the darkness sets in, their true beauty is revealed only if there is a light from within.  Elizabeth Kubler-Ross The best and most beautiful things in the world cannot be seen or even touched. They must be felt with the heart. Helen Keller This online course at http://www.zurinstitute.com/beautycourse.html will: Compare psychological, evolutionary and other theories of beauty Identify ways in which perception of beauty is modulated Recognize the negative impacts that the pursuit of beauty may have on women's mental health Assess negative mental health and pathological consequences associated with the pursuit of beauty Clinical Update, July 2006 Sacrifice, Martyrdom, Suicide & Suicide Bombers The moment the bullet tore into the calf of my leg and a nearby explosion ruptured my eardrum, I collapsed. I yelled for a fellow officer to take over my unit before the medics injected me with morphine and loaded me onto an open personnel carrier headed to the field hospital. This was 1973, when Egypt and Syria launched a surprise attack against Israel. I was a lieutenant, part of a paratrooper unit staffed with hundreds of highly trained young men ready to sacrifice themselves for the defense of their country. We were on the West-Egyptian side of the Suez Canal, hundreds of miles away from the border. Friendly and unfriendly gunfire was everywhere. Neither felt friendly . . . For the rest of the article on my (OZ) personal experience and reflection on sacrifice, go to http://www.zurinstitute.com/onsacrifice1.html I am pleased to introduce a timely and unusual course: Sacrifice: A Psychological Exploration at: http://www.zurinstitute.com/sacrificecourse.html This opportune course reviews the different forms, theories, sources and history of sacrifice and differentiates them from martyrdom, suicide, scapegoating and victimization. The September 11th tragedy and the daily suicide bombers in Iraq have underscored the importance of understanding the meaning and psychology of sacrifice, martyrdom, terrorism, suicide and suicide bombers. SACRIFICE Sacrifice derives from the Latin word “sacrificium.” It is a combination of the words “sacer,” which means something set apart from the secular or profane for the use of supernatural powers, and “facere,” which means “to make.” In other words, sacrifice means to make something holy or pure in worship of the divine. Humans have sacrificed the life and blood of their own species. They have also sacrificed animals and animals' blood, crops such as flowers or rice, wine and honey, and many other symbolic offerings. In the Christian tradition a sacrifice is the offering of an object by a priest to God alone and the consuming of it to acknowledge that He is the Creator and Lord of all things. Jesus made the ultimate self-sacrifice. In nature we have the archetypal example in the mother Killdeer bird that pretends to be distressed or to have a broken wing in order to decoy predators away from the nest and thus save her vulnerable young. Then there is sacrifice of children by their parents. Medea killed her children rather them let them die ignominiously at the hands of King Creon, who sought to revenge himself on her.  Abraham was ready to sacrifice his son, Isaac, in order to prove to God his devotion through obedience. Also according to the Old Testament, Jephthah sacrificed his daughter in return for God's leading him to military victory. Agamemnon of Mycenae sacrificed his daughter, Iphigenia, at Aulis where he slew her on the temple altar in order to turn the wind so his troops could depart after the fall of Troy. Then we have the sacrifice of millions our young sons to gods of war. The more modern, secular interpretation of sacrifice is the giving up of something valuable or important for somebody or something else considered to be of more value or importance. MARTYRDOM Martyrdom is different from sacrifice and suicide. The word “martyrdom” itself comes from the Greek martyrs, the earliest meaning of which was “eyewitness.” Martyrdom, in modern times, is grounded in profound religious faith. Martyrs are willing to die, to sacrifice their lives in this world in order to be assured a place in the next world and a guarantee that they will not be condemned to hell. TERRORISM Terrorism is an elusive term. The goal of terrorism is always to install terror in order to achieve certain political or other goals. In the '60s there was a popular and rather accurate saying, “One man's terrorist is another man's freedom fighter.” Beyond agreement that terrorism aims at inducing terror, no common definition has been found. Consequently, it has been used as “name calling” against any “enemy of the state.” More recently, many district attorneys have used it to prosecute criminal cases that involved threats. Typically, terrorist organizations do not poses aircraft carriers, tanks and missile launchers but do posses the capacity to carry out surprise attacks at the heart of the enemy land. Terrorism is often a characterization used by powerful governments when their enemies employ means that do not assure the big power victory in war. Terrorism has been described as one out of many types of warfare (i.e., primitive-ritualistic wars, colonial wars, holy wars or liberation wars.) As with any war, it is aimed to reach a certain political goal through violent means. Terrorists, often more so than most soldiers, are prepared to make whatever sacrifice they deem necessary to achieve their goals, including their lives. This introductory level course (at http://www.zurinstitute.com/sacrificecourse.html) on sacrifice defines and differentiates between sacrifice and the related terms of martyrdom, scapegoating, terrorism and suicide. It gives an overview of the psychological work of Jung and Freud along with other theories of sacrifice. It then provides an anthropological and historical review of sacrifice and definitions, descriptions and resources on sacrifice.  Clinical Update, June 2006 Psychodynamic Diagnostic Manual (PDM):   A New Approach to Diagnosis in Psychotherapy A first-of-its-kind online course on the recently published PDM: http://www.zurinstitute.com/pdmcourse.html The PDM was released this month and presents an exciting, new, useful and invaluable resource for clinical work. Regardless of your theoretical orientation the new PDM offers a refreshing, new approach to diagnosis and assessment. The PDM goes far beyond a diagnosis that is based on a list of symptoms, to include descriptions of healthy functional patterns and healthy personality.   The New York Times, in its review of this new and exciting development, states that the PDM "Emphasizes the importance of individual personality patterns...which qualify as full-blown disorders only at the extremes." Whether you are psychodynamically oriented or not, you are likely to benefit from reviewing this new PDM approach to assessment of clients' full range of human functioning. The PDM special task force has gone further than the DSM and developed a new diagnostic manual that is based on current neuroscience, treatment outcome studies, other empirical investigations, as well as on psychoanalytic theory. The PDM is a result of a collaborative task force, which was appointed by a coalition of prominent organizations representing most psychoanalytically oriented therapists. The PDM is likely-to-become-popular new manual, which covers all ages from infancy and early childhood through adulthood and old age, is designed to complement the DSM and ICD. The new manual insists that personality be evaluated first and symptoms considered as secondary. This is because symptoms cannot be understood, assessed or treated in the absence of an understanding of the personality structure of the person who has the symptoms. While the PDM sees it as important to differentiate between "personality disorder" and personality per se, the PDM does not present a hard-and-fast dividing line between the two but suggests a continuum of severity. For each personality disorder, clinicians learn what transference and countertransference reactions to expect in the clinical hour and what treatment approach to consider. For many diagnoses the possible psychological roots of the client's problems are mentioned. Depending on their evaluation of a client's location on this severity dimension, therapists need to behave with important differences in emphasis, level of activity, explicitness of boundary setting, frequency of sessions and other features of technique. The psychodynamic manual considers subjective experiences and typical relationship patterns in the description of a person's overall functioning. The PDM addresses the full range of mental functioning by using a multi-dimensional approach to describe a person's functioning -- including ways of engaging in the therapeutic process. Our new course (at: http://www.zurinstitute.com/pdmcourse.html) will aid you in: Understanding the PDM in the context of the history of other diagnostic manuals. Recognizing how the PDM responds to concerns with the DSM.  Utilizing the information from the PDM for possible etiologies and implications for treatment. Learning about the possible impact of the PDM on the field of psychotherapy. The content of this densely written, 850 page manual is designed to expand many clinicians' understanding of their clients' personalities, the meaning, extent and the roots of their suffering, as well as appropriate treatment approaches. This course offers a well laid out, systematized summary of the individual diagnoses and their implications for the therapeutic process. Much of the course material is presented in a well-structured bullet-point format that allows the reader to grasp the PDM easily and to use the training material as a valuable reference tool in the future. ^^Top of Page Clinical Update, June 2006 Suicide Assessment, Diagnosis, Prevention and . . .  Choice For an online course on Suicide Assessment, Diagnosis, Prevention and . . .  Choice: Click here. We engraved my mother's gravestone, as she had requested many years prior to her death, "Trees Die Erect", testifying to her refusal to retire from her role as an educator, psychologist and social activist.  She chose to die at the top of her career in what my sister called "Suicide by work."  The question of suicide reared its head to me again when I worked in East Africa as a fish-ponds expert and was shocked to notice how so many rural tribesmen did not hesitate to chop down the few palm trees left in the oasis and let the cattle defecate in the only water hole in an arid area.  It looked normal to them but pretty suicidal to me.  Part of this experience helped me shift my focus from fish to people.  Early in my career as a psychologist, I encountered suicide when I worked in a mental health clinic in a local jail and was ordered to conduct a suicide assessment on a death row inmate.  My bafflement quickly turned to outrage at how ludicrous it was for me to  determine whether a prisoner should be placed on suicide watch so he would not kill himself before the state had a chance to execute him.  Then, like most clinicians, I have encountered many situations, in which depressed, psychotic, disillusioned, hopeless or depleted clients felt desperately suicidal and where suicide prevention was necessarily and often welcomed by them. (OZ) NIMH reports that in 2001 there were twice as many deaths from suicide as from HIV/AIDS.  Four times as many men kill themselves than do women.  Nearly 75% of all suicide deaths in 2001 were males. Vulnerable populations such as youth and the elderly are far more likely to die by suicide than others do.  In addition, those with psychiatric and medical conditions also pose higher risks for suicide. Comprehensive assessment of suicidality requires evaluation of an individual's: ideation; intent, plan and lethality; motivation to die; emotional and physical state; coping skills; and epidemiological risk factors. Successful treatment planning for managing suicidality involves: Identification of a range of treatment alternatives Involvement of appropriate friends, relatives and medical team members Incorporation of current treatment modalities into the long-range plan Selection of appropriate levels of client observation and supervision Documentation of suicidality as well as treatment plan components Heightened awareness of the increased risk presented by many concomitant psychiatric disorders. While we may be aware of the risk that mood disorders play in suicide, we may be less aware of the risks associated with chronic mental illness such as schizophrenia.  Research by Harvard Medical Institutions suggests that nearly 75% of patients with schizophrenia have suicidal ideation.  Nearly half those with schizophrenia attempt suicide at one time or another, and suicide is far more common in those who are in the early phase of their illness, are feeling hopeless and recognize deterioration. While many clinicians are aware of risk factors associated with an individual's psychological state, they may underestimate the impact of sociocultural risk factors such as: barriers to access to mental health treatment (geography, transportation, $); stigma associated with psychiatric disease and suicidality often inhibit help-seeking behaviors; cultural and religious beliefs; suicide "epidemics" in groups, such as school, ethnic, online communities, etc. As clinicians, we often look at suicide prevention from our clinical or medical perspective and concern ourselves with one patient at a time.  We may have far greater impact by approaching suicide from a Public Health perspective, which examines the roots of our current society for this phenomenon. Most clinicians are well-aware of the risks posed by post-partum depression but often misconstrue those risks as purely hormonal or biochemical in nature.  Careful attention must be paid to the impacts of long-term sleep deprivation, both for new parents as well as for the elderly. Complaints of poor or non-restorative sleep increase with age and impact half our elderly population.  Research suggests that poor sleep strongly correlates with depression and eventually with increased risk for suicide. Incarcerated persons are significantly more likely to suicide than those in the general population. Research suggests that there is higher suicide potential among LGB youth.  Four factors are suggested as prime reasons for increased suicidality: increased drug use and alcoholism; heightened sexual activity; increased risk of victimization or violence by others; and heightened risk of becoming defensively violent as a result of persecution about being visibly gay. Debate about the legality of suicide, or death control, has continued for decades. As a culture, we continue to struggle with the concept of suicide.  Over the years Szasz has continued to remind us that suicide is neither a crime nor a sin nor a mental illness, it is a personal choice.  The much debated Oregon suicide assistant law has led the way in accepting terminating one's life as a legitimate conscious choice.  The increased number of baby boomers who nurse their elderly parents and are facing the question of how to die, place the issue of suicide high on our personal and professional issues. The way we choose to die is closely tied to the way we choose to live. We must keep the dialogue regarding suicide open and ongoing. * The new online course (http://zurinstitute.com/suicidecourse.html) on suicide will: Provide you with updates on facts and statistics for suicide Recap ways to conduct suicide risk and lethality assessment Provide you with two basic forms, Suicide Contract and Suicide Risk Review Help you design and implement treatment plans for suicidal clients Provide you with ways to identify increased risk for suicide in vulnerable populations Help you think of the moral, existential, biological, medical and other considerations regarding suicide Clinical Update, June 2006 MEN: Contemporary Theories and Creative Interventions for Male Depression, Aggression, and Relationship Issues The divorce rate in the United States has hit an all-time high.  It's easier than ever to give up and get out.  Domestic violence rates have also skyrocketed as stressors have become ubiquitous in families where both partners (or parents) must work and try to juggle responsibilities for family, career and marriage.  These are the couples that are knocking on our doors. Psychologist and author, Dr. David Wexler, has come to our rescue!  Dr. Wexler  has developed a fabulous new online course for us entitled MEN: Contemporary Theories and Creative Interventions for Male Depression, Aggression, and Relationship Issues available at: http://www.zurinstitute.com/mencourse.html. Dr. Wexler uses a blend of material from his new books, When Good Men Behave Badly: Change Your Behavior, Change Your Relationship and Is He Depressed or What?: What To Do When The Man You Love Is Irritable, Moody, and Withdrawn, as well as excerpts from his clinical text, STOP Domestic Violence: Innovative Skills, Techniques, Options, and Plans for Better Relationships. Here's a look at some of the issues discussed in this innovative course: Theories and therapies designed to better understand men have been under development since the late 1960's.  But today's man seems to be barraged by stressors unlike in any other era.  New theories of male psychology are a must! Men are very susceptible to "emotional hijacking by the limbic system" in situations that they perceive to be emotionally threatening. And they are more prone to "emotional flooding" in relationship conflict situations. The latest research about male brain patterns suggests that men have an atypical response to depression.  It is imperative that clinicians have a good working knowledge of these impacts. Men are a complex breed and can be highly defensive in psychotherapy.  Do you feel adept at bringing out the best qualities in your defensive male clients? For example, acknowledging men's strengths and positive contributions in a relationship often relaxes male defensiveness-so the therapeutic message can really sink in. And men respond much better if they think of therapy as "coaching" or "consulting.' When men are aggressive or violent in their relationships, it is often difficult to access our empathy.  Try as we might, we may even find ourselves becoming judgmental.  The self-psychological perspective enables us to avoid negative countertransference and to better understand these "good men behaving badly." Just as in a love relationship, recognizing the underlying anxiety and sense of powerlessness in these men allow us to recognize ourselves in them.  Most of us can recite the DSM criteria for a Major Depressive Episode in our sleep.  We know by heart the symptoms of anhedonia, worthlessness, poor concentration, loss of energy, weight changes, hopelessness and suicidality.  But in men, often those symptoms are absent, though we know the man is depressed.  Do you know what signs and symptoms to look for in order to assess male-type depression? Exaggerated behavior, blaming others, avoidance and escape, and discontent with self are classic signs of "male-type depression." Women often come to us with complaints that their male partners are unemotional and withdrawn.  It's time to develop a more informed and compassionate perspective about men's emotional struggles in relationships and ways that you can help men enhance their relational function. Men are extremely sensitized to the "broken mirror" experience in their relationships with the women they love, and they often experience women as holding the power to govern their self-esteem and sense of well-being-even though women rarely ask or desire this power! When we provide education and communication skills building to couples in therapy, men often tell us that they'd "never talk like that!" In order to help your male clients better deal with their emotions and to communicate more effectively in intimate relationships (using "guy talk" rather than "therapese"), you'll need some innovative new strategies! Offering more compassion and patience can be framed as "relational heroism." Managing temper can be framed as "getting power" over oneself. In this online course, Wexler paves the way for us to become more adept at treating men.  He summarizes the latest research about male brain function, as well as ways in which men respond differently to depression than do women.  Wexler outlines a new therapeutic approach to use with our male clients that reduces shame, enhances communication and brings out the best in this complex breed! Clinical Update, May 2006 Patriot Act, Confidentiality & Subpoenas: Therapist as Informer Following are several ONLINE COURSES for CE credits that are closely related to the above topic:   Confidentiality   HIPAA Friendly   Record Keeping   Subpoenas This clinical update provides a summary and an update of the Patriot Act of 2001 regarding the concern that the Act may force therapists to disclose clinical information while, at the same time, forbid them to inform their clients about the disclosure. This can create a very complicated situation, where therapists may act more like informers than psychotherapists. Following is a brief summary of the issues involved: Following the events of September 11, 2001, Congress passed the USA Patriot Act. The purpose of the legislation is to make it easier for law enforcement to act to prevent future acts of terrorism. As part of this new legislation, Section 215 of the Patriot Act authorizes certain FBI agents to request a subpoena from a special court. FBI subpoenas can require access to any requested records, and the subject of the investigation (i.e., the patient) may not be notified. Revealing to clients that their clinical records have been subpoenaed by the FBI is not permitted under section 215 and could result in serious penalties.   As clinicians we are expected to assert the privilege of confidentiality on behalf of our clients. We are encouraged to notify a client when their records are being subpoenaed and to see that the client, when appropriate, has signed the authorization-to-release-records form before releasing any information. The Patriot Act stipulations can create a compromised situation for a clinician, where a client's entire treatment records are released to an FBI agent without the client's knowledge of the disclosure. It is difficult to imagine that continuation of the treatment would be in the best interest of the patient, since the treating psychotherapist is, in fact, acting as an informant rather than as a therapist. This circumstance itself is a clear violation of the Hippocratic oath, which says "First, do no harm," and it probably runs counter to most professional codes of ethics and professional guidelines. According to some sources, as of 2005, the Department of Justice indicated that no requests for medical records had ever been made under the provision. At the heart of the conflict resulting from provisions in the Patriot Act is the tension between individual rights and communal or societal rights. Some experts have suggested resolving this kind of dilemma by terminating the relationship with the client. Others have proposed to include a disclosure regarding the Patriot Act in the Office Policies. While reasonable, these options do little to ease the clinical, ethical and legal complexities of the situation. Slightly good news: With the joint efforts of several professional associations raising serious concerns regarding privacy issues, a new legislation was signed into law on March 1, 2006. It includes: A requirements that FBI agents show prior written approval and reasonable, factual grounds to prove that the records sought under Section 215 are relevant to a terrorism investigation.  A requirement that requested records are identified as actually pertinent to the activities of a suspected terrorist or person in contact with a suspected terrorist.  Most importantly, the new legislation allows the recipient of a records request to consult with an attorney and file a challenge to a records request with an FISA court judge. In summary and as always, be informed and consult, consult and consult. For more information on the Patriot Act: http://www.zurinstitute.com/subpoena.html#patriot ^^Top of Page Guidelines that are provided above are meant to be aspirational and general, as they may not apply to certain situations, clients and settings. For more details go to zurinstitute.com/privacy.html . ^^Top of Page

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