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, 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 of 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 Clinical Update, May 2006 Humor in Therapy: Using it Effectively and Responsibly For an online course on Humor in Therapy: Click here. When I thought about the long list of health benefits associated with humor and found out there are over 100 theories on humor and almost as many types of humor, I realized that humor is no laughing matter.  I was also fascinated to discover that there is no agreement about what humor is, in the first place.  If one tells a joke well and no one laughs, does it count as humor?  If one laughs at a mundane joke after inhaling nitrous oxide or while nervous, is the joke made funny by the reaction?  And there is the ultimate question: Does God have a sense of humor? "Doctor, I have a ringing in my ears." "Don't answer!" - Henny Youngman Realizing that none of us have been offered a graduate course on the Clinical Application of Humor, I asked Jim Lyttle, Ph.D., MBA, who is a serious humor researcher, professor at Long Island University and an active member of the International Society for Humor Studies, to develop a new online course on Humor Therapy and to tackle the question of whether a laugh a day, indeed, keeps the doctor away.  He took the challenge as no joke and constructed a new, first-of-its-kind course on Humor Therapy. Following are some serious facts about Humor Therapy: Researchers say children laugh about 300 times a day, adults perhaps 15 times a day. The sound of roaring laughter is far more contagious than any cough, sniffle or sneeze. Humor and laughter can cause a domino effect of joy and amusement. Laughter is very powerful medicine. Some of the health benefits of humor and laughter include: Fosters instant relaxation and lowers blood pressure Boosts immune system. Improves brain functioning and protects the heart. When we laugh, natural killer cells, which destroy tumors and viruses, increase along with Gamma-interferon (a disease-fighting protein), T-cells (important for our immune system) and B-cells (which make disease-fighting antibodies). Laughter increases oxygen in the blood, which also encourages healing. "When you laugh, your mind, body, and spirit change" Mark Twain Mental health benefits of humor and laughter include:   Reduces stress, depression, anxiety and fear.   Elevates mood.   Increases energy and can help us perform activities that we might otherwise avoid.   Can be a safe way to introduce ourselves to others.   Laughter, like a smile, is the shortest distance between two people. It makes people feel closer to each other.   When we experience humor, we talk more, make more eye contact with others, touch others, etc.   Marriages and relationships can tremendously benefit from humor and laughter.   When people laugh together, they feel bonded and can better go through hardship together.   A healthy sense of humor is related to being able to laugh at oneself and a way of accepting oneself. Benefits of humor in therapy:   Enhances therapeutic alliance and increases trust between therapists and clients.   Helps clients feel good about themselves.   Helps clients gain perspective.   Humor can help clients' thought processes by helping them to get unstuck.   Helps clients cope with difficult situations, such as death and illness.   Helps clients accept themselves.  ("The older you get, the tougher it is to lose weight, because by then your body and your fat are really good friends." - Bob Hope)   Activates the chemistry of the will to live and increases our capacity to fight disease.   Humor can be used diagnostically.  Goethe said: "People show their characters in nothing more clearly than in what they think laughable." The kind of humor people use often shows the kind of people they are.   Laughter is cathartic. Concerns with humor:   It can be hurtful, demeaning, sexist and racist and a way to dominate.   It can be self-depreciating in unhealthy ways.   Laughing with others is an icebreaker, however, laughing at others is an icemaker. The 100 theories of humor can be sorted into three groups. Biological, psychoanalytic or relief theories that consider the function of humor. They explain why we laugh and what survival value humor has. Incongruity, surprise and configuration theories consider the stimuli for humor. They explain what makes funny things funny. Cognitive theories consider the response to humor. They explain how and why we find things funny. Types of Humor (partial list): Black humor, circular, connotation, context deviation, defeated expectation, denial, escape, exaggeration, expand metaphor, false reason, free association, hypocrisy, impossible, insight, irony, juxtaposition, logical fallacy, mimicry, name-calling, nonsense, paradox, personification, practical joke, projection, pun, reduce to absurd, reversal, riddle, ridicule, satire, self-deprecation, self-referential, simile, stereotype, trick and many others. Clinical Update, April 2006 Existential Psychology: Is it an Existential Angst or Anxiety Disorder For an online course on Existential Psychotherapy: Click here. I grew up in a post-Holocaust household where my parents replaced their belief in God with belief in humanity.  Dinners in my household have not been about the "soup of the day" but the "idea of the day."  Rollo May, Buber and Sarter were often served as the "Existentialist of the day."  Existentialism was the religion of the household at the time.  As a result, I have learned to identify my existential angst and to continuously attempt to come to term with my sense of loneliness and mortality.  As a clinician, I try to differentiate between depression and anxiety and, when appropriate, view human struggling in existential terms rather than DSM terms. It was very exciting when Dr. Kirk Schneider, prolific author and editor of Journal Of Humanistic Psychology, agreed to develop a new online course on Existential Psychotherapy. Here is a quick refresher about what existential psychotherapy is all about: In today's quick-fix, "efficiency" oriented mental health market place - where the emphasis is on speed, instant results and appearances - existential psychology reminds us that all this speed and all the purchases in the world would not provide us with meaning or even freedom. Existential therapy aims not at "patching people up," but, as Rollo May put it, "setting people free." Freedom within contemporary existential therapy is understood as the cultivation of choice within the natural and self-imposed limits of living. Existential humanism embraces the following values and principles: Freedom: The capacity to choose and the burdens that come with it. Experiential reflection: The capacity for embodied, here-now awareness and the capacity to create meaning. Responsibility: The capacity to respond, taking responsibility for one's actions and to act on that for which one becomes aware. Come to terms with our mortality. Come to terms with our sense of loneliness, even in the midst of community. Freedom to do is generally associated with external, physical decisions, whereas freedom to be is associated with internal, cognitive and emotional stances. Within these values we have a great capacity to create meaning in our lives - to conceptualize, imagine, invent, communicate and physically and psychologically enlarge our worlds. We also have the capacity to separate from others, to transcend our past and to become distinct, unique and heroic. Conversely, we can choose to restrain ourselves, to become passive and to conform to others. Existential-integrative therapy is one way to understand and coordinate a variety of intervention modes  - such as the pharmacological, the behavioral, the cognitive and the analytic - within an overarching ontological or experiential context. Experiential, in this context, puts an emphasis on four dimensions - the immediate, the affective, the kinesthetic and the profound or cosmic. Existential therapy, therefore, is not merely a fly-by-night technique to rid the mind of struggle, but a rigorous, intensive forum for the fully lived life. This course focuses on two contemporary trends within existential therapy:  existential-humanistic therapy and existential-integrative therapy. Existential-humanistic therapy derives from both the European emphasis on the tragic (yet poignant) limits of life, as well as the American emphasis on people's capacities to (partially) transcend those limits and to achieve a centered, whole-bodied vitality. Existential-integrative therapy is an effort to enlarge the conventional emphasis on experiential (i.e., embodied)  change in existential-humanistic therapy to include the diversity of modes (e.g, physiological, cognitive-behavioral, psychosexual) through which change may be facilitated. Existential-integrative therapy is thus a practical, interdisciplinary approach, which can address practitioners and clients of many orientations. Clinical Update, March 2006 Introduction to Humanistic Psychology For an online course on Humanistic Psychology: Click here. In today's climate of managed care and manualized techniques, there is a hunger for hands-on, personal contact. Traditional analytic and behavioral therapies don’t cut it. Therapies modeled from humanistic psychology are not only more effective but more needed than ever. As we stretch ourselves further and further in our race to keep up with the Joneses, we isolate and alienate ourselves from others. Many patients suffer from a sense of derealization, depersonalization and loneliness. Humanistic psychology directly addresses the human need for contact and connection, and reminds us that it is the human relationship and presence of the therapist that creates attunement and healing for the client. Consider the impact of the Baby Boomer generation: a large percentage of our population seek ways to avoid pain and the finality of aging and death. Billions of dollars are spent on plastic surgery, nutritional supplements and alternative therapies that promise extended life and the visage of youth. Existential and humanistic psychologies teach us how to confront mortality and create life in the face of the void. In this hustle and bustle world, many clients suffer from a lack of meaning in their lives. Humanistic psychology helps us understand how to help our clients discover meaning and purpose in work, relationships and everyday life. As we become an ever-more diverse nation, issues of culture, politics, spirituality and divergent morals and beliefs come to the foreground. We need therapies that permit clients to explore values and meaning so that they can find peace with these issues and their place in the world. While some therapies, such as the field of positive psychology, focus only on the search for happiness, humanistic psychology also includes exploration of the dark side of human experience. Given how many of us are plagued by ambivalent feelings and difficult choices, humanistic psychology offers a more well-rounded option and addresses the depths of the human condition. Finally, Humanistic psychology is client-centered and empowers clients to live authentically and reach for their highest potential. Clinical Update, March 2006 Dr. Thomas Szasz and The Myth of Mental Illness For an online course on Thomas Szasz: Click here. Many years ago 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 the ludicrousness of the request for me to determine whether the prisoner should be placed on suicide watch so he would not kill himself before the state had a chance to execute him.  Trying to ground my refusal and indignation, I came across Thomas Szasz's 1986 article, "The Case against Suicide Prevention," published in American Psychologist.  Twenty years later, a couple of months ago, I was able to tell the story to Dr. Szasz in person.  It drew a sweet affirming smile and an outraged look of recognition of the immorality of the situation. Today, we at the Zur Institute are celebrating our 50th online course, which is devoted to the work of Dr. Thomas Szasz, the world's foremost critic of psychiatric coercions and excuses.  It has been 45 years since he wrote his ground-breaking book, The Myth of Mental Illness. Thomas Szasz, author of 30 books, has been the scourge of the psychiatric establishment. Over the past four decades Szasz, an MD, has argued passionately and knowledgeably against involuntary commitment of the mentally ill, against the war on drugs, against the insanity defense, against the use of medications to "cure all ails," and for the right to commit suicide. Most controversial of all has been his repudiation of mental illness as an accurate label to describe problems of living. Regardless of whether one agrees with Dr. Szasz's views on psychiatry or not, I believe that it is important that every psychologist, social worker, family therapist, counselor and psychiatrist at least becomes familiar with his critical views.  Therefore, we have developed a new online course, entirely dedicated to Szasz's much-ignored and highly important work.  While many of us might have difficulty digesting and espousing Szasz's passionate beliefs, others of us can relate to Szasz's own famous words: "If you talk to God, you are praying; If God talks to you, you have schizophrenia.  If the dead talk to you, you are a spiritualist; If God talks to you, you are a schizophrenic." Here are some of Szasz's highly controversial ideas: Psychoanalysis is a moral dialog, not a medical treatment. Emotional and psychological symptoms do not reflect diseases of the brain and, therefore, are not indicators of mental illness. Involuntary psychiatric intervention is likened to imprisonment and is unethical and immoral.  Suicide is an issue of personal responsibility rather than organizational liability.  It is an act of choice, not a reflection of disease. The general public believes that if all human problems are defined as symptoms of disease, they become maladies remediable by medical measures and are easily resolved. Child molestation, domestic violence and many other abhorrent behaviors are crimes, not sicknesses. Separation of medicine and the state is necessary for the protection and promotion of individual liberty, responsibility and dignity. In many ways public health projects have the potential to impact many lives, but guarantee little to each individual. 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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