Document Sample
					                           ETHICAL CONSIDERATIONS
                                  Mark Zalona

        If you are like many therapists, when you receive your newest copy of The
California Therapist, you turn first to the page listing the latest B.B.S.E.
disciplinary actions. We are curious to see if we know someone who lost his/her
license. So far, I have yet to see anyone being disciplined for receiving
Christmas fruit cakes or Chanukah latkes from their client during the holidays.
But in today's climate, you never know.
        Last issue, I proposed for your consideration the dilemma of clients
offering us gifts for the holidays. What is the harm of accepting a card, a box of
See's candy, an original work of art? When I've discussed the issue of client gift-
giving (not just during the holidays) with a group of therapists, there is a wide
range of opinion. Some think that there is no problem with accepting the
occasional gift and that more harm can be done to the therapeutic relationship
by refusing. Others refuse any and all gifts and tell clients it's just their general
policy. Most will agree that gifts can be used as grist for the therapeutic mill. (Of
course, most will agree that everything is grist for the mill). There is always the
danger of stepping over the line into a dual relationship when accepting services
in exchange for therapy but what is the harm of a client showing a little extra
appreciation for the hard work we do? You know, like a little tip for good service.
Well....the problem is when the client attaches different meaning to your
accepting the gift than they do.
        One rule of thumb some therapists use is that it is okay to accept a gift if it
is consumable--chocolate, cookies, and cakes. But, one therapist asked me,
"What if your client is a bulimic who binges on ho-ho's and brings in a box to
share?" Or, how about a recovering alcoholic who offers you a bottle of wine for
Christmas? What message are you giving by refusing, by accepting? There are
also more subtle gifts that we sometimes inadvertently solicit. For instance, what
if the client is an auto mechanic and hears or sees something wrong with your
car? Her offered advice is a "gift" to you which may in fact save you some
money. Early in my private practice career, I got into a discussion with a client
whose expertise was computers. I mentioned that I was having trouble retrieving
some lost files. He came in one day with some floppy disks to help me recover
my files. I was uncertain as to what to do. I did end up accepting his gift but it
made me feel uneasy. It didn't seem to interfere with the therapeutic relationship
but perhaps it was my guilt that made me unable to use the disks properly.

       Next, for your consideration and comment: How do money issues (i.e.
potential loss income) affect clinical decisions about which clients to take and
when to terminate?

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323
                          ETHICAL CONSIDERATIONS
                                 Mark Zalona

                When the Tao is forgotten, ethics are created.
                When ethics are forgotten, laws are created.
                                                                           Lao Tzu

        The column originally planned for this slot (the effect of money issues on
clinical decisions) has been temporarily postponed so we may bring you this late
breaking story. On Friday, March 25, at the irregularly scheduled CAMFT
meeting at India Joze, five members of the Santa Cruz ethics committee lead a
spirited discussion of a controversial issue: What are the limits of confidentiality
when dealing with a client who is HIV positive who is knowingly having unsafe
sex? Does Tarasoff apply when the possibility of bodily harm and death will not
be immediate? What is the responsibility, if any, of the therapist to report the
behavior to the probable victim(s)? Some at the meeting said it is part of the "job"
of therapist to teach and encourage our clients to live more "morally." Ah, but
whose standard of morality? Others said that we must not make value judgments
of our client’s behavior or else we risk damaging the therapeutic relationship. Ah,
but isn't our silence a way of condoning? A couple of therapists who had been
licensed a long time lamented the passing of the time when everything said in
the therapy room was confidential, when there was no mandate to report and
clients could be assured that nothing they said would ever leave the room.
        The discussion was heated and energetic. At the end, people seemed
grateful to have the opportunity to have a conversation about a topic which we
do not usually have enough time to discuss. Oftentimes, we are isolated in our
private offices and left alone to deal with our ethical dilemmas. Other
professional associations (social workers, licensed psychologists, medical
doctors) have tackled the issue of HIV and breaking confidentiality by producing
a set of guidelines or procedures to which their members can adhere. Some take
solace in such guidelines as an aid to doing the right thing ethically and
protecting themselves legally. Others feel uncomfortable with yet another
intrusion into the client/therapist relationship. Most at the March meeting wanted
the Ethics Committee to encourage the State CAMFT to write a set of guidelines
modeled on those of other professional psychotherapists. Someone expressed
their concern that State CAMFT investigate whether the malpractice insurance
company would go along with our guidelines since there is no legal precedent
yet. Another person wanted the guidelines to include all long-term communicable
diseases that could be spread knowingly through sex.
        I believe the discussions were fruitful and reflective of the complex and
litigious times in which we find ourselves. The most apt and succinct comment
made was when George Gottlieb supplied the above quote from Lao Tzu. For a
deeper understanding of these complicated issues we often have to look to the
ancient wisdom.

        Have you ever made a therapeutic decision largely influenced by
monetary considerations? Have you ever taken on a client, or were reluctant to
terminate with a client because you needed the money? When a client (or two)
cancels or doesn't show up, do you inwardly groan because you already had
plans for that money? It is the dilemma of being in business for oneself while
trying to give clients the best treatment and care they deserve. This is especially
true in these competitive, therapist-glut, managed-care times.
        During the 1980's, the so-called "Golden Age" of private practice,
therapists could make a very good living and not have to worry about having
enough clients. They would refer to others because a particular client did not
"feel" like a good match. Or, they knew another therapist had more experience
than they with a particular kind of case. In times of abundance it is easier to be
ethical and generous. As the economy tightens or a therapist has a financial set-
back, it might be harder not to "find" more things "wrong" with a client to justify
further treatment and therefore further income. Monetary considerations could
influence therapeutic decisions even before managed care.
        Now, most therapists I know have substantially less clients than they
would like. More and more interns with their M.A.'s fresh in hand are going into
private practice internships increasing the competition for clients in a small
community such as ours. If we sign up with a managed care company (if we are
"lucky" enough to get on the "board"), we often are given a limited number of
sessions for a less-than-our-normal-fee amount of money. A not uncommon
dilemma for a therapist: the assessment/diagnosis/uncovering of problems would
normally result in an agreement to see the client longer than the six sessions the
company has allotted. But that's all you get. The "sacred" relationship between
the therapist and client has been breached. A third party has triangulated into the
relationship in the person of the case manager. We are often faced with having
to terminate with a client when neither party desires it. We do not like this
intrusion on our independence. And yet, if we do not sign on with managed care
companies, we fear our referrals will dry up and we'll have to close our practice.
Once again, money can influence therapeutic decisions.
        The choices are not easy ones. We could keep going along with the
decisions of a company manager which can take more and more of our
autonomy away. Who should be making the decision about a client's treatment?
Is that something that should only be between the therapist and client? Or
should the entity that pays the bills decide when and how much treatment is
necessary and justified? We could all seek, or go back to, low-paying agency
jobs where our salary is not paid directly by the client. Or, we can see clients
outside the insurance system who want help but can only pay a fraction of our
usual fee. What's an ethical therapist to do?

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                  Soquel, CA 95073
                                   (831) 479-0323

                          ETHICAL CONSIDERATIONS
                                 Mark Zalona

                      Listening to the Dis-Ease in our Bellies

        As therapists, we try to teach our clients to pay attention to their own
intuitions, instincts, and inner wisdom. What I have been wondering about lately
is the times we therapists lose touch with our own intuitions, instincts, and inner
wisdom. Sometimes, due to our personal fears and anxieties, we forget what is
important. Many of us believe that the relationship between the client and the
therapist is the therapy. That is what makes it special and different from all other
types of relationships. This relationship is sometimes delicate and precarious
and we try not to let anything outside get in the way of the trust and bonding that
can occur (the main reason for confidentiality).
        And yet, under the onslaught of managed care and our fear of being shut
out of the marketplace for clients, we acquiesce to a third party (usually the
"case manager") invading the therapeutic relationship. Someone else decides if
we may see the client and for how long. Now the case managers are even
telling us how to conduct the therapy. Recently, after approving only 8 sessions
for an adolescent girl who had slit her wrists, a case manager tried to tell me I
should be paying more attention to substance abuse. But I hadn't asked for
case supervision and one of my areas of expertise is substance abuse. Does this
feel right in our bellies? No! We want to decide with our clients the course and
length of treatment. However, we go along because if we don't we may not have
enough clients because we may not be on enough "provider lists."
        The therapist "glut" and the fear of competition from our colleagues make
us ignore our bellies and do things against our better natures. I know of two very
close therapist friends who allowed the "managed care movement" to get in the
way of their heretofore supportive relationship. One did not want to share with
the other the list of companies to whom he had written in order to become a
"provider." He saw his friend as a potential competitor who might interfere with
his livelihood.
        Is this what we want to be driven to by third party payers? There will be
those who think it is only good business and sometimes you have to "go along to
get along." Perhaps they will be the ones who emerge the most [monetarily]
successful in this new managed care, or managed competition, era. Is this why
we became therapists?
        Another dis-ease about managed care is that some of us sign up to be on
provider lists agreeing to take less than our normal fees. If some want to hold the
line on salaries, there are others who will work for less in order to get client
referrals. This is strikingly similar to other labor struggles where corporations pit
one group of workers against another. One group bands together to obtain better
treatment or wages and the company hires "replacement workers" who are
willing to cross picket lines.
        And then there is the issue of confidentiality. There is no law preventing a
managed care company from sharing client information with their employer. The
case managers ask for increasingly more detailed information about a client's
"condition." We either provide it or risk not being authorized to do therapy. Some
therapists found some companies so intrusive that their bellies would not let
them work for those company anymore. We are asked to fill out forms, leave
messages on voice mail or have our phone calls about clients recorded without
knowing who or how many people will have access to the information. We have
to do a lot of ignoring of our uneasiness to go along with this assault on
        In thinking about these issues, I wondered if there would be others who
were listening to the queasiness in their bellies. There are and here are some of
their comments:

        "The insurance companies and their monster creations, the managed care
companies, have essentially taken control of our profession (and) the driving
force behind the managed care revolution is the financial interest of the
insurance companies, not the well-being of clients."
        "Managed care is damaging to the efficacy and integrity of
psychotherapy...unfortunate(ly) ...most mental health professionals seem to
regard managed care as...a 'done deal' to which we must all now learn to adjust.
... Managed care is an oxymoron. It has little to do with either quality or care.
...Consumers are waking up to repeated intrusions and invasions of privacy, and
restrictions of benefits and choices."
        "Patients are increasingly aware that there are good reasons not to use
insurance, even if they have some kind of coverage. They resent having some
clerk halfway across the country deciding how many sessions they can have,
and they worry about who will see the details of their treatment and their
personal lives that the insurance companies now feel entitled to demand."
        "Coping with managed care has saddened me in a way that goes beyond
the loss of financial security and autonomy. The only way managed care can
work is to force us to reduce the ambiguity in the consulting room to a series of
numbers with which the bureaucracy can deal. But this process threatens to
impoverish our view of our clients and our profession, and ultimately of

*All quotes are taken from therapists' letters to the editor in the July/August issue
of The Family Therapy Networker in response to a previous issue on managed

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323
                          ETHICAL CONSIDERATIONS
                                 Mark Zalona

"Some believe that it is never okay to be sexually intimate with an ex-client,
that you would never be able to 'overcome' the therapeutic relationship.
But what about a friendship?"

         Have you ever wanted to know what happened to a client long after
termination? In the old days, before managed care, we could see clients for as
long as they wanted. Sometimes this relationship extended over years and we
really were able to know them quite well. If we saw a client once a week, we
often spent more time with them than our closest friends. Then, suddenly or
gradually, they were gone from our life. "So what?" some may react, "if you have
feelings about this then it's a problem with counter-transference."
         Once, I had been seeing a couple for marital therapy. After many sessions
of little progress, the man finally revealed that he was involved with another
woman. The marriage eventually did fall apart. I only learned that because the
woman called me for a session after several months. She wanted help before
confronting her husband in a meeting with lawyers. She never called again after
that one session and I was left curious about what had happened. Many months
after that, I starting thinking about her and wondered if it would be okay to give
her a call to see how she was doing. Was it ethical? I called and found out she
was in a women's support group and doing quite well. She thanked me for calling
and I have never had contact again. It seemed harmless and was satisfying to
both of us.
         Lately, I have been curious about how another client is doing. I "saw" her
through a separation and divorce and came to respect and admire her greatly.
After over a year of therapy, she "late-canceled" and then never called. I wrote
her and left a message requesting payment and asked if she wanted another
appointment. She never responded. It is now 14 months since I last saw her in
therapy. I really want to know how she is doing but I'm afraid to call because I'm
uncertain about her response--complicated by the money she owes me. In a
different context, we may have become good friends.
         The reasons for the prohibition of most "dual-relationships" with clients are
obvious. Having a sexual or business relationship with a client could be the very
antithesis of therapeutic. The somewhat arbitrary "rule" is that another type of
relationship--romantic, friendship, etc.--is permitted only two years after therapy
has ended; (as if something magical happens after 24 months). Some believe
that it is never okay to be sexually intimate with an ex-client, that you would
never be able to "overcome" the therapeutic relationship. But what about a
friendship? With my former client, perhaps I should just wait 10 more months to
reach the target two years and not have to worry about the ethical implications.
What do you think? Have you ever become friends with a client after treatment?
        In graduate school, or perhaps from the popular culture at large, we
accepted the notion that therapists were supposed to be totally neutral
listeners/observers. It is a stereotypical tenet of Freudian psychoanalysis that the
clients' projection on to the psychoanalyst is a large part of what therapy is. Woe
to the therapist who "imposes" her/his personal beliefs unto the client. Well, as
so-called "objective reporting" in the media has proven to be an oxymoron,
likewise "neutral" therapy. We are not supposed to take sides when seeing a
couple, for example, but it is very difficult not to let our beliefs (projections,
counter-transferences) about relationships influence the course of treatment.
The Family Therapy Networker's issue on "Mending Marriages: What's Really
Best for the Children?"(May/June 1994) had many prominent psychotherapists
urging clinicians to make "no pretense of neutrality when couples are considering
splitting up." They were saying that we should be more explicit concerning our
beliefs about marriage and divorce to our clients.
        As with many things in therapy, acknowledging/clearly stating our personal
beliefs and philosophy (mainly to ourselves) helps us not to impose subtly, or
sometimes not so subtly, our "stuff" on to our clients. When we have not or can
not acknowledge that these beliefs are just our beliefs, the power dynamics
inherent in the therapeutic relationship makes this quite unfair, and sometimes
dangerous, to a client. I had someone come in looking for a new therapist after
over two years with the same one. He said that when he tried to terminate with
her, she told him that it would be a mistake because they had been doing the
same "karmic dance" in previous lives together for a long time. It would be better
for him if he stayed in therapy with her and worked it out "in this life". Now, I do
not happen to believe in past lives (although some of my best therapist friends
do) so I treaded softly by asking him if that was something he believed. He said,
"Not at all! That's just what she believes." He felt very angry that she was trying
to keep him in therapy in this way.
        Another tricky area is political beliefs. It used to be said that if you wanted
to keep your friendships (or family members), it is better not to discuss politics or
religion. This may be true of clients also. Sometimes clients will bring up issues
of the greater, external world that has been affecting them personally. My clients
have discussed being pained by and cried about the destruction of the rain forest
or their peers being sent off to fight the Gulf War. What if we, as therapists, have
strong beliefs which either agrees with or vehemently disagrees with our clients’?
In fact, during the Gulf War, our CAMFT chapter had a lively discussion about a
proposal by one of the members to put an ad out deploring violent aggression as
a means to solve problems. The argument that carried the day was that as an
organization we had to remain "neutral". We had to be open to doing counseling
with military families too. Many of us did put out an ad anyway but signed it as
individuals. I have wondered if seeing my name did affect any current or future
clients. But if we worry about that, we can never take a public stance about
anything even racist propositions such as 187 or the anti-gay Briggs initiative of
years ago. (It would have barred homosexuals from teaching in the schools).
        Speaking of homophobia, what do you do with a client who yells out, "I
don't want my son to grow up to be a faggot!" The father of one of my clients
who had been molested by his step-father had expressed just such a "fear". Do
you simply work with his pain and fear? Do you give him "neutral and objective"
information that the overwhelming majority of adults who molest children are not
gay and the gender of a molester does not determine your child's future
sexuality? Or do you confront his homophobia head on? (This is all assuming
that you have confronted your own homophobia).
       I think it is obvious that a therapist's political and religious beliefs and
personal value system can affect the therapeutic relationship. We are not, and
never can be totally objective. Our intention should be to deepen our awareness
of the complexities of the relationship to further therapy and not distort it.

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323

                          ETHICAL CONSIDERATIONS
                                 Mark Zalona

managed care company) WITHOUT THE ADVANTAGES.

       In this column, I have written about my ethical and therapeutic problems
with the managed mental health care system. I should not object too strenuously,
however, because the system certainly provides plenty of discussion material for
therapists about new ethical dilemmas they face. Take client fees for example.
That used to be a matter strictly between therapist and client. You had a set fee,
or a sliding scale, and made payment arrangements with the person(s) in the
room with you. Now, it is so much more complicated. If you are signed up with a
managed care company, the contract usually states (among many other long
and tedious clauses) that you are forbidden from seeking payment directly from
a client (other than a co-payment). Recently, a fellow M.F.C.C. called to mull
over this problem. She wondered what to do if the "company" would not cover
couples' counseling (because "the other person" was not on the plan) when she
had already begun treatment. Clients come in totally confused about what their
coverage is. Sometimes it takes weeks for them (or you) to find out. Are we
supposed to wait and wait before starting therapy? (We all know how important it
is to strike while the iron is hot. It often takes quite a lot of pain in order for
someone to ask for help from a therapist).
       The therapist who called me said that the "company" told her that the
client was guilty of fraud if they brought their partner in. As a therapist, are we
supposed to lie and say we only saw the individual? Just not get paid? We are,
in a sense, employees of the "company" but without guaranteed salary. Who is
responsible for paying us if not the client? It isn't the person who put us on the
"panel". It isn't even the case manager who does have approval power but not
financial. We have all the disadvantages of being an employee without the
advantages--they do not have to use us or pay us regularly.
       Another call I received recently from a therapist also involved a managed
care company. She was perturbed that a case manager's voice mail said not
even to bother leaving a message unless you had your client's Social Security
number, birth date, and diagnoses on all five axes. But what really boiled her
blood was when the case manager wanted to assign a diagnosis of "intermittent
explosive disorder" without, of course, ever having seen the client. ("Intermittent
explosive disorder"--312.34 DSM III R--is rarely diagnosed. It involves loss of
control without provocation that leads to violence against property or people. The
behavior is out of proportion to the person's psychosocial stressors). Is this a
case of long distance diagnosis by a frustrated therapist caught working for a
managed care company?
       As I said, the advent of managed care has brought on interesting ethical

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323

                          ETHICAL CONSIDERATIONS
                                 Mark Zalona

Editor sidebar: "...therapists who withhold their own inner life from the
(client) because they are afraid of burdening the (client) or being
inappropriate, do little for that (client) but teach (him/her) that the inner
world of feeling and passion is frightening and is to be avoided."

       I am happy to announce that the art of letter-writing is alive and well! (Or
perhaps I have finally written an article that is worthy of response). I have
recently received a three-page reaction to my review of Carter Heyward's book,
When Boundaries Betray Us. I wish publicly to thank Peter Coster for his
thoughtful, compassionate, honest and energetic reply to the book. I am gratified
to hear that there are others who are thinking about and troubled by the
sometimes artificial boundaries and pretense of neutrality that therapists erect
between us and our clients.
       Space prohibits me from printing Coster's letter in its entirety but here are
his major points: "The idea that a therapist can and should remain 'neutral'
response to a client's request for friendship or for anything else does an injustice
to the therapeutic relationship as a healing alliance between two persons." He
takes an honest look at himself and writes, "...what causes me to withdraw in the
therapeutic relationship is the fear of real intimacy. Because this fear is so
intense, it becomes confused with 'boundary violation', inappropriate sexual
closeness, or outright acting out." Coster strongly asserts that "therapists who
withhold their own inner life from the (client) because they are afraid of burdening
the (client) or being inappropriate, do little for that (client) but teach (him/her) that
the inner world of feeling and passion is frightening and is to be avoided." Of
course, "it is not appropriate to just blurt out everything one is feeling or thinking.
This does not produce intimacy. Rather intimacy is a delicate unfolding."
        Coster has captured and summarized the gist of Heyward's book from his
viewpoint as a therapist. Both say much about loosening the straight-jacket we
have allowed to be tied around us and which gets in the way of our (hopefully)
healing relationships with our clients. But I still have a caution. I do not entirely
trust myself/ourselves to work through the issues of transference and counter-
transference solely between client and therapist (as Coster suggests). Reading
accounts of therapists who ended up sexually exploiting their clients (see the
"When Therapy Does Harm" issue of the Family Therapy Networker) reveals that
they believed they had a "special" or loving relationship with the client. My
caution is that we seek support from our colleagues when we are confused,
frightened, etc. about our own feelings about our clients.

A potpourri of ethical issues:

1. Speaking of boundaries, here is a great oddity in the standards for "dual
relationships". Still on the books is the provision that you may not engage in a
sexual relationship with a client for at least two years after the therapeutic
relationship has ended. A new provision is that we may never supervise
someone who was once our client. Therefore, if I stop seeing a client today I can
be in bed with her/him on July 1, 1997 but I can never be his/her supervisor.

2. There was a discussion at the last Ethics Committee meeting about the need
for on-going or at least periodic consultation with peers about cases. Is it
somehow "unethical" to work solely on one's own in private practice and never

3. A legal/ethical question came up about the responsibility for reporting to CPS
a case involving a 17 year old pregnant girl who was being beaten periodically by
her boyfriend. If the boyfriend was over 18 and therefore legally an adult, could
he be reported for child physical abuse? It was complicated by the fact that when
a female is pregnant she temporarily becomes an "emancipated minor" for the
purpose of making decisions about the future of the pregnancy and medical
cure. (I believe this is still the case in California although other states have
enacted "parental inform" laws about abortion). If this girl was legally an adult
due to the pregnancy, could the boyfriend still be reported to CPS? We did a
"theoretical" with CPS and they said it was reportable. It turns out that the
boyfriend is also 17 and the girl has not yet divulged his name.

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323
                                ETHICAL CONSIDERATIONS
                                       Mark Zalona

("...we brain-stormed all the possible Situations in which we have found
ourselves with clients, or feared to find ourselves.")

What Do You Say To a Naked Client?

One day at the Spa, a woman has just emerged from the shower and is standing
at her locker with a towel wrapped around her. She is approached by another
woman, equally disrobed.

"Oh Hi, Jenny! Look Kristie! It's my therapist, Jenny."

Startled, Jenny can barely reply, "Uh, hello, Holly."

H: "My, you're looking good. Do you work out often?"

J: (Trying to get dressed as quickly as possible) "As often as I can."

H: "Wow, that's a great looking bra! Where did you get it?"

J: (Grabbing her stuff and hurrying off in a disheveled manner) "Look, I'm in a hurry. I have to go."

H: (To Jenny's exiting back) "Okay. Great to see you. I'll see you on Thurs."

         We had a little bit of improve. theater at Santa Cruz CAMFT's monthly
meeting with the Ethics Committee providing the theatrics. We (the Committee)
facilitated a discussion about the intricate web of relationships which are created
in such a small community as Santa Cruz. The dialogue turned into a "de-
briefing" of therapists' experiences and how to deal, emotionally and
therapeutically, with the possible entanglements/dilemmas these situations bring.
         First we brain-stormed all the possible Situations (beginning with "S") in
which we have found ourselves with clients, or feared to find ourselves. Those
included: Showers (at the Spa), Shopping (having our food preferences checked
out), being caught buying Sexy clothes, in contact through the Single ads, at a
Spiritual retreat, Swearing in public (or at another driver who turns out to be our
client),etc. Then we talked about overlapping community interfaces such as: your
ex bad-rapping you to potential clients, being friends with your client's friend,
having a client take your medical history at a local doctor's office, having your
child in the same class with your client's, etc. Since the smallness of Santa Cruz
makes these inter-weavings inevitable, imagine how much more this is true when
you are a member of an even smaller sub-community such as: the
gay/lesbian/bi-sexual community, the Latino/a community, the Jewish
community, the 12-step community, etc.
        We then had a very fruitful discussion about ways to handle these
dilemmas. Some therapists bring up the possibility of chance meetings outside of
the office during the first session. They let the client know that they will not
acknowledge them unless the client acknowledges the therapist first. If the client
is with a friend, it is up to the client to decide how to describe the connection. But
what if the therapist is with his/her significant other? Usually, we do not want the
client to know with whom we share our bed. This led into the topic of self-
disclosure. There was a general agreement that what we choose to reveal to
clients in session should always be dependent upon the individual client and its
therapeutic value (for the client, of course, not for the therapist). Oftentimes, as
the examples above illustrate, more is revealed to our clients by these
encounters than we would normally choose. That is another reason why it is
important for a therapist to make it a practice of bringing up any collateral contact
in the very next session after it occurred.
        Often times, an ethical dilemma arises when the interest of the client and
the therapist's self-interest conflicts (for instance, to reveal or not reveal
"personal" information). Counter-transference should always be heeded. Once
again, the value of being in a consulting group was emphasized as an aid to our
dilemmas, our issues. We all need a safe place to consult, to de-brief, and to
share solutions with other therapists. Last month's meeting with the Ethics
Committee was just a small example of how important it is to continue to have
these types of discussions.

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323

                          ETHICAL CONSIDERATIONS
                                 Mark Zalona


       What do the national economy, the health care and insurance systems,
immigration policies and discrimination have to do with the practice of
psychotherapy? (No, this is not yet another column about the evils of the
managed care system). There have been many discussions, articles and books
written about how the wider world intrudes on individual therapy and how
psychotherapists should, or should not, respond. Three recent cases have re-
introduced these issues for me.
        The first one involves a young man who has a B.A. in Urban Planning
from U.C.S.C. He originally came to me after receiving his second D.U.I. He is
bright, articulate, extremely well-read and creative in his writing and sculpting. He
decides that he wants to learn how to be a cook. So he gets a job in a local
restaurant and quickly moves from busing to dish washing to prep cook to main
cook. He acquires skills quickly and then becomes bored with them. Despite the
low wages and high cost of living in the political economy that is Santa Cruz, he
is able to save several thousand dollars (so he can move out-of-town) by working
six days a week and doing split and double shifts. I am aware that this talented
man wants to and should be making a valuable contribution to our society.
Where is the place he can put his talents to good use? Why aren't there the
types of jobs which would support and challenge him? Is it his fault? (He
wonders). Do I say something as his therapist to encourage him to look at the
larger picture; to help him realize it isn't his fault?
        The next case involves a middle-aged man who is self-employed and has
no health insurance. He suddenly discovers after a trip to the doctor's, for
something else, that he has diabetes and hepatitis C. He is stretched to his limit
financially and wonders how he will be able to afford the insulin, testing kits and
expensive tests for the hepatitis. After much strenuous searching, he is able to
find an insurance company which will take him but with very high premiums, co-
payments and deductibles. He waits for months hoping to get on a cheaper plan
which will allow him to find out how damaged his liver is. He lives with the
uncertainty and questions concerning what he did wrong. Do I, as his therapist,
mention something about the health care system in this country? Do I discuss
with him the fact that he would not be in this situation if the insurance companies
and others hadn't spent millions to defeat single-payer health care in California?
        The third case involves both discrimination and immigration policy. The
client comes in because he has recently learned he is HIV positive. Besides all
the other issues this diagnosis brings up, there is the question of who to tell. My
client is understandably concerned about other people's reactions. Will he be
fired from his job? Will his friends reject him? Should he let a person know on
the first date? He knows in his head that other's possible responses to him are
not his fault. But in his heart, it is difficult not to take it personally. He ends up
telling some family members, one or two close friends from his country of origin,
and me. The isolation and loneliness he feels is due to a culture which reacts to
AIDS just as others did long ago to leprosy, i.e., blaming the victim. In his being
overwhelmed in dealing with the disease, he forgets to "renew" his green card.
He has been in this country for over six years and has always worked and paid
taxes. Suddenly, he is "illegal" and fearful of the backlash against immigrants,
legal or not. But his priority is his physical well being. He will worry about his
immigration status later.
        This last client asked me something no other client has. He asked me who
I was going to vote for in the presidential election. Do I tell him about my decision
not to vote for Clinton after he signed a "welfare reform" bill which will send even
more children into poverty? Do I tell him how disgusted I am with both major
candidates who will do nothing (or make worse) the problems of health care,
insurance companies, immigration policy and AIDS treatment? I control myself. I
tell him I try to vote for the person who I believe will do the least harm. He

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323

                          ETHICAL CONSIDERATIONS
                                 Mark Zalona

       As therapists, we are asked to be in a state of meta-awareness, at least
part of the time. Besides just listening to the words of our clients, we have to be
observing their affect, tone of voice, body language, etc. We also need to be
aware of our own reactions; being keenly conscious of any counter-transferential
emotions on our part. Another, important part of our awareness must be about
the "therapeutic relationship." How does what we say and do impact the client?
Do we notice any transference issues? How much will self disclosure aid or
hinder the therapeutic process? (These, of course, are all generalizations with
different theoretical orientations emphasizing different types of awareness and
asking different questions). The point is, we are asked to respond to others (our
clients) in a manner unlike "normal" human intercourse. So what happens when
we decide to take off our masks? Shouldn't we always keep them on for fear of
the effects on our clients or even the people we clinically supervise?
       What I mean about taking off our masks is what Rita Townsend wrote in
the "Editor's Note" of the last issue of this newsletter. We are supposed to
present to our clients and colleagues (and ourselves?) the mask of selflessness,
serenity and professionalism. What I mean by keeping our masks on is what
Heather Turey wrote about in her article. We "edit our personalities" and only
show small portions of ourselves in the consultation room. Some of us had an
opportunity to take off our masks and unedit our personalities at the
Enmeshment produced show, "Shrink-Wrapped," which took place in June.
       We (the Enmeshments) knew that there were many talented, artistic
people among the therapist "community". We provided an opportunity, a venue,
to see behind the therapist mask. The event was billed as being "an evening of
entertainment by therapists, for therapist and their friends". From all indications,
it was highly successful and, in retrospect, I feel compelled to make some
comments as an "ethical therapist."
       Since a) most graduate schools have a requirement that all budding
therapists have some experience of therapy as a client and b) we therapists
usually feel comfortable going into therapy whenever we "need" to, there was a
good likelihood that some in the audience would be clients of some of the
performers. In fact, a message I received from a client canceling our
appointment contained the statement, "But I'll see you Sunday night at the
performance." I found myself having to ignore that eventuality because the show
must go on no matter who is in the audience. (Other performers also mentioned
that they had clients in the crowd). I wonder now what effect it had on my client
as I sang, goofed around and generally made a fool of myself and managed care
(I mean "fool" in the court jester kind of way).
       Some of us are more invested than others in keeping parts of ourselves
well-hidden from our clients. But some of us are interested (due to theoretical
orientation or personality) in breaking down the usual barrier between therapist
and client. We want to flatten out that hierarchy and let the client share her own
expertise on her life. Well, what a better way to break that barrier than to do
something vulnerable such as performing on stage; or, being a fellow performer
alongside one of our former clients or supervisees. (Yes, that happened also).
Some would say that this is not okay. Perform in another town if you must
perform. But what a great role-modeling - to put yourself out, to express another,
very important side of your personality; to show your client that risk-taking can be
       Next year, put yourself up on that stage.
Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323

                          ETHICAL CONSIDERATIONS
                                 Mark Zalona


        As a parent, I cannot imagine anything worse than the horror of losing a
child. I have to believe that therapy helps, but there are some losses from which
we can never fully recover, never completely heal. If your child is taken from you
by the actions of another, it is completely understandable that you would want
justice/punishment/revenge on the guilty. But does it bring your child back?
Since our criminal justice system has dropped any pretense of rehabilitation in
favor of punishment, what is the proper sentence for one who commits an
irresponsible, but not intentional, act which results in the death of others?
        The tragic case of 18 year old Bryce Kurek (who was recently sentenced
to eight years in state prison for driving drunk and causing the deaths of three of
his companions and the severe burning and maiming of a fourth) has evoked a
great deal of emotional response in the Santa Cruz community. It has also
caused me to wonder how we as therapists “should” respond if we had any of
the directly affected individuals (family and friends) in our offices for therapy.
First of all, it would be helpful if we could become clear what our personal
responses are. This tragedy evokes grief, sadness, anger, confusion, etc. It also
raises issues of crime and punishment (e.g. for what offenses should someone
be punished as an adult?) and how best to “treat” alcohol abuse in young
       I know none of the people directly or indirectly affected by the accident
(although I do know therapists who know them). I can only imagine the grief and
anguish of all the parents involved. As they are quoted in the Sentinel, most of
the parents of the victims talk about wanting “justice”. The mother of one of the
boys speaks of mercy, “It’s enough of a sentence that he knows until the day he
dies that he killed his friends.” What is the difference between these two
reactions? Why do some react more from the anger of their grief while others
come from their forgiveness and acceptance? And then there are Kurek’s
parents who are terrified of their son going to prison. Have the parents talked to
each other or are they separated in their pain? (These are neighbors after all).
       As in most court cases, not everyone will be satisfied with the sentencing.
(There was no question about the verdict since Kurek pled guilty). Personally, I
was disturbed greatly by the sentence (since I did not lose a child in this tragedy,
it would be unfair of me to judge the reactions of those who did). Although I do
not know Kurek, I have worked with teenagers for many years. An eighteen-year-
old may be legally an “adult”, but most people that age are years away from
knowing themselves very well. Or, as one therapist friend put it, their “souls are
undeveloped”. Through the pain, guilt and sadness of being the cause of
friends’ deaths, one can become “ensouled”. Rather than turn Kurek over to the
adult prison system for eight years, where he has a good chance of being
traumatized and/or of being criminalized, what if we figured out a better way of
giving this young man guidance instead of punishment? At the very least, the
California Youth Authority should have been considered. It is no picnic there but
at least he would have been with people closer to his own age and perhaps still
“redeemable” in terms of turning their lives around. The guards there would also
be more experienced in dealing with young people.
       Another, albeit probably unpopular, route would be for Kurek to do
community service with a purpose. What if Kurek were “sentenced” to working 8
years with people who had been maimed or burned in accidents? What if he had
to do public speaking to parents who lost their children to drunk drivers or to
teenagers about drinking and driving? It would be difficult for him to stay in denial
about his catastrophic actions if he had to be confronted with them every day for
years. He could be on “house arrest” with frequent urine tests so his partying
days would have to end or he would go to jail. Therapy? Of course, but at his
own expense. If we blow this opportunity (as it looks likely we will) to witness and
nurture the creation of a soul, what good to society and to himself will Kurek be
in eight years?
       Then there is the issue of “a culture surrounded by alcohol” (as one of
Kurek’s lawyers put it). How many of us have worked with young people with
drug/alcohol problems? How much therapy, out-patient, in-patient, 12-step
programs have we seen not change the behavior of teenagers? Will more
adolescents question their own use of substances because of the prison
sentence handed out in this case (“sending a message” as the criminal justice
system is fond of saying) or because they personally knew someone who died or
a friend of one of the victims? We do not often know the best way to reach
young people about their drinking/using but we cannot give up trying.
       Sometimes, we therapists are powerless in the face of such a tragedy.
There is some pain, some grief which will never entirely go away. We can
witness, cry with, even hold those who lost a son, a brother, a best friend. But we
cannot ever entirely take away their pain. Neither will putting the perpetrator in
prison for years.

Mark Zalona (MFC 16121) is past-Co-Chair of the Ethics Committee of Santa Cruz CAMFT.
He can be reached at:
                                2715 Porter St. Rm. 206
                                   Soquel, CA 95073
                                    (831) 479-0323