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Paradoxically, excessive risk management tends to increase the rate of complaints about therapists. How can this be? As we've seen, as more and more-risk management practices infiltrate the field, they gradually insinuate themselves into the definition of the standard of care—lengthening the list of behaviors considered inappropriate or downright suspicious. For example, for a long time, risk-management advisors have recommended that therapists carefully bill for all the time that therapy takes—neither underbilling nor overbilling. So, therapists who don't charge for some sessions, bill for hour-long sessions that actually last two hours, or simply forget to send an invoice often find that, according to risk-management principles, their sins are as grave as the usual suspects—self-disclosure, nonsexual touch, gifts, out-of-office treatment, and dual relationships. It's suggested that they're suddenly giving treatment that's below the standard of care.

Even more perverse, rigid risk-management rules can actually contribute to the exploitation of clients. The rules mandating in-office-only treatment and no dual relationships tighten the isolation of the therapeutic encounter, both physically and psychologically—creating a hermetically sealed little world in which the therapist has all the perceived power. As we know, child and spousal abuse usually occurs in isolation, as does the exploitation of people who join cults. Similarly, exploitation by a therapist of a client doesn't happen in the public arena, but in the sacrosanct privacy of the office. Therapists are actually less likely to exploit those with whom they have some kind of connection—through family members and friends or in the community beyond therapy. When implemented with care and integrity, dual relationships with clients and the familiarity that follows are likelier to deter exploitation than invite it.

Finally, when therapists confine themselves to strict risk-management behavior, they also risk blunting their own creativity, spontaneity, and sensitivity to their clients' best interests. It can be hard even to establish a therapeutic alliance with a client if you're too frightened of what might happen to allow yourself some flexibility. Case in point: I saw a young man, referred to me by his family after a drug-induced, single psychotic episode that landed him in the hospital. When I met him, he neither wanted to be in therapy, nor saw any reason for it. He was unpleasant, sarcastic, uncooperative, and uncommunicative. Working with his parents, uncle, and brothers, I discovered that, like me, he loved to play basketball, so I suggested we meet on the basketball court for our next session. He was taken aback, but regained his swagger and sized me up as if to say, "What can an old man like you do on a basketball court?" At the next session, on the court, after a few minutes of warm-up, we decided to play one on one. Trailing 1–5 in the opening minutes and breathing hard, he turned to me and asked, "How old are you?" To which I responded, "We're here to play, not talk." Eventually, his energy picked up, his game improved, and his connection with me intensified. After a couple more games, at his suggestion, we walked across the street to a coffee shop. Now, he was doing most of the talking. Therapy had begun, and it continues with great progress—on and off the basketball court.

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stephen144  - Appreciative of clear thinking   |Registered |2011-02-25 13:19:06
I appreciated this article and your presentation on Digital Ethics. You made a
convincing argument and a clear distinction between standard of care and risk
management... very useful.

Thank you.
ivkennedy  - LCSW   |Registered |2011-02-24 10:22:07
Dr. Zur, Your presentation on digital ethics has been so helpful. The
information is good. Your emphasis on the importance of therapeutic competence
rather than fear and risk management offers more possibilities for solutions to
these dilemmas. Your ideas are refreshing and show you are a curious and
creative clinician. Thank you.
ggro@comcast.net  - The ethical eye   |Registered |2011-02-24 09:08:15
This is the clearest article on ethics that I've ever read. It is a much needed
rebuttal to the fear mongering that is so prevalent today. My thanks to the
author for both his learned and common sense thinking.
snordquist  - Thanks for clarity   |Registered |2011-01-23 00:22:30
For a new PsychoSocial Rehabilitation Practicianer working with children and
adolescents, I found freedom and wisdom in learning the ethical boundaries,
learning the importance of good records, and consulting with trusted colleagues
for advice. I'll be reading more of your articles at your website.
mitelpunkt   |2011-01-05 20:58:11
I don't remember who said that "there are patients that we build a set to
treat them, and patients that we treat them to build a set".
The most
impressive change in a psychotic patient acurred once that a made an "acting
out" inviting him to a drink. After this event, very significant in
repairing his (and mine) relation with his father, he never again felt inot
psychotic states!!!
I was then affraid of bringing it to supervision, I never
did it, but it was a truely therapeutic act.

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