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The Downside of Risk Management

Even if these risk-management principles are over the top, aren't clients better served by excessive strictness than too much laxity? How does it harm therapy in the long run?

In the first place, an obsession with risk management makes therapists refuse to treat people they could genuinely help, and avoid interventions that are genuinely useful. Some years ago, soon after moving to the small California community where I now live, I got a call from the mother of a child in my daughter's kindergarten class, whose father, a lawyer, was on a basketball league with me. This couple was in a crisis. The woman, already the mother of four children, told me she had an unplanned pregnancy and didn't know what to do. She was inclined toward abortion and her husband, who was pro-life, was against it. For obvious reasons, they had to make a decision within a few days. Could they come see me?

At first, I demurred. I said that, technically, this would constitute a dual relationship and that it would be inadvisable. Her husband then got on the phone and practically yelled at me. "That's why we called you! We know you—we've seen you with your kids, we've heard you lecture, we've seen you on the basketball court and your wife in the bleachers. We chose you because we knew we wanted to work with you." After telling them I'd get back to them, I consulted a philosopher-psychologist friend, Sam Keen—about as far removed from the risk-management zeitgeist as it's possible to be—who was just as annoyed with me as the father had been. "You come from generations of rabbis, who for thousands of years have counseled people they knew. You've spent time sitting with shamans in Africa, who not only know the people they counsel, but know their ancestors, and the spirits of their ancestors. What's your problem, anyway?"

I called the couple back, made an appointment, and they came to see me at my home for the next five evenings as we thrashed out the issues raised by the pregnancy. In the end, we found a way to resolve the dilemma that they could both live with, and which actually strengthened their relationship. This work was a wake-up call for me, making me realize how out of touch the culture of risk management and emotionally-distanced psychoanalytic principles are with the way real human beings live their lives. Somehow, as a profession, we've created this myth that it's better for people who need help to look in the yellow pages or online directory than to turn to somebody whom they may know and trust.

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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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