New Techniques in Psychotherapy: 1940s Edition

Well isn't this a precious video clip? Here we are, back in the 1940s, when humanity was discovering new ways to talk about our behavior that includes an understanding about how were once were effects  how we currently act.

We also get this fabulously delicious line: "Now tell me about your mother."

Confidentiality and the Unthinkable: Murder

Perhaps you've been in therapy at some point in your life. Your therapist--whether they be a psychologist, social worker, psychiatrist, mental health counselor, or marriage and family counselor--should have notified you about the nature and limits of your confidentiality.

I've been thinking about this a lot recently. The news report instantly got my attention. Anderson Cooper reported that a notebook that was mailed to a psychiatrist at the University of Colorado was handed over to the police. That notebook, made by the alleged killer James Holmes, detailed his plans for the murders in Aurora Colorado. More news has since come forward. The psychiatrist, Dr. Lynne Fenton, treated James Holmes for schizophrenia. He was at one point, her patient.

We don't know the nature of that treatment. We don't know how the journal was released to the authorities. Unnamed sources. That's what the news reports say. Unnamed sources leaked information that James Holmes was treated for schizophrenia and sent his psychiatrist a notebook that contained stick figure drawings of his plans for the massacre that left twelve dead and 58 wounded.

What is the nature and limits of confidentiality in psychotherapy? Here is what I tell each and every patient that walks into my office. I'm not a lawyer. Keep that in mind. This is my best understanding of the laws that govern my practice as a licensed psychologist in the Commonwealth of Massachusetts. The laws don't differ much from state to state.

What you say here, stays here. It is important to me that you know that this. As a licensed psychologist the things we talk about remain confidential except under very specific circumstances. I want to spend some time talking about this and I'd like you to spend some time asking me questions. Confidentiality means that I cannot and will not talk to other people about you and our work except under very specific circumstances that I will explain. This means your husband, wife, partner, friend, parents, or police can't call me up and ask about you. If they do, I say I cannot confirm or deny knowing you. As soon as I get a call like this, I will contact you and tell you. If you are under 18, your parents can ask about you, and have a right to know what we are talking about. If you are over 16 and under 18, you can tell me not to talk to your parents and I would have to respect your wishes. However, your parents still have the right to inspect your medical records.

That is the basics of confidentiality. I don't ever reveal information, except in certain special circumstances, about my patients. It is the beginning of a special relationship where a patient can talk about whatever they wish. Their fantasies, their fears, their hopes, their traumas, their crimes, and their crimes against others. I listen. I don't talk to other people about it. Without this basic trust no patient would ever feel safe exposing the contents of their minds, hearts, and souls.

Psychologists have a duty to protect people from abuse. This is what I say:

Here are the limits of confidentiality. It's important that you know them. I do not want you to find yourself in a situation where you talk about something and then have unexpected consequences because I have to take action. We can talk about this as much and as often as you'd like. You can ask me hypothetical questions should you want to know what I'd do in particular kinds of circumstances. If you talk about and identify a child under the age of 18 that is being abused, anyone over the age of 60 that is being abused, and anyone, of any age, that has a disability that  is being abused, I will have to break your confidentiality. It is important that you understand that if you identify the person being abused, or I can reasonably ascertain their identify from what I know about you, I will have to break your confidentiality and protect that person.

Psychologists have a duty to protect patients from committing suicide. This is part of what I say:

The second circumstance when I would have to break your confidentiality is if I have reason to believe you will kill yourself. This doesn't mean that I will immediately hospitalize you if you talk about having a dark night of the soul, or wonder what it would be like to not be alive. Many people talk about suicide and contemplate their own deaths. Many people are also chronically suicidal and do not require hospitalization. We can talk a lot about this, what this means and what it doesn't, and we'll work together to make sure you can talk openly about any feelings you have about suicide while also making sure you are safe.

Psychologists have a duty to warn and protect intended victims of homicide. This is what I say:

The last circumstance when I would have to break your confidentiality is if you are planning to kill someone. Often times people say "Oh my boss, I could just kill him." I understand that is a figure of speech. You wouldn't be hospitalized for that. However, should you have planned and and have intention to commit murder and you tell me about it, and you identify your intended victim or victims, I will have to take every action at my disposal to protect you from committing this crime and protect your intended victim. This likely means I will attempt to have you secured in a psychiatric hospital. If I cannot do this, I am required to warn your intended victims and am required to warn the police.

Think of what would have happened should that journal Holmes made was been found before the crime was committed. Lives could be saved. Traumas could be prevented. Dark Night Rising would be about Batman, not about murder. Our  movie theaters could feel safe.

None of this, of course, will ever happen. Nothing will undo the murder of twelve people and injuries of 58 others. Nothing can undo what has already happened.

Had Dr. Fenton had knowledge of the intended crime before it happened, she would have had an affirmative duty to protect and warn. We do not know what Dr. Fenton knew, and when she knew it. We only know that Holmes was in treatment at some point in time, and that a journal detailed the crimes arrived at the University of Colorado at some point in time.

What does a psychologist do when a patient has already murdered someone? What if the unthinkable happens and a patient of mine walks into my office, sits down on the couch, and confesses to a murder?

I cover this in my first session with patients.

If you murder someone, and then tell me about it, I believe that I cannot break your confidentiality. You need to understand that. I would have a lot of questions for you. We would talk about what you did, and how you want to move forward in making the right choices. This would be very difficult for me, however, your confidentiality would remain and it is my understanding that I would not be able to turn you in to the authorities. Any other crime you might be involved in, as long as it doesn't involve planning murder or the abuse of a child, person over 60, or a person with a disability, is not something that I can tell other people about. 

How could someone get my records? That's covered in the first appointment, too.

Your records are confidential, as is the contents of anything we talk about inside this room. If you give me permission to release information about you to someone, and we agree it is in your best interest, I will do that. I will release information without your permission if you are a risk to self, risk to others, disclose abuse that I am mandated to report, or if your decision making is impaired based on the symptoms of a mental illness. Short of that, I would need a court order from a judge to release information. Am not required to hand over medical records based on a warrant or a subpoena. 

I also share with patients how I break confidentiality in these circumstances. There is a specific and progressive order of steps that I take that escalate until I either am assured the individual is safe or I have progressively exhausted all means I have available to protect an individual.

So why am I writing about this? I believe I have no business, as a  member of the public, knowing that James Holmes was in treatment for schizophrenia. I believe I have no business knowing that he wrote a journal in which he detailed his plans for the murders.

As difficult and as unpopular as this might be, if I was his psychologist, I believe I would have the responsibility to hold onto this confidentiality and not release the journal or any information about his treatment until such time as I was served with a court order. 

Somewhere, somehow, Holmes lost his confidentiality. I think it was wrong that this happened. He had already committed the alleged crimes. There was no duty to warn or protect, therefore no ethical or legal reason to disclose the journal or information about his treatment.

There was every reason to protect his confidentiality. Not because of Holmes, mind you. We needed to do a better job of protecting Holmes' confidentiality because of everyone else that ever enters into a therapeutic relationship.

My work starts with a promise. I promise to keep your confidentiality and hold your secrets. I promise to do my best to keep you safe. I promise to keep those around you safe. This breach of confidentiality (whether a failure of the doctor, the university, a mail clerk, a student assistant at the health center...) makes every patient, everywhere, a little more afraid to reveal the contents of their minds, hearts, and souls to the professionals they entrust with their secrets. 

That promise, the most important promise of the therapeutic enterprise, was broken.

____
Updates

As I find specific information for licensed individuals in various jurisdictions I'll add them here.

Ohio 

(G) Divisions (A) and (D) of this section do not require disclosure of information, when any of the following applies:

(1) The information is privileged by reason of the relationship between attorney and client; doctor and patient; licensed psychologist or licensed school psychologist and client; member of the clergy, rabbi, minister, or priest and any person communicating information confidentially to the member of the clergy, rabbi, minister, or priest for a religious counseling purpose of a professional character; husband and wife; or a communications assistant and those who are a party to a telecommunications relay service call.

(5) Disclosure would amount to revealing information acquired by the actor in the course of the actor's duties in connection with a bona fide program of treatment or services for drug dependent persons or persons in danger of drug dependence, which program is maintained or conducted by a hospital, clinic, person, agency, or organization certified pursuant to section 3793.06 of the Revised Code.

(6) Disclosure would amount to revealing information acquired by the actor in the course of the actor's duties in connection with a bona fide program for providing counseling services to victims of crimes that are violations of section 2907.02 or 2907.05 of the Revised Code or to victims of felonious sexual penetration in violation of former section 2907.12 of the Revised Code. As used in this division, "counseling services" include services provided in an informal setting by a person who, by education or experience, is competent to provide those services.

Demons of Sixth Grade: Red Circles of Incineration

Image from National Geographic

I grew up fearing a demon. I wasn't alone. Many of us learned, whether in school or through the news, that this demon was out to get us. The demon was different than us. They didn't believe the same as we did. They wanted to hurt us, hurt us so much that they had these horrible weapons pointed in our direction. The demon was called the United Union of Soviet Socialist Republics.

A specter of nuclear war hovered right outside my young mind. I didn't know why the USSR was the demon. No one ever took the time to actually teach me anything at all about the USSR. I just knew I was supposed to be scared. I also knew that I wasn't supposed to like "those" people.

My knowledge of the USSR? Minimal. Really none. My eighth grade history teacher, known for coming to class in a Elizabethan period outfit, skipped the lesson on the Soviet Union to "punish" us. He was mad, for some reason now faded from my memory, and refused to teach us. "This will be important stuff to you some day," the teacher said. "You'll be sorry you didn't get the lesson. We'll sit here in silence today."

Yeah. My public school wasn't the most progressive experience. I've come a long way from Center Junior High School. Hopefully they too have come a long way.

We have new demons to fear now. The process, however, is still the same. The xenophobia and ignorance is still the same. Children raised in the world since the World Trade Center came down have been taught by fearful adults to enact xenophobic fears toward people in Muslim countries--and people of the Muslim faith who are our neighbors in our own country.

The cycle continues. Someday a new demon will rise and replace our fear of Muslim people. When we turn our eyes away from the Muslim world they too, might turn their eyes away from us. They'll grow fearful of another demon as shall we. 

We seem to be unable to find our way out of this cycle of fearing that which is different. 

You can find this same xenophobia in the movie Trinity and Beyond: The Atomic Bomb Movie. Narrated by William Shatner, Trinity offers up stunning visual imagery of the destructiveness of the weaponry. It provides an engrossing and terrifying spectacle of destruction. The movie fails to question why the bomb was really developed. Maybe the horror is enough. The demon unleashed from the atom speaks for itself.

I wish the documentary moved beyond "othering" those outside of the United States. The same tired old xenophobia is laced through the movie. The bomb was developed, as suggested in the movie, to end a terrible war with Japan. It also makes allusions to needed to protect ourselves against the danger of another more ominous other, the Soviet Union. The most haunting image of all was at the end of the documentary. Horses raced onto a mock battle field, faces and eyes covered with gas masks. Riding the horses were similarly masked human soldiers. When the mask was removed we saw the rise of a new other--the Chinese tested their own nuclear bomb.

The horrifying cycle continues. German. Japanese. Soviet. Chinese. Muslim. We can't seem to find a way to see the other as part of ourselves. 

Click here to watch the movie. 

We hardly ever talk about nuclear war now. Now we fear terrorist acts. Dirty bombs, suitcase sized nuclear destruction, or biological warfare. Destruction can come in an envelope loaded with anthrax, or as demonstrated yesterday in Aurora Colorado, can come while sitting in a movie theater. These are the new staples of fearful living.

When I was in sixth grade people were afraid of nuclear war. People were terrified. I was terrified. I remembered that terror last night when I watched the documentary

Man would unleash the destructive power of the demon locked within the very fabric of matter and plunge the world into the atomic age.

My sixth grade teacher Mr. Joe Smith, taught me about this demon within the walls of my classroom at Zellers Elementary School. He'd just come back from a workshop on teaching children about nuclear war. He put a map up on the board. Our school was ground zero. He drew circles around the school. The first circle represented the area that would be totally incinerated. Another circle represented total destruction. Some rubble might remain but every living thing would perish. The circles continued. Everything I knew was destroyed. Incinerated. Burned. Dead from radiation.

I had a vague notion about the people who had these terrible weapons pointed at my school. I didn't know why. Mr. Smith hadn't been taught to teach us about that. The cycle of fearing the other was passed on to me. No reason to know anything about the other (as then, of course, they would no longer be the other).

I was terrified. Maybe for the first time in my life.

I did something when I got home. I went home and sent away for a list of addresses of potential pen pals. I wanted to learn about those people who had weapons pointed at my school. I also sent away for information from organizations like SANE and FREEZE. I was far too young to actually volunteer to do anything, but I felt like I needed to do something. These bombs were pointed at my school and going to burn me up. They were going to burn  my family up, and everyone else, too.

I did not fully understand why I took these steps. I hadn't really thought about any of this until today. Looking back, it was the beginning of my superpower as a psychologist--a superpower that I wouldn't fully understand until decades later when I was working on my doctoral degree.

It was all there when I was sitting in my sixth grade classroom. With a red circle of incineration drawn over my head, I was launched on a path toward learning about connection. There under the fear of nuclear incineration, I found the need to make the other part of me, and to let the other make me part of them.

Can you make yourself vulnerable enough to find yourself in the other?

The Last Pictures by Trevor Paglen: Impermanence and Mindfulness

This morning I came across a project by Trevor Paglen. He will launch 100 images into space to serve as a lasting reminder of who were were when all that we are is gone. I'm looking forward to seeing the images--for both what is included as well as what is not. The answers to both reveal so much rich information about any given person's understandings of the world.

The project, of course, isn't really about leaving a memory of who we were. There is no permanence. While perhaps the satellite that carries these images as payload will be aloft for "billions of years," those billions of years will come to and end. The structures of the machinery will decay. The images will degrade. The light of the sun will end. All that is will some day no longer be. At least that which is, will no longer be, something that is a form that can be recognized as something that was once us.

Despite this truth of impermanence, we all struggle, in our own ways, to leave behind a memory. We wish to make some statement that we too were here. We wish to extend ourselves into the no-thing-ness and evade impermanence. We seek to quell our fears about non-existence.

Imagine for a moment a life without these fears. Imagine a life built around existence rather than fear of non-existence. I am--I am here--right now. Not--I was there. I was. Remember what I was.

So much of my work as a psychologist is about finding and recognizing those complicated moments in time where patient and therapist breathe into an experience and connect with the act of being present in a moment. It is a rare place to find--one in which we aren't what we did, we aren't what we will do, we aren't what we are doing. We are being.

Almost there. Take out the we are.

Being. That's it. That's all there is. Being. Not being now. or being later, or being before.

Just being.

Being.

Trevor Paglen - The Last Pictures from Creative Time on Vimeo.

Field Of (Broken?) Dreams

Field of Dreams, Tewksbury State Hospital 

Dinner is Served: Asylum Kitchens

When I returned to the abandoned Medfield State Hospital yesterday I got to thinking about how the little details that remain decaying on the property offer glimpses into what life was like for the patients and staff that lived and died working in this place. I discovered that my imagination is greatly helped if I simply peer into the windows of the buildings with windows that aren't completely covered with red painted plywood. Near the center of the campus is a building that appears to have been built in the the 1940s or 50s.  It is easily identified by a spray painted sign over a door. 

Here in the kitchens, some 2,000+ meals were prepared three times a day for employees and patients at the asylum. They grew and raised  much of what they ate. Medfield Public Library's Adults Services Librarian Mare Parker-O'Toole opened up her files for me yesterday. Within her files I discovered an invaluable presentation prepared by a nurse who started working at the hospital in 1952. Veronica Hill wrote:

The Farm House, which is across the street from the Medfield Complex, as completed in 1901 to provide living quarters for the head farmer and his family, as well as 14 farm hands and 30 patients. The farm was to play a very important role in the lives of the patients and the economy of the hospital for many, many years. It was finally closed in the late 1960s as it was no longer economically feasible. It was really a shame to see the farm house and all the farm lands quiet down and no longer be productive. This had been a great source of patient working and needless to say we, and I mean that collectively, at the hospital enjoyed their efforts and their hard work by enjoying their fresh vegetable, the eggs, dairy products, and etc. It was really something. The patients really enjoyed it and we enjoyed the outcome of their work.

The farms were indeed productive places. Below is a scan of the bounty produced by the hospital during it's first six months of operation in 1896. They sure ate a lot of pickles. There was enough so every staff and patient could eat at least 30 pickles that year.

I discovered that my imagination isn't the only thing I have going for me. I can look at small details on the abandoned grounds. I can forage in archives for oral histories and other documents that describe what life is like. I can also just simply peer into the windows of the buildings with windows that aren't completely covered with red painted plywood. Near the center of the campus is a building that appears to have been built in the the 1940s or 50s.  

It is easily identified by a spray painted sign over a door that says "kitchen." Let's take a peek.

If you visit, be careful when you peek. First, the vast majority of the buildings are falling apart and the wooden porches are rotting. The floors aren't able to support any weight. Additionally, there is a private security guard that randomly roams the property. He requested that I don't stand on porches (stable or not) to peer in windows. 

I've always had a listening problem.

The Views From There: Abandoned Lives Edition

Part of what I find so striking about the abandoned Medfield State Hospital are the small moments of decaying remnants that still reflect the experiences of the people who lived and died at this now abandoned asylum. While I walked through the grounds today, accompanied by an occasional turkey running off to the side of me and the sounds of cicadas surrounding me like a summer symphony, I tried to picture what it was to see these images when the asylum was bustling with life.

Here are a few of the moments that captured my imagination. What memories do you think are hidden within these images?

Happy Independence Day

Tips to Stay Cool

Our friendly therapy dog offers up some helpful tips on how to stay cool this summer.

Cambridge Turkey Orders Cold Drink

The View From Here: Sushine Edition

Sometimes a thank you comes in the form of a flower.

We too have lived

After my walking tour of the abandoned Medfield State Asylum property yesterday, I set out looking for the cemetery where many of the people who called the hospital home were buried. If you blink while driving along Route 27 you'll miss this sign that is obscured by greenery.

From the opening of the hospital in 1896 until the influenza epidemic of 1918, patients who died while in the care of the hospital were buried in one large anonymous grave at the Vine Lake Cemetery. Deaths were not uncommon at the asylum. The first annual report of the institution stated that 24 patients died in the first five months of operation.

From 1918 through 1988, the hospital buried patients in their own four acre cemetery. This is the cemetery that I visited yesterday. It is fitting, somehow, that the cemetery is difficult to find. The people buried here disappeared with a blink of the eye from the view of society. All that remained of their lives were fist sized stone grave markers engraved with a number. The person's catalogue number, the only memory of who they were, are in some cases erased from the erosion of water and wind. 

In other cases, the number remains but the records of who they were were long since lost. People--mothers, fathers, sisters, brothers, children of someone where banished from the view of society and left in the care of the state. All the remains of these individuals is a number etched in stone.

In 2005 a group of citizens including a troop of dedicated boy scouts. cleaned the cemetery, scoured public records, and raised funds to place gravestones in the cemetery that remembers the names of those who were erased from time. Many--though not all--of the lives of those forgotten are now remembered.

A newspaper article quotes a former hospital volunteer who said "I was surprised by the lack of respect shown to these people. It was almost like warehousing, it made it smooth and quick. It was to keep things anonymous. A lot of people felt the mentally ill people are not as important in life or death. It was a combination of factors, perhaps because they were considered less important than others in society."

I'm left to wonder the stories of these people lost to the cemetery. I wonder about the lives they lost and the families that have forgotten them. I also, at least in the case of Elvine Kiwisaun, wonder about the families that do remember them.

As I walked through the cemetery I thought about the collective importance of people like Fred Colson. Dead at aged 18. Perhaps he was considered insane for a developmental disability, masturbation, or hearing voices. Fred, and all the named and unnamed people lost to this cemetery, remind me the importance of witnessing and resisting any effort to devalue, repress, and forget the power of the human experience--normal or not, sublime or distasteful.

It isn't as if these forgotten lives were a thing of the distant past. The staff of the Medfield hosptial were reducing people to numbers in this cemetery as last as 1988. Here on the right, is among the last of the patients at the then called Medfield State Hospital that were forgotten and lost until 2005.

Spend a moment today thinking about what you aren't looking at. Turn your attention to the things you avoid. Look at what you think you cannot look at. We owe it to people like Number 650, Fred Colson, Robert Smith, and Elvine Kiwisaun. We owe it to ourselves.