By Danny Wicentowski
By Lindsay Toler
By Lindsay Toler
By Danny Wicentowski
By Anne Valente
By Lindsay Toler
By Ray Downs
By Lindsay Toler
Marie Clark walks into the consultation room chuckling. A little boy just came by to see whether her ten-year-old son was at work with her. The minute the boy walked into the waiting room, all the men got up and left.
They were sex offenders, waiting for their state-mandated group therapy at Clark's Behavioral Science Institute.
"He thought he scared them," she explains. "He probably saw their faces -- they are not supposed to be in the same room with children." She chuckles again. "Sometimes they think we set them up, but we don't."
Clark sits down in a straight-backed armchair, feet flat on the floor, knees well apart, braced for anything. Her red pantsuit clashes with the room's powder-blue serenity, and she glares at the floral sofa. "I hate pillows," she says. "When I picked that out, I didn't realize it had all those pillows."
She played college basketball, and even at age 48 she has an athlete's physical presence -- heavier now but solid, without squish or billow. As for her personality, it's as bold and sure as a slam-dunk, and it vibrates with the same energy. Too restless to sit behind a desk, she usually roves around the office, loses her coffee along the way, finds it hours later, gulps it cold. She can spin every detail of BSI's $500,000-a-year operation on one fingertip.
Clark always dreamed of owning her own business. She started BSI in 1988 after six years spent directing Missouri's first sex-offender program, known as MoSOP, for the state corrections department. "I wrote the Missouri Sex Offender Program," she says proudly. "Nobody knows the history of where all this came from but me." Her eyes darken. "They're changing the program now. Jim [LaBundy, chief of sex-offender services] thinks I do 'shame-based therapy.'"
Tilting her head, she adopts a syrupy tone: "'Oh, they are so ashamed.'" Then she leans forward. "No, they're not," she says. "They're caught."
Though "sex offender" reads as a single vile concept, the category takes in everyone from the brutal rapist who forces sex on strangers in a sadistic lust for power to the drunken fraternity pledge who coulda sworn his date was willing. A sex offender is anyone convicted of a sex offense -- from indecent exposure to sodomizing a five-year-old. Unless they're classified as sexual predators, offenders eventually wind up back in the community. If they have served their full sentences, they need only register with the state. But if they're on probation or parole, they're required by the Missouri Department of Corrections to receive therapy until they're "off paper" -- released from state supervision.
That's where Marie Clark comes in. Along with a handful of other providers in the St. Louis area, Clark offers group-therapy sessions for every offender who's still "on paper." (Clark works with about one-fifth of the estimated 450 sex offenders now in treatment here.) Offenders must pay for their own treatment; BSI charges the going rate of $150 per month. Therapy typically goes on for about five years. There are also sixteen-week "nonoffender" courses, which must be completed by a "supervisor" -- a friend, relative or paid stranger who agrees to take charge of the offender in public situations. In addition, Clark works as a consultant, presenting workshops all over the state. She won't reveal her fee for these presentations, but consultants with far less cachet command well over $1,000 a day, plus travel expenses.
Past participants say BSI's therapy sessions can be brutal. Fred Jones (a pseudonym) says that at his first BSI session, "Marie barged in, handed this guy a piece of paper and said, 'Sign this.' It was a confession that he had skipped sessions and withheld funds from BSI. He looked at her and said, 'None of this is true.' She threw the paper down, took her pen and threw it across the room and ordered him to crawl over, get the pen and crawl back to sign the paper. Then she started mentioning her close relationship with his parole officer. She got him so scared that he crawled over and signed it."
Clark denies the account: "I've never done anything like that, never in my life! And 'withheld funds'? You can't enter our office without paying. It says on the wall: 'Payment due at time of service.' You don't pay, we won't see you. You can't come in."
She does, however, recall other incidents Jones relates. For instance, the time she "came into group yelling at the top of her lungs," telling an offender who'd gone with his supervisor to the St. Louis Science Center -- technically in violation of the agreement he'd signed with BSI not to go anywhere that children frequent -- "that he couldn't possibly be that stupid and she was sure he had victims left behind at the Science Center now." He says she'd "point to people and shout, 'Child molester! Pedophile! Exhibitionist!' and say how despicable they were. When one man was recounting his criminal act, which was a misdemeanor, and was very much ashamed of himself, she said, 'You should be disgusted, I hope you vomit all over that white shirt you're wearing.'"
Responds Clark: "I don't know about yelling at the top of my lungs. I do raise my voice, I will not lie to you about that. But in this particular incident there was no reason to." As for the vomiting, she says, "I've never told anybody that. The guy was in total denial; he said he was not a sex offender like the others, and so I went around the room saying, 'Yes you are, and you are not the only one.'"
As far as Clark is concerned, denial is a boulder that must be shoved out of the way, and everything else is a pebble. For Jones, whom Clark says she transferred to another group after he started tape-recording her sessions, the treatment was degrading. "You can confront people because you care about them or because you hate them," he says. "Marie Clark stimulated a spirit of hatred."
Clark knows offenders lie -- "I don't care if they are twelve years old," she'll tell you. "We don't believe 'I've only done it one time.' We get a mix in the group of how many times you have been caught." That's why she goes at them so hard. "Once you get people to take responsibility for their own behaviors, then you can work on their self-esteem, because they can say, 'Yes, I did this.' Until then, I'm saying, 'What did you do?' and I'm gonna say it every week until they get off of it."
She's also willing to take matters into her own hands. One former client, she says, refused to tell his second wife that he'd molested his son during his previous marriage. "She had a nine-year-old daughter," Clark recounts. "We called our lawyer and said, 'We're goin' out on that limb,' and then we called her in and told her. She packed her bags early the next morning.
"I brought another guy in and said, 'Tell your mother what you did,'" Clark continues. "She said, 'Why are you making him tell those lies?' He was crying, 38 years old. Child molesters cry all the time. That's why we don't bring them in this room, because we have Kleenex in here. 'Waah-waaah, I was molested myself as a child.' Well, we are not talking about you. We'll get to you -- because you have to address their issues -- but that's not the focus now."
She sighs. "They are very immature. When they get here and say, 'I don't have money to pay,' I'll go to group and go to the big board and say, 'Let's do a budget here, because I want this money. How much do you spend on such-and-such?' Many still live with their mothers. We have caused them to move out. You talk about attorneys calling! We've gotten grown people don't know what size pants they wear."
Not all Clark's clients leave angry. "I owe BSI my life," says one former therapy participant. "Marie might be a little abrasive, but she does have your best interests at heart. You don't realize that right away -- it could take months. But if you are in recovery and you haven't reoffended, how the hell could she be too tough? I mean yeah, she's a bitch and she's money-hungry, but today I'm successful, and I used all the knowledge that she taught me."
Says another former client: "After a while I started loving this whole therapy thing. I just became really, really interested in it." He laughs dryly. "Then again, if you rebel, you are never going to get out of there. She knows a lot of people, has some kind of connection with Missouri.
"She wasn't one of my favorite persons when I first got there," the former client adds. "She always had this attitude, let me say, bitch. But that's not really Marie. She is not this totally bad bitch you would think she is. She is great and wonderful. And you can't fool her."
Clark's colleagues see it differently. "Marie can get down and dirty; she doesn't do a lot of psychobabble, and she's not pompous like the rest of us," says a local therapist, who speaks on the condition that his name not be published. "She's a great entertainer. But she humiliates and dehumanizes her clients to make them admit -- and then nothing positive follows.
"Everyone wants to hate sex offenders," the therapist continues, "and Marie's a very boastful, strong woman whom no one has ever challenged. I don't know that anyone's willing to take her on."
From 1982 until 1988, Clark worked for the Missouri DOC, where she set up the state's first sex-offender program. MoSOP's modus operandi consisted of gathering offenders into groups and hammering at them until they exhibited new ways of thinking and behaving. Clark still has her handwritten drafts of the principles she insisted they memorize: "Problems will be the focus of group work, not strengths.... Assume the worst. Never trust your thoughts or actions because they haven't worked very well yet.... Don't waste time with WHY the problem exists or with WHO caused it." Nearly two-thirds of all participants failed to graduate from the program.
In recent years MoSOP has reinvented itself, housing the state's 4,000-plus offenders in a "therapeutic community" and integrating treatment plans as individualized and multifaceted as sexual behavior itself. "The old MoSOP wasn't clinical; it was more like 'beat 'em up,' says Jim LaBundy, the state's chief of sex-offender services. "Heavily confrontational, what I would call a shame-based program. Now it's humanized. We see the whole person, not just the offender. That doesn't mean we don't hold them accountable. But healthy people are less likely to relapse."
Clark, meanwhile, has tailored her methods along the lines of the old MoSOP. Law-enforcement officers love her because she has worked "inside the wire." She speaks the same tough, vigilant language they do, doesn't coddle or make excuses. She watchdogs her clients' behavior like a prison guard, setting conditions stricter than any judge would impose -- and requiring clients to sign an elaborate contract at the start of treatment that precludes them from suing for violations of their rights. And she often testifies as an expert witness for the prosecution.
Whereas many therapists protect the boundaries of group sessions in an attempt to create an atmosphere of trust, Clark welcomes officers of the state's Board of Probation and Parole to sit in on her group-therapy sessions. Veteran supervising officer Karen Tindall says about one-third of her caseload consists of rapists who got probation without ever serving time. Her primary goal isn't their personal growth, she says, it's keeping them from reoffending -- so she saves her toughest cases for BSI. "She holds them so accountable," Tindall says. "They just don't fool her."
Most Missouri regions have a sex-offender-treatment coordinator -- a licensed clinician who monitors therapists' credentials and methods. St. Louis has Mary Davis, a former supervising officer for the probation-and-parole board who now serves as the local sex-offender coordinator for the DOC. Davis acts as the liaison between the department and the therapists and also evaluates the providers' programs, reports and credentials regularly. In the year she has had the job, Davis has cut the list of local state-approved providers from about fifteen to just five.
Davis says she values Clark's decades of experience and willingness to collaborate with the board. When she first worked as an officer back in 1988, Davis says, it was Marie Clark who taught her everything she needed to know about sex-offender patterns and treatment. Now Davis is nearing completion of a master's degree in social work, and she has arranged to do her internship at BSI. Local therapists arch their eyebrows at this close alliance, given Davis' control over who receives state approval and case referrals. "I don't see any conflict of interest," counters Davis, noting that her job only involves auditing the therapists, not doing therapy herself.
Complaints to the state licensing board are confidential, but Clark freely admits that at least eight or nine have been filed against her. One came from Anthony Schuham, a licensed counselor who was shocked when BSI deemed his client a bad risk despite his having scored within the normal range on a psychiatric test. Clark recommended that the man be incarcerated. "Basically, my concern is that the Behavioral Science Institute plays fast and loose in its interpretation of psychological test data, and in its 'therapeutic' practices," Schuham wrote last spring to Pamela Groose, executive director of the State Committee of Psychologists, elaborating on the formal complaint he filed in 1999. "This is not a game of horseshoes in which 'close counts.'"
Paul D'Agrosa, the attorney who represented Schuham's client, prevailed on the judge to ignore Clark's recommendation and give his client probation. "He moved to Texas, where they're traditionally tough on sex offenders, and he's going through sex-offender therapy with flying colors," reports D'Agrosa, flipping through a file of monthly progress reports. "His clinical status is 'very low risk for reoffending.'"
D'Agrosa is one of nearly a dozen defense attorneys whose ears steam at the mention of Marie Clark. "I have children of my own; I'm no advocate of sex offenses," chimes in attorney Dan Juengel. "But I don't see what BSI is doing as positive in any way. I've heard nightmare stories from my clients about Marie Clark. We don't refer our clients there any more; we ask the judges to send them to a different counseling agency."
Adds another attorney, who asked not to be identified: "There's a significant amount of hostility generated in the classes at BSI, a lot of threats about revocation of probation. I think part of it is to humiliate the people so much, they could never stand to be back there. I've gotten that sense from Clark's program more than anyone else's."
What frustrates defense attorneys the most is the Catch-22 they say is written into Clark's program: If a client has pleaded guilty to a particular act but Clark feels he needs to be admitting to more, she stays on him until he does. If he refuses, she says he's in denial and reports to the state that he is making no progress in treatment -- whereupon his probation or parole can be revoked and he can be sent to prison. If, on the other hand, he admits to worse than what got him convicted, that too is noted in his file and relayed to the judge when it's time to decide whether to release the offender from state supervision.
Mark Robinson, a counselor who has worked with sex offenders, notes that not only is it possible for someone to be wrongfully convicted, but defendants also sometimes plead guilty to crimes they didn't commit in exchange for probation, rather than risk a trial and a stiff sentence. "One guy was worried that he'd be convicted regardless, so he waived his right to a trial and plea-bargained, but without ever confessing to the crime," says Robinson. "He was booted out of Marie's program because he wouldn't confess to something he said he didn't do."
Lawyer Scott Rosenblum puts it bluntly: "My experience with Marie Clark is that she's more interested in getting these guys to admit to something, even when they have steadfastly maintained their innocence, than she is in actually administering the therapy."
Rosenblum still marvels at the faith of the probation-and-parole officer who told him, "I have never heard of someone being wrongfully convicted -- never -- in a sex case."
The complaints filed against Marie Clark are essentially moot: The state of Missouri cannot impose discipline or revoke her license, because she's not a licensed therapist. "My problem's passing the test," Clark says cheerfully. "One time they told me not to put 'therapist' after my name. In 2000, they told me to practice as a 'psychological assistant' or something. I don't even do therapy, so I don't care."
Yet when Clark teaches classes for the Missouri Baptist Children's Home, the facility distributes a biography that says, "She specializes in the treatment of adult and adolescent sexual offenders and the treatment of incest families." A probation officer's report from 2002 refers to Clark as the offender's "therapist." Her company's name sounds like that of a research center, and indeed BSI offers a long list of psychological services. Yet Clark's staff consists of a receptionist, two therapists and Clark's partner Christie Lynch, who holds a bachelor's degree in criminal justice and comes in once a week to do intake interviews. (A second partner, Priscilla Grier, died of cancer two years ago.)
"Marie does everything," says Lynch. "I'll call her in and say, 'Can you talk to this guy -- is he getting by on me?' and she's amazing. She'll just ask a few questions and walk out and say, 'He did this, this and this; he's as guilty as guilty can be.' She knows what to ask, and she gets those certain questions answered the way she's expecting, and it's just another confirmation. Guilty, guilty, guilty."
State records reveal that one of Clark's therapists, Ramona Prater, has not been licensed by the state since 1996. Clark says Prater showed her a license that doesn't expire until September. "I thought my license was in order, but it is not," Prater confirms. "As soon as I learned it was not in order, I quit practicing. I'm not trying to do anything illegal."
Sex offenders who have gone through BSI say the therapists run the groups but Clark sets the tone, storming into the sessions a few times each evening to yell, curse and throw her clipboard. Clark says she occasionally visits the group sessions, and she describes case after case in which she has decided the tone of treatment, determined what disclosures must be reported to a parole officer, ordered that a wife or mother be coerced out of denial, judged whether a client is lying and so on.
Judith Becker is professor of psychology and psychiatry at the University of Arizona and past president of the Association for the Treatment of Sexual Abusers, the professional organization whose standards now govern Missouri's treatment system. "The importance of licensure is that there is a governing body to oversee the therapist's practices," Becker says. "Licensing bodies have ethical codes, and people have to abide by those codes. When someone has no license, a client has no recourse."
Clark did try, twice, for licensure as a marriage and family therapist. She was denied for the second time this past August because she did not meet the education and supervised-experience requirements.
A few years ago, somebody tried to explain Clark's approach by speculating that she was once attacked by prisoners.
Absolutely false, says Clark: "Never even had a fingernail broken."
She grew up in a southern suburb of Chicago and attended Eastern Illinois University on both academic and basketball scholarships. She majored in math and chemistry but foundered in college algebra during her freshman year, and by spring her parents withdrew her with a severe ulcer. "When I came back, I was scheduled to do finite math and I didn't know a way around it," Clark recalls. "A friend said, 'Change your major; then you can take what you want' -- and we were standing in front of the psychology building.
"Once I got involved in psychology, that was it," Clark continues. "The professors were friendlier, more accessible. The math professors were like The Paper Chase. But the psych profs wore jeans and put their feet up on their desks. It helped me to relax."
Soon Clark was taking graduate-level courses and teaching. One of her professors, Sue Stoner, remembers her as an entrepreneur even then: "We didn't have Xerox machines, so she had this machine in her dorm room, and she'd make copies to sell to the other kids."
Clark says she always wanted to own her own business. "My vision was to have a private practice: individual and family therapy. Wives whose husbands don't want them to work -- life issues." She laughs. "I probably would have been bored out of my mind."
Instead, she earned her master's degree in one year and went to work at Kankakee State Hospital in northern Illinois. "You hit the ground running, and I mean literally," she recalls. "'Here's 156 clients -- see you later.'" The patients were so severely ill, Clark says, that after she went to see One Flew Over the Cuckoo's Nest she decided she'd wasted three bucks: Her job was far more intense.
She later learned that the staff had bet she wouldn't last four weeks. "Young black female psychologist," she shrugs. "But I'd get there at 6 a.m. sometimes, stay till 7 p.m. I wanted to help these folks. A lady on suicide watch took a hairbrush and cut her wrist clean through. Later I had a client at BSI who said he'd cut his wrist. I said, 'What happened?' He said, 'The blood shot everywhere.' I said, 'Then you really did cut your wrist.'"
She looks off into the middle distance, remembering again. "I cried at least once a week at Kankakee. My parents said they'd pay for me to go back to school, because they hadn't taught me to not get so upset. Other psychologists gave off this air of having it all under control. I was, like, 'Aw, God, what did I miss?'"
After three years and several promotions, she began sending out résumés and found four job openings in St. Louis. "One said to be a psychologist working with sex offenders with the newly passed law. I didn't know one thing about sex offenders. Zero. I knew they were bad people, they committed rape. In the interview they said, 'What are your thoughts about working with child molesters?' and I said, 'Child molesters?' They said, 'They're sex offenders too.' I said, 'Well then, child molesters it is.'"
As director of MoSOP, Clark designed the program from scratch, trained staff statewide and wrote policy upon policy, loading up on conditions and waivers. "There were 82 lawsuits against me. I've been in every federal court in the state. But we never lost, because the inmates had signed forms.
"I have those same forms here," she adds. "They just say BSI."
After Clark covered MoSOP's backside, she gave the program teeth: "You gotta remember, I was 27 years old. They would come to me and say, 'We have a murderer who's also a rapist -- will you treat him?' I felt honored. I said, 'Yes, if we can make parole release contingent upon successful completion of MoSOP.' And 30 days later they had implemented that."
Meanwhile, she was rifling through big-city phone books at the public library, tracking down authors of journal articles and asking them questions. "I called up Gene Abel -- he was the penile-plethysmograph man," she mentions, referring to a procedure for measuring arousal. "He wanted me to use one of his machines, but I said, 'Gene, I just can't be hookin' up no penises.'
"And after about three years, people started calling meup."
Spend an hour with the three therapists at Professional Psychotherapy Services, another state-approved local provider, and sex-offender treatment spins around like a stage set to reveal a different world. Psychologist Roger Gennari speaks in a voice that stays gentle even when he's outraged. He believes it's possible to challenge and probe without attacking, humiliating or shutting down clients' emotions.
Gennari refuses to comment on Clark's program but readily explains the methods employed at PPS. "Untrained therapists don't know how the hell to do what we're doing, so they say you can't do it," he says. "If we react with compassion and acceptance, then they feel safe to express themselves." That doesn't mean tolerating the behavior, Gennari adds quickly. "Acceptance isn't predicated on 'Everything you do is fine.' It's predicated on 'You are a human being like me' -- because if I haven't worked on my empathy, they are not going to work on theirs."
Len Powers, a former clinical director at Masters and Johnson, is one of the two licensed therapists who works with Gennari. "When someone discloses something that is painful or personal, we deal with it in a way that encourages him to continue talking about it," Powers says. "We don't shut people down if they get emotional. Once you shut somebody down, they may not get back there for a long time. In group this week, a guy disclosed being abused as a child -- how that changed his relationship with his parents and with men in general. Everybody else in that room has molested a kid. They are seeing the results of what they did, 25 years later. That's much more powerful than if we sat there and pointed it out."
When an offender's mother insists her son is innocent, the PPS therapists don't feel obliged to confront her; they just don't permit her to serve as his supervisor. If a client denies, distorts or lies, they take careful note but don't attack. Nor do they make elaborate rules to control a client's wardrobe or budget or force him to get an apartment on his own.
"The direct prescription of behaviors tends to produce compliance, not deep change," Gennari explains. "And compliance breeds hostility. It also lulls the community into a false sense of security, when all the dynamics of abuse are still going on underneath."
PPS therapists emphasize that 90 percent of sex offenders can be treated, but they screen the pedophiles and rapists who fall into the other 10 percent out of their groups. Clark takes them. Overall, she estimates, 85 percent of her clients are in some form of denial. "We have a man right now, he's been arrested, like, eight times for exhibitionism, and he says, 'But I'm not a sex offender.' OK, what do you do with that? Do you say, 'Aw, let's talk about your life'? No: 'You're a liar!'"
Until the late 1990s, no one paid much attention to sex-offender therapists' styles. But studies undertaken at Her Majesty's Prison Service in England found that "in both community and prison programs ... therapists who treated clients with respect, challenged supportively, and displayed empathy toward clients, generated far greater behavioral change than did more authoritarian, confrontative, and unempathic therapists."
A team of Canadian researchers discovered much the same phenomenon and recommended that "[sex-offender] therapists pay attention to the influence of their behavior in treatment and attempt to adopt a more empathic, warm and rewarding style.... Similarly, an excessively confrontational style should be eliminated."
One of the Canadian researchers is Yolanda Fernandez, clinical director of Rockwood Psychological Services in Kingston, Ontario. "When I travel and train therapists, those who are married to the confrontational model claim it works," Fernandez says. "And it does work, for some things. Both forms of therapy got equivalent decreases in treatment-specific goals, like taking responsibility for what you've done or reducing cognitive distortions. What the confrontational therapists didn't get were more generalized effects, like reductions in hostility, reductions in anger, reductions in rumination and increases in empathy."
Marie Clark counters that BSI's goals include all those aspects. "We do see a big problem with empathy," she concedes. But she argues that the problem lies with the sex offenders themselves and is not a function of BSI's approach.
Judith Becker, the former ATSA president, says what's important is to treat clients with respect without letting them slide away from accountability. "You have to hold sex offenders accountable for the behavior," Becker says, "but the therapeutic relationship is very important. The client has to feel a degree of comfort and trust in order to disclose important information the therapist needs to develop a plan for treatment.
"There are degrees of confrontation," Becker adds, speaking not about Clark (whom she doesn't know), but more generally about the range of styles within the profession. "Some people actually yell at their clients. But if someone yells, all you hear is the screaming, and you have a physiological response to that screaming. In the face of heightened anxiety, it's very hard to integrate information."
Clark says she has succeeded with clients other therapists couldn't reach. Conversely, other therapists say people who have gone through Clark's program come out raw: They know the lingo, but there has been no real change. These therapists believe Clark's cynicism can be a self-fulfilling prophecy.
Fred Jones, Clark's pseudonymous former client, agrees. Jones, who underwent treatment with another therapy group besides Clark's, says that in the other group "the attitude is: 'You can probably never completely change, but you can definitely control yourself.' Marie's attitude is 'It's just a matter of time until you do something heinous.'
"It affects you," Jones adds. "You have to protect your own hide, and that makes you extremely cautious and anxious. And she preys upon that vulnerability. Just keep admitting you did bad things, that's the goal: Admit it. Admit it."
A woman who went through one of Clark's nonoffender classes shudders at the memory: "She said she wished all sex offenders were dead; she'd dance on their graves. And then she did a little dance. I think she should be ashamed. And so should the people who take her word for everything."
Clark says that if she didn't believe offenders could be helped, she would have quit the field years ago. "Even though we have a certain ... what I call 'approach,' we continually reassess our program. Our goal is not to degrade the client. Our goal is to try to get them to accept responsibility in a manner we believe will be productive for them in the future. We can't get moral values into a 40-year-old, but we can tell them how to behave. We can tell them that how they think is much, much different from other people."
Mark Schwartz, a nationally recognized psychologist who directs the Masters and Johnson clinics, says that when he started working with sex offenders, he was "more like Marie. I'd be really confrontive and really go after them, like addicts. But that's not the solution."
Now, Schwartz says, he asks why; he probes for trauma and pathology and welcomes disclosures. He says he treats clients with respect and has always received respect in return. But he burned out a few years ago and withdrew his name from the state-approved provider list.
"Our society does not want to be compassionate," Schwartz sums up. "What Marie does is actually much more popular. You fool with her, and you will pay the consequences -- that's the typical prison mentality." He pauses for a moment, then concludes with a more deliberate tone: "Treating people abusively is not a good way of doing therapy at any time."