BOUNDARY CROSSINGS AND VIOLATIONS STFM Conference on Families
BOUNDARY CROSSINGS AND VIOLATIONS STFM Conference on Families & Health, Austin, Texas March 1, 2007 Amy Ellwood, MSW, LCSW Professor of Family Medicine & Psychiatry University of Nevada School of Medicine Las Vegas, Nevada ellwood@med. unr. edu
Objectives Learn differences among moral codes, ethics codes and administrative codes. Differentiate boundary crossings from boundary violations. Learn about licensing board complaint processes. Become familiar with research on disciplined, impaired professionals
Core Competency: Professionalism Honest, trustworthy, empathy, respect Sensitivity to varied cultures, gender, race Sensitive to issues of literacy, age, disability Ethical in patient and peer relationships Appreciates psychosocial attitudes of patients Accepts responsibility for own actions Adheres to confidentiality, academic integrity, duty to and responsibility for patient care.
Moral Codes Universal expectations for human conduct “ Thou shalt not…”
Moral Principles Autonomy: promotion of self determination Beneficence: promotion good for others Nonmaleficence: avoiding doing harm Justice or fairness: providing equal treatment to all people (Corey, Callanan, 1993)
Ethics Ideal rules for professional behavior made by members of that profession “Psychiatrists, psychologists and social workers are held to a higher standard” ………………. . Stephen Levine, MD, 2002
Ethics Codes Are designed to prevent harm to the patient/client. Do not require that a particular behavior always result in harm. Are based on the potential for harm. Endorse standards that transcend legal and constitutional requirements (Gabbard, 2002)
Example The Constitution guarantees freedom of speech. A psychologist, clinical social worker or physician would not betray confidentiality based on that right. The Nevada Administrative Codes give the legal minimum standards, ie: dual relationships ( 3 years for social workers)
Fiduciary Relationship Legal term: Therapist/Physician-Patient Relationship – Imbalance in power – The patient’s needs come before yours – You have more power – You are not allowed personal gain from the relationship – The courts can come after you (Gabbard, 2002)
Fiduciary Duty as Professional Standard of Care State legislature defines legal standards of clinical practice State licensing boards define practice requirements Ethics Codes define ideal rules for professional behavior
Nevada Revised Statutes (NRS) BASICS Failing to disclose conflict of interest Practicing beyond scope of license Failing to maintain proper records or altering/falsifying records Failing to report other professional in violation of chapter or regulations.
Basic Statutes Sexual activity with patient/family Disruptive behavior Violating trust for financial gain Failure to offer appropriate care for financial gain Discouraging second opinion Terminating care without adequate notice.
HIPPOCRATIC OATH 2500 YEARS AGO… “ Into whatever houses I enter I will go for the benefit of the sick and will abstain from every voluntary act of corruption: and further I will abstain from seduction of females or males be they bond or free…while I fulfill this oath and do not violate it, may I enjoy life and art, respected by all persons at all times, but if I transgress this oath, may the reverse be my lot. ”
NASW Code of Ethics Under no circumstances shall any clinical social worker engage in a sexual relationship with a client, supervisee, student, employee or research participant.
Other Ethics Codes www. apa. org/ www. aamft. org www. abecsw. org Principles of Medical Ethics, American Psychiatric Association www. agpa. org
Boundary Crossing A break of one of the rules of therapy that can and should be discussed Therapy continues and the episode can be skillfully used to advance the process (Stephen Levine, 2002)
Example A therapist was preoccupied with her own mother’s illness during a session. As therapist and patient got up, the patient asked, “ so what are you doing this weekend? ”. Therapist responded, “going to visit my sick mother in Colorado”.
Discussable At the next appointment, therapist let patient know she should not have burdened her. They beneficially explored patient’s reactions to therapist’s comments about her mother No lasting harm done It led to further discussion (Gutheil & Gabbard, 1998)
Boundary Violation Egregious and destructive transgressions It is difficult to discuss by therapist Therapist/physician is motivated to obscure his/her motives The patient is harmed (Levine, 2002)
Example Therapist who hugs patient after each session and says, “ I love you” Therapist who asks patient to pick up his/her dry cleaning Repeated disclosure of therapist’s own personal problems that burdens the patient Overt sexual contacts
Video #1 “ Some Women Are. . ” Tony kisses Dr. Melfi Boundary crossing ? Violation? (“Pax Soprana”, The Sopranos First Season, Episode 6, HBO Home Video, 1999)
Video #2 “ I Love You” Boundary crossing or violation? Is she going down the “ Slippery Slope? ” What are the transference countertransference issues? (“Pax Soprana”, The Sopranos First Season, Episode 6, HBO Home Video, 1999)
Video #3 Tony shows us the other side of his personality (“I Dream of Jeannie Cusamano” The Sopranos, First Season, Episode 13, HBO Home Video, 1999)
Licensing Boards Consider Context A patient trips leaving the office and the clinician catches patient in his arms to prevent the fall Clinician who drives patient home in his jeep during a blizzard in a prairie town may be judged differently than one who lives in urban area with a subway What is cultural norm?
Post Termination Sexual Relationships Most end for the purpose of having the sexual relationship Major psychiatric disorders require ongoing care The point at which treatment is ended is unclear The patient may assume differently (Gabbard, 2002)
Post Termination Sexual Affairs Patients file lawsuits when the clinician ends the sexual relationship You may not be able to control who you fall in love with but you can control who you fall in bed with Seek consultation/supervision
Duty of Licensing Boards Protect the public
NEVADA STATE BOARD OF MEDICINE Two board members review complaints If due cause, then formal complaint may order physical or mental examination of physician; consent is implied. Hearing within 30 days Due process not required Proof of injury not necessary
Formal Result of Complaint Dismiss charges in writing Probation with conditions Public reprimand Limit practice or supervision Suspend or revoke license Require drug/alcohol tx Fine or community service Report to National Practitioner Data Bank and Federation of State Medical Boards of the US Posted online
Nevada Board of Social Work Examiners Board members do not see complaint Executive Director (ED) reviews, letter sent to SW 14 days to respond or extension if social worker (SW) seeks legal counsel ED responds to SW and consults board counsel from Attorney General’s Office ED may use consultant
Decision: Three Possibilities Dismissal Preliminary investigation: gather information Complete investigation
Violations Follow-up letters Formal complaint filed Consent Decree ( Settlement Agreement) or Court if SW refuses to sign Consent Decree
Consequences Public reprimand: NASW NEWS/Web Probation for specific time Limit practice ie: no kids, elders Impose fine up to $5000 Order SW to pay all costs Order continuing education, supervision
Consequences Order Psychiatric or Medical Evaluation Suspend or revoke license Report to Discipline Action Reporting system (DARS)/Police Report to other states where licensed Report to other licensing boards May report to other country’s licensing boards (England, Scotland, Ireland) Post online
Professional Consequences Job loss Hire a lawyer. . take a year of work & $$ Malpractice may not cover licensing hearings Lose membership in professional organizations Loss of reputation & referrals New vocation; go back to school Many personal consequences!
Something to Ponder No one is invulnerable to boundary violations. We are all human. We could all go down that slippery slope. Be compassionate toward impaired colleagues but hold them accountable
What Were They Thinking? Are they? – Bad – Mad – Sick – Naïve – All of the above? – None of the above?
Explanations Poorly educated & naive Culturally determined by training program (Pope, 89) Oblivious to state statutes and codes Rationalize they do no harm “ I was helping the patient” “ It is true love”
Explanations Physical illness: CNS processes, dementias, cocaine or drug use, brain tumors, serious illness that generates sense of entitlement (Katsavdakis, Gabbard, Athey, 2004) Psychiatric illness: Psychotic states, mania, depression, paraphilias, addictions, Cluster B personality disorders (Levine, 2002)
Katsavdakis’s Study Menninger Program N=334 67% male 33% female Most frequent DSM-IV diagnoses – Mood Disorder 47% – Substance/Alcohol Abuse 15% – Personality Disorder 15%
Most Common Problems Leading to Referral Suicidal behavior Marital problems – Separation, verbal conflict, domestic violence, lying Work problems Boundary violations Substance abuse
Other Researcher’s Findings Those at Risk Non white Non board-certified Family Medicine Psychiatry and OB Low scores on MCAT Previously disciplined in medical school (Morrison, 01, Khaliq, 05, Cardarelli, 04, Papadakis, 05)
Least Likely to be Disciplined Women Hispanic and Asian physicians
Words of Wisdom Know your state’s laws, licensing board’s regulations and resources. Whenever concerns arise, try to understand them. Evaluate the source of the information. Attempt to identify all options for action Choose an option but realize you still have other alternatives. The goal is to maintain the highest standards of the profession for patients.
SUMMARY Transference/Counter-transference is ubiquitous in all relationships Clinician has fiduciary responsibility to monitor the relationship and understand transference-counter-transference. The fiduciary relationship will last beyond the end of treatment Seek supervision Balint Group
Curriculum Integration Professionalism is an essential competency Zero tolerance for misconduct Needs reinforcement in medical school, residency and beyond Practice management/ ethics Attend Board of Medical Examiners meeting
Resources for Impaired Professionals Talbott Recovery Campus 5440 Yorktown Drive Atlanta, Georgia 30349 800 -445 -4232 www. talbottcampus. com
Resources Menninger Professionals in Crisis Program 2801 Gessner Drive, Houston, TX 77280 800 -351 -9058 Efrain Bleiberg, MD Medical Director John O’Neill, LCSW Program Director Baylor College of Medicine www. menninger. edu
Resources Hazelden Springbrook Professionals Alcohol and Drug Addiction Treatment Program 1901 Esther St. Newberg, Oregon 97132 800 -257 -7810 www. hazelden. org/
Resources Mc. Lean-Harvard Impaired Professionals Program www. mclean. harvard. edu/patient/adult/pav. php – Pavilion Program, 2 weeks, $2800 per day all inclusive Ron Shouten, JM, JD consults on an out patient basis www. massgeneral. org/allpsych/Law/index. asp
Resource Dale Atkinson, JD – Executive Director, Association of Regulatory Boards – Represents Optometry, Pharmacy, Veterinary, Social Work, Chiropractic, Nuclear Medicine Technology Boards aandaatlaw@aol. com 847 -864 -0070 Frequent speaker for regulatory boards
Resources Michigan Department of Community Health Professional Recovery Program www. hprp. org/html www. michigan. gov/mdch/ Program run through private contract to five of the state’s professional organizations. Maintains separation from licensing boards. Operates under criteria established by Health Professional Recovery Committee. Members appointed by each licensing board plus two public members.
Resources Reports of Occupational Licensing Boards State of Nevada Hard copies with detailed reports available 775 -684 -6800 www. leg. state. nv. us/general/occupational/ Reports. cfm Check with your state’s board for reports
Nevada Revised Statutes and Administrative Code Nevada Board of Examiners for Social Workers http: //leg. state. nv. us/NAC-641 B. html Nevada Board of Medical Examiners http: //www. leg. state. nv. us/NAC 630. html http: //www. leg. state. nv. us/nrs-630. html
References American Psychiatric Association: Principles of Medical Ethics with Annotations Applicable to Psychiatry, Washington, DC: APA (2001) Borys DS, Pope, KS (1988) Dual relationships between therapist and client: a national study of psychologists, psychiatrists and social workers. Professional Psychology: Research and Practice, 20: 283 -293 Cardarelli, Licciardone J, Ramirez G. (2004) Predicting risk for disciplinary action by a state medical board. Tex Med, Jan; 100(1): 84 -90
Corey G, Corey M, Callanan, M. (1993) Issues in Ethics in the Helping Professions. Pacific Grove, CA: Brooks/Cole Publishers Elias EG, Keating AJ (1996) Clear and Present Danger: A Medical-Legal Dilemma, Maryland Medical Journal, 45: 2: 103 -107 Enbom J, Thomas C (1997). Evaluation of sexual misconduct complaints; Oregon Board of Medical Examiners, 1991 -1995, Am J. Obstet Gynecol, 176(6): 1340 -6 Fletcher CE (2001) Michigan’s unique approach to treating impaired health care professionals. J. Addict Dis, 20: 4: 97 -111
Gabbard G. (2002) Post-termination sexual boundary violations, Psychiatric Clinics of N. America, 25: 593 -603 Gabbard G. (2002) Psychology of the Sopranos, New York, NY: Basic Books Gabbard G. (2001) Commentary: boundaries, culture and psychotherapy. The J. of American Acad of Psychiatry and the Law, 29: 3: 284 -286 Gutheil TG, Gabbard G. (1998) Misuses and misunderstandings of the boundary theory in clinical and regulatory settings, Am J. Psychiatry 155: 409 -414, March
Gutheil T (1989) Borderline personality disorder, boundary violations and patient-therapist sex: medicolegal pitfalls, American J. of Psychiatry, 146: 5: 597 -602 Katsavdakis KA, Gabbard G, Athey G, (2004) Profiles of impaired health professionals, Bull Menninger Clin, Winter, 68: 1: 60 -72 Khaliq A, Dimassi H, Huang, C et al (2005) Disciplinary action against physicians; who is likely to get disciplined? Am J. Med. July; 118(7): 773 -7 Levine S, (2002) Boundaries: purposes, crossings and violations presented at 15 th Psychiatric Congress, Las Vegas, NV, October 28 -31.
Morrison J, Morrison T (2001) Psychiatrists disciplined by a state medical board. Am J Psychiatry, Mar; 158(3): 474 -8 Papadakis M, Therani A, Banach M et al (2005), Disciplinary action by medical boards and prior behavior in medical school, NEJM Dec 22; 353(25): 2673 -82 Papadakis M, Hodgson C, Teherani A et al (2004) Unprofessional behavior in medical school is associated with subsequent disciplinary action by medical boards, Acad Med Mar; 79(3): 244 -9
Norris D, Gutheil T, Strasburger L. (2003) This couldn’t happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatr Serv 54: 517 -522, April. Pope KS (1989) Teacher-student sexual intimacy. In G. Gabbard (Ed) Sexual Exploitation in Professional Relationships, Washington, DC: American Psychiatric Press
Reamer, F. (1992) The impaired social worker, Social Work, 37: 2, 165 -170 Ryder R, Hepworth J. (1990) AAMFT Ethical Code: dual relationships, Journal of Marital and Family Therapy, 16: 127132
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