Evaluation of the Professional Who has Crossed Boundaries


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Evaluation of the Professional Who has Crossed Boundaries

  1. 1. Evaluation of the Professional Who Has Crossed Boundaries Gary R. Schoener Licensed Psychologist & Exec. Director Walk-In Counseling Center Minneapolis, Minnesota www.walkin.org
  2. 2. EVALUATION SITUATIONS <ul><li>Administrative or Supervisory Role – info. or complaint leads to the need to assess the situation; </li></ul><ul><li>Professional misconduct has been established by evidence or admission – Is rehabilitation is possible? ; </li></ul><ul><li>Impaired or Offending Professional requests help or Medical Council or Employer requests Rehab. </li></ul>
  3. 3. What Type of Cases? <ul><li>Sexual contact with patient was the original focus of this work, but today it can include: </li></ul><ul><ul><li>Sexual talk; sexual harassment </li></ul></ul><ul><ul><li>Social relationships via email </li></ul></ul><ul><ul><li>Mixing roles; over-involvement </li></ul></ul><ul><ul><li>Pattern of boundaries crossing </li></ul></ul><ul><ul><li>Emotional breakdown; alcohol </li></ul></ul>
  4. 4. BOUNDARY CROSSINGS <ul><li>Myth of the Slippery Slope : There is not good evidence that one boundary crossing leads to another – however, if boundaries are being broken down there may be a succession of crossings. </li></ul><ul><li>Myth of the Small Violation : Some times a seemingly minor crossing is ignored – is it the beginning of a major breakdown or the one visible sign of it? </li></ul>
  5. 5. OVERVIEW <ul><li>Investigation – complaint/report </li></ul><ul><li>Review of patient records; </li></ul><ul><li>Review of personnel data; </li></ul><ul><li>Interview of professional; </li></ul><ul><li>Psychological & clinical testing; </li></ul><ul><li>Collateral interviews; </li></ul><ul><li>Formulation – review with prof. </li></ul><ul><li>Report and recommendations </li></ul>
  6. 7. Investigation of Complaint <ul><li>Even if accurate, stories do change, and memories change; </li></ul><ul><li>Details about entire relationship are critical– even simple facts; </li></ul><ul><li>Words can be misleading; </li></ul><ul><li>Blanket denials are meaningless – ”I did not have sex with that woman” President Bill Clinton </li></ul>
  7. 8. False & Misleading Complaints Rare but they do occur. <ul><li>Mistaken Identity </li></ul><ul><li>Misunderstanding; </li></ul><ul><li>Cognitive Distortion; </li></ul><ul><li>Purposeful Fabrication; </li></ul><ul><li>Exaggeration – real violations, but patient embellishes story </li></ul><ul><li>False Memory recovery </li></ul>
  8. 9. Review of Chart/Records <ul><li>Review of treatment records ( warning : poor documentation ) </li></ul><ul><li>This may include items from patient: emails, phone records, calendars, </li></ul><ul><li>This may include photographs, alleged gifts, diaries, etc. </li></ul>
  9. 10. Private Knowledge <ul><li>Knowledge of the professional’s body </li></ul><ul><ul><li>Scars , etc. in pelvic or other areas; </li></ul></ul><ul><ul><li>Unusual physical characteristics; </li></ul></ul><ul><ul><li>Pubic hair color (if different from head) </li></ul></ul><ul><li>Knowledge of inside of professional’s home, etc. [but be careful of internet] </li></ul><ul><li>Inaccuracies do not necessarily invalidate; caution patient to not guess </li></ul>
  10. 11. Review of Personnel Data <ul><li>Personnel file; </li></ul><ul><li>If necessary, with release, may need to check past employment situation; </li></ul><ul><li>Any history of complaints/discipline? </li></ul><ul><li>Ask practitioner & then obtain data; </li></ul><ul><li>Sometimes information from internship has been relevant. </li></ul>
  11. 12. Interview(s) of Practitioner <ul><li>“ Not as a Stranger” – the challenge of evaluating a colleague; </li></ul><ul><li>Countertransference; </li></ul><ul><li>Admissions of guilt don’t explain things – you need details; </li></ul><ul><li>Revisit discrepancies and claims by patient and/or colleagues; </li></ul><ul><li>We cannot detect truth or falsehood </li></ul>
  12. 13. Clinical Inquiry <ul><li>Personal history, family background </li></ul><ul><li>Education & training; motivation to enter the field; </li></ul><ul><li>Work history; accomplishments & problems; strengths & weaknesses </li></ul><ul><li>Health & mental health history </li></ul><ul><li>Specific situation regarding the complainant </li></ul>
  13. 14. Psychological & Clinical Testing <ul><li>Challenges of testing a professional; </li></ul><ul><li>Psychological testing: </li></ul><ul><ul><li>Psychopathology (e.g. MMPI-2) </li></ul></ul><ul><ul><li>Projectives & other personality </li></ul></ul><ul><ul><li>Cognitive & memory if relevant </li></ul></ul><ul><li>Screening for drugs & alcohol </li></ul><ul><li>Neurological evaluation if relevant </li></ul>
  14. 15. General Evaluation Issues <ul><li>Remember that your goal is a parsimonious explanation for what happened; </li></ul><ul><li>No one element of the evaluation is definitive; </li></ul><ul><li>Psychological testing, for example, can at times “miss” </li></ul>
  15. 16. Collaterall Interviews <ul><li>Spouse or partner of the practitioner; </li></ul><ul><li>Practitioner’s therapist(s); </li></ul><ul><li>Colleagues or supervisors; </li></ul><ul><li>Other service providers who were treating the complainant; </li></ul><ul><li>At times someone connected to the complainant such as a spouse. </li></ul>
  16. 17. Formulation <ul><li>A reconstruction of what happened </li></ul><ul><li>Factors related to practitioner’s adjustment or functioning; </li></ul><ul><li>Factors related to the timing and situation of the practitioner; </li></ul><ul><li>Factors related to the case or the patient – note on the “Perfect Storm Case” </li></ul>
  17. 18. Situational Factors <ul><li>Situational factors are often present </li></ul><ul><li>Distinguish the degree to which they are key to what happened; </li></ul><ul><li>Examples: </li></ul><ul><ul><li>Death of a loved one or child, </li></ul></ul><ul><ul><li>Physical or psychological breakdown </li></ul></ul><ul><ul><li>Divorce </li></ul></ul><ul><ul><li>Acute psychological breakdown, </li></ul></ul><ul><ul><li>Family crisis, bankruptcy </li></ul></ul>
  18. 19. Lacunae in Training <ul><li>Work outside normal expertise – e.g. a GP doing therapy </li></ul><ul><li>Difficult patient – beyond expertise </li></ul><ul><li>Lack of training regarding transference/countertransference </li></ul><ul><li>Failure to obtain consultation or supervision with difficult case </li></ul><ul><li>Lack of awareness of boundaries </li></ul>
  19. 20. Social Ineptitude <ul><li>Difficulty in “small town” environment such as rural area, campus, etc. </li></ul><ul><li>Difficulty in special situation – e.g. work in a correctional setting, work with prisoners, adolescents, etc.; </li></ul><ul><li>Weak in terms of managing boundaries in social situations; </li></ul><ul><li>At the extreme, mild Asperger’s </li></ul>
  20. 21. Compromised Executive Functions <ul><li>Cognitive impairment due to senility or brain injury; </li></ul><ul><li>Psychosis – acute or chronic </li></ul><ul><li>Severe alcoholism or drug addiction </li></ul><ul><li>Severe mood disorder; </li></ul><ul><li>Bipolar Manic ( note on the “manic defense” ) </li></ul>
  21. 22. Impulse Control Problems Lack of Empathy for Impact <ul><li>Sociopath or psychopath </li></ul><ul><li>Narcissistic Personality Disorder </li></ul><ul><li>Sexual Impulse Control Disorder: frotteurism to violent assault </li></ul><ul><li>Arrogant & self-centered </li></ul><ul><li>Sexual harassers who lack aware- </li></ul><ul><li> ness or empathy </li></ul>
  22. 23. Other psychological issues <ul><li>Socially isolated – relies on patients for social life </li></ul><ul><li>Neurotic & emotionally needy on a chronic basis </li></ul><ul><li>Emotionally needy on a situational basis </li></ul><ul><li>Struggling with sexuality or other conflicts </li></ul>
  23. 24. Report & Recommentations <ul><li>Is practice safe at present? If so with what limitations or safeguards; </li></ul><ul><li>The issue of having an observer or chaperone in the examination room; </li></ul><ul><li>Is Rehabilitation possible in theory? </li></ul><ul><li>What sort of re-evaluation will be done at the end? </li></ul>
  24. 25. Elements of Rehabilitation <ul><li>Coursework on boundaries, ethics, techniques, etc. </li></ul><ul><li>Change in clinical practice </li></ul><ul><li>Practice limitations </li></ul><ul><li>Supervision </li></ul><ul><li>Therapy; treatment </li></ul><ul><li>Boundaries re-training </li></ul>
  25. 26. Outcome Criteria – practice re-entry plan <ul><li>If rehabilitation is successfully completed, a re-entry plan is needed; </li></ul><ul><li>There may be practice safeguards and/or requirements </li></ul><ul><li>There may be personal adjustment requirements (e.g. bipolar cannot drink and cannot go off medications without medical consultation) </li></ul>
  26. 27. Videotape examples <ul><li>Schoener. G. Assessment of Professionals who have engaged in boundary violations. Psychiatric Annals, 25, pp. 95-99 </li></ul><ul><li>[email_address] </li></ul>