Rehabilitation of Offending Professionals


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By Gary Schoener

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Rehabilitation of Offending Professionals

  1. 1. Rehabilitation of the Offending Professional Who Has Crossed Boundaries Gary R. Schoener Licensed Psychologist & Exec. Director Walk-In Counseling Center Minneapolis, Minnesota
  2. 2. REHABILITATION SITUATIONS <ul><li>Impaired/Offending Professional seeks help; </li></ul><ul><li>Employer decides rehabilitation is possible and makes referral ; </li></ul><ul><li>Medical Council or regulatory body makes referral and requests Rehabilitation </li></ul>
  3. 3. Professional Seeks Help <ul><li>Many such situations are not truly “voluntary” – what pressures ? </li></ul><ul><li>Is there expectation of reporting to anyone/making a recommendation? </li></ul><ul><li>Informed consent regarding situation in which you believe risk to patients </li></ul><ul><li>What other limits of privacy exist? What about child endangerment? </li></ul>
  4. 4. Employer Seeks Help <ul><li>What are the specific expectations ? </li></ul><ul><li>What sort of report is to be done? </li></ul><ul><li>What is at stake ? </li></ul><ul><li>There needs to be an agreement about contact with regard to risk to patients; </li></ul><ul><li>You need access to personnel data ; </li></ul><ul><li>You need access to collaterals </li></ul>
  5. 5. Medical Council <ul><li>What are the disciplinary stipulations ? </li></ul><ul><li>What is the factual background ? </li></ul><ul><li>You may need additional background : </li></ul><ul><ul><li>From the Council or other body; </li></ul></ul><ul><ul><li>From current or past employers </li></ul></ul><ul><li>Has there been an evaluation ? </li></ul><ul><li>What additional evaluation is needed? </li></ul>
  6. 6. Most Common Problems <ul><li>Inadequate investigation – not enough background from complainant; </li></ul><ul><li>Inadequate info. on the offense – “confession” accepted as full story; </li></ul><ul><li>Nature of the problem is such that rehabilitation is not likely possible ; </li></ul><ul><li>The practitioner reveals additional information that changes the picture </li></ul>
  7. 7. What Type of Cases? <ul><li>Sexual contact with patient; </li></ul><ul><li>Sexual talk; sexual harassment; </li></ul><ul><li>Social relationships via email; </li></ul><ul><li>Mixing roles; over-involvement; </li></ul><ul><li>Pattern of boundaries crossing; </li></ul><ul><li>Emotional breakdown; </li></ul><ul><li>Alcoholism -- Drug Addiction </li></ul>
  8. 8. Emotional Breakdown Alcoholism/Drug Addiction <ul><li>Emotional Breakdown – is this part of a chronic problem or acute only? </li></ul><ul><li>Alcoholism/Drug Abuse – treat through traditional means </li></ul><ul><li>Do you have a professional treatment group? Is that best for this person? </li></ul><ul><li>Practice implications [Case example: </li></ul><ul><ul><li>Bipolar with drinking] </li></ul></ul>
  9. 9. Sex - Related <ul><li>Sexual Contact with patient (or with children, parent of a patient) – unnecessary touch or examination, frotteurism, masturbation, voyeurism, touch by either doctor or patient </li></ul><ul><li>Sexual Harassment or inappropriate talk – unwanted sexual advances; sexualizing the environment with staff or patients; </li></ul>
  10. 10. Boundaries Crossing <ul><li>May involve a “near miss” with sex </li></ul><ul><li>May involve a repeat of behavior after a warning has been given </li></ul><ul><li>Situations in which professional has sought help for “patient harassment” where poor boundaries set the stage </li></ul><ul><li>Disciplinary situations due to rule violations </li></ul>
  11. 11. Special Note on the Internet <ul><li>In the US and Canada, a huge percentage of cases now involve emails as part of the evidence; </li></ul><ul><li>Email exchanges have hazards and we lack clear standards of practice; </li></ul><ul><li>The internet can provide chances for unintended social interaction; </li></ul><ul><li>Patients can research doctors on internet & learn much personal info. </li></ul>
  12. 12. 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>
  13. 13. Rehabilitation Overview See Diagram <ul><li>Investigation – complaint or 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 subject; </li></ul><ul><li>Report and recommendations </li></ul>
  14. 15. Countertransference Traps* <ul><li>Therapist as Cop; </li></ul><ul><li>Therapist as Rescuer & Obsolver; </li></ul><ul><li>Therapist as Authoritarian Parent; </li></ul><ul><li>Supervisor as Corruptible Object </li></ul><ul><li>* Gabbard . Transference & Countertransference in the psychotherapy of therapists charged with sexual misconduct. Psychiatric Annals, 1995, 25,100-105 </li></ul>
  15. 16. Therapist as cop <ul><li>To the degree that the therapist is seen as an extension of employer or council’s oversight, the therapist can drift into the role of a disciplinarian or “watch dog” </li></ul>
  16. 17. Therapist as rescuer & absolver <ul><li>Professional often arrives to therapy in a traumatized state and may seek confession and absolution. This can ignite rescue fantasies in the therapist. </li></ul>
  17. 18. Therapist as an Authoritarian Parent <ul><li>Many offending professionals have a rebellious streak in them and are resentful of authority. They will challenge the therapist in a self-defeating effort to bring on an authoritarian response. </li></ul>
  18. 19. Therapist as a Corruptible Object <ul><li>Some professionals will seek to demonstrate that the therapist has the same flaws as they do by undermining boundaries through various challenges. </li></ul>
  19. 20. 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 or combination – note on the “Perfect Storm Case” </li></ul>
  20. 21. Lacunae in Training --addressed in therapy or through additional training or practice limitations <ul><li>Work outside normal expertise 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>
  21. 22. Social Ineptitude: insight, plan for role limits, work site choice <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>
  22. 23. Executive Function Problems: Role limits, retirement, etc. <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>
  23. 24. Impulse Control Problems Lack of Empathy for Impact <ul><li>Sociopath or severe narcissist not treatable; </li></ul><ul><li>Sexual Impulse Control Disorder requires special treatment & practice limitations; </li></ul><ul><li>Therapy can help some with empathy </li></ul><ul><li>Boundaries training programs do address victim empathy </li></ul>
  24. 25. 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>
  25. 26. Remedial Boundaries Training <ul><li>Individualized through meetings, exercises, discussions, videos </li></ul><ul><li>Programs involving group meetings, presentations by victims & by offenders </li></ul><ul><li>Programs involving use of practice demonstrations </li></ul>
  26. 27. Boundaries Programs <ul><li>Behavioral Medicine Inst. of Atlanta </li></ul><ul><li>Professional Boundaries Inc. </li></ul><ul><li>Professional Resource Center (PRC Kansas) & Accumen Assessments </li></ul><ul><li>PACE – Medical School, U. of Calif. – San Diego </li></ul><ul><li>POPAN – Professional Boundaries in UK is organizing a program </li></ul>
  27. 28. 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>
  28. 29. Outcome Criteria – practice re-entry plan <ul><li>If rehabilitation is successfully completed, a re-entry plan 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><ul><li>Myth of the “safe” environment </li></ul>
  29. 30. Videotape examples <ul><li>Celenza, A. Sexual Boundary Violations: Therapeutic, Supervisory, & Academic Contexts. NY: Jason Aronson, 2007 </li></ul><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>