Saturday, November 26, 2011

Please Don't Tell

Earlier, we were talking about an ethical dilemma in The Very Badly Behaved Health Care Practitioner-- What should a therapist do if he's treating another therapist who confesses he's been having an affair with a patient?  Should the treating therapist report his patient to their respective licensing board?  Of course, the comments are the most interesting part of that post. 

It got me thinking about two things:  Doctor-Patient Confidentiality and What is a Patient? 

From the Encyclopedia of Everyday Law:
The Oath of Hippocrates, traditionally sworn to by newly licensed physicians, includes the promise that "Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." The laws of Hippocrates further provide, "Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated into the mysteries of the science."

Doctor-patient confidentiality stems from the special relationship created when a prospective patient seeks the advice, care, and/or treatment of a physician. It is based upon the general principle that individuals seeking medical help or advice should not be hindered or inhibited by fear that their medical concerns or conditions will be disclosed to others. Patients entrust personal knowledge of themselves to their physicians, which creates an uneven relationship in that the vulnerability is one-sided. There is generally an expectation that physicians will hold that special knowledge in confidence and use it exclusively for the benefit of the patient.
Most psychiatrists I know (at least in Maryland) do not violate their patients' confidentiality unless 1) there is an issue of child abuse and this is because state law mandates it be reported, and 2) there is an imminent risk of danger to self or others.  There may be reasons other physicians break confidentiality, for example the mandated reporting of contagious diseases or driving issues with epilepsy, but these do not generally happen in psychiatry.  The thinking behind doctor-patient privilege is that no one would trust a physician if they worried their problems would be repeated.  When I am not sure what to do, I will ask a trusted colleague, but there are clearly times when what is in a patient's best interest is not what's in society's best interest (such as prescribing an expensive medication or ordering an expensive test or revealing information learned in treatment) and I generally feel that my job is to keep my patient's best interest in front of me.  It's hard to be everyone's agent.

For the most part, I don't endorse laws that mandate the reporting of past child abuse against the wishes of the patient (--not that anyone has ever asked me, but hey, it's my blog so you get my opinion) --at least not by psychiatrists as an after-the-fact event. In an Emergency Room with an injured child victim it's a different story and it's hard to imagine that it would ever be in the best interest of the patient to send them home to a violent setting.  For psychiatry, I believe that such laws prevent people with problematic behaviors from getting help, and they prevent victims of abuse from having therapy if they do not want  the scrutiny of the legal system or the turmoil that may bring if family members were involved. If a patient reports an active urge or plan to commit a violent crime,  taking action is generally in that patient's best interest as well as society's and violating confidentiality may be the clear right choice.   

In the vignette given in the Badly Behaved Behavior Health Care Practitioner, the situation asked whether a therapist should report a patient who is also a therapist who is having a sexual relationship with an adult patient.  There is no "law" about reporting such behaviors (at least not in our state), though some Licensing Boards  make statements that professionals are required to report colleagues who are impaired or incompetent.  Some of our commenters wrote in to say that the therapist should be reported-- that patient safety should come first.  My thought was that when a patient walks in the door for treatment, she is a patient and not a colleague and such licensing mandates do not pertain the way they would if the therapist in the next office knew illicit sexual activity was going on.  It seems to me that the spirit of such mandates is to get the licensee help, something she is already doing by seeking care, and that these mandates were probably not made in the spirit of trumping confidentiality with patients, but I could be wrong.  Reporting the therapist might help prevent future harm to patients, but in the big picture, it means that badly behaving psychotherapists can never get help in a confidential setting. 

  I suppose one way to get help for a misbehaving therapist to get help would be to seek care from a therapist in another specialty-- there is nothing in the Licensing Board mandates that suggests a licensee needs to report an incompetent member of another specialty or profession, so a social worker who is having an affair with a patient could perhaps seek treatment from a psychologist or a psychiatrist?    And the other thing I wondered about-- does reporting the therapist necessarily help the current victimized patient?  An adult patient, after all, is free to report her abusive therapist.  If she chooses not to, perhaps there is a reason-- perhaps it would blow apart her marriage, or perhaps the inquiry that comes with such events would leave the victim feeling even more victimized.  These aren't easy scenarios-- one can imagine all types of configurations-- the victim could deny the abuse/affair happened,  the victim could be thrilled to hear that a confession occurred which will help with the prosecution, or the victim could feel not at all like a victim, but like someone who chose to have a consensual relationship and does not want the attention of the therapist's disciplinary proceedings.  

These are really difficult situations.  I'm not sure what the rules are for psychologists or social workers, but for physicians the default requirement is for confidentiality and there needs to be a really good reason to violate it, and revealing a patient's secrets may leave the psychiatrist open to his own scrutiny, disciplinary action, and lawsuits.  We treat people even when they have behaviors or beliefs that are deplorable to us.  I hesitated, however, to write this, because I can think of scenarios where confidentiality in the doctor-patient relationship might warrant a breech, and I'm happy I've never been faced with one of these situations. 


Anon8 said...

I guess there's a sense of a frustration at a sort of double standard: no, psychiatrists shouldn't have to be perfect, but no, my psychiatrist should not be engaging in harmful behavior.
A person who sees a therapist to deal with past hurts, past abuses, perhaps even from other therapists - he expects, he trusts, that his therapist will not engage in the same abusive behaviors.
No, we can't expect perfection from our shrinks. And yet...shouldn't we be able to? Perhaps that's the frustration underscoring these comments - that we cannot expect perfection, and the thought that perhaps there is another professional out there who is condoning our therapist's misconduct - that's a terrible instance of cognitive dissonance. A terrible vulnerability.

No, psychiatrists aren't special and shouldn't get any special treatment...except that the work they do demands that we, as patients, are at least able to not consider that our treaters engage in outright abusive or harmful behaviors. Thinking that other professionals condone these behaviors.... that's screwed up.

jesse said...

@Anon8, I'm not sure what led you to conclude from Dinah's blog that the treating therapist in any way condones the behavior mentioned. Dinah has it exactly right.

Dinah said...

I think we all agree that abusive behaviors are horrible, even more so when it occurs within a relationship we believe is trusted-- those with our teachers/religious leaders/doctors/and law enforcement personnel. Honoring a professional requirement to confidentiality can be a far cry from "condoning" deplorable behavior. And perhaps if using psychiatrists as law enforcement were an effective way to catch criminals it might worth the tradeoff, but having psychiatrists report illegal behavior doesn't increase the numbers of people who are caught, it simply means that those who are misbehaving don't tell psychiatrists and don't get treatment.

Anon8 said...

@Jesse and Dinah, you're right, that wasn't clear. I did not mean to say that a therapist would condone clearly deviant behavior in another therapist. Though to be fair, it is not a long stretch to go from a premise of confidentiality - IN ORDER so that therapist x who does x y and z is able to be treated which is what Dinah repeatedly states - to well, not not condoning x y and z.

It's the idea of the not not-condoning that is troublesome. Again, I am not speaking from a theoretical paradigm....I'm speaking from a place of theoretical patient vulnerability. This would be one more instance in which a therapist would have more "value," or "validity," then a patient - therapist says x or y and patient says m, other consulting docs are far more likely to hear x and y (not you of course). The thought that a therapist might be seeing a therapist for behaviors related to or contributing to patient disrepair and that another therapist is outwardly "okay" with those behaviors - not not-condoning, at least - is troubling. Reality, yes. Fair, yes. Troubling to the patient - very.

jesse said...

@Anon8, first, thank you for the "8." While it is true that therapy can be effective only when there is confidentiality, the requirement for confidentiality comes first, whether or not any given patient is in therapy.

Perhaps it might help to consider this: When a patient comes to a physician the information he gives does not "belong" to the physician. Rather, the physician is a trustee whose duty it is to make use of that information solely in regard to that patient (with the exceptions as to children and imminent harm that Dinah mentioned). The information is "owned" by the patient. This is a general concept and applies to many things. The physician may become aware through his patients of information of a business, legal, personal, nature and make no use of it.

There have been times when I learned of things that would have been very important to friends or family members, and I did not let on to anyone of what I knew. Yes, this at times can be extremely difficult, which is why Dinah referred to "ethical dilemmas."

So one very small subset of this general rule applies to psychiatry, and therapy is another small subset of that. The effects of boundary violations for the patient of a therapist can be devastating, and no properly trained psychiatrist treating that therapist would dismissive of that patient's needs.

Anonymous said...

I'm glad my therapist reported my psychiatrist. Not suprisingly, this wasn't my psychiatrist's first trip to the state capital for this sort of behavior and likely won't be the last as he enjoys sitting next to his patients taking their hands and talking to them about trust, keeping them so drugged they can't see straight, hospitalizing them, and then pressuring them for sex - this is his MO. He's a creep and has done a lot of damage to a lot of people. He would never seek psychiatric care on his own, because he would never admit he has a problem. I'm surprised to learn that some of these sex offenders do seek treatment on their own, maybe there is some hope for them.

Sexual misconduct is not an affair, it's abuse and especially when they are putting their patients in the psych ward against the patient's will. Sexual misconduct is unethical in every state, and illegal in many. People who do this to their patients should lose their licenses and return every cent they defrauded the patient out of. In some states they can go to jail for this, and I would argue that they should.

Dinah said...

Last anon: It sounds like your therapist reported your psychiatrist with your permission (and perhaps your blessing), in which case there is no issue with confidentiality and then there is no issue that reporting is the absolute right thing to do.

jesse said...

@Last Anon: "I'm surprised to learn that some of these sex offenders do seek treatment on their own, maybe there is some hope for them."

Having heard of cases of abuse for decades I have never heard of even one instance of a serial abuser who acted like your psychiatrist seeking help on his own.

rbh said...

Just a question is a therapist/patient sexual relationship necessarily abuse? Isn't love sometimes where you find it? What if the patient finds another therapist, is the relationship OK then?

jesse said...

@rbh, wow, that is a difficult question for a blog answer but I'll try. First, "abuse" is not a specific psychiatric term but a judgment (although an important one). Clearly there are instances such as Last Anon described that virtually anyone would categorize as abuse. There are other instances in which the therapist and patient developed a "dating" relationship, neither having ever done this before, and then married. There was such a circumstance a number of years ago in Maryland (public record) and there are actually some famous examples of this.

But whether or not it leads to marriage our profession looks at it in a very negative light. It is fraught with danger to both parties, however honest each is purportedly trying to be. These are the instances in which both do seek therapy with other therapists especially because of all the mixed feelings that each has. One could say a lot about the unconscious parental and child role that each finds himself in, the significant dangers of acting them out, and the effect of the power differential, but as this is a short answer, not an essay, consider just this one aspect of it:

In a therapy relationship the therapist is easily seen in an idealized light by the patient: understanding, tolerant, always paying attention. The patient may equally be seen in an idealized light by the therapist: engaged, not distracted by others, listening to every word, and so on, so that each one represents to the other only a very small part of what occurs in a normal relationship. It is effective for therapy but highly unrealistic in regard to life. This is part of what we call transference.

This can quickly blow apart if therapy becomes sexual; the recriminations and rage can be palpable and dangerous. It is like incest, and patients are seriously harmed by it.

There is much more to it (none of it in support of such activity) but the effects are well known enough that all the professional societies and licensing boards consider this to be a major assault on the patient, regardless of how it transpired. There may be instances in which it has worked out well, but they are certainly exceedingly rare.

We would not say that if one man survives a firing squad because every bullet missed, that firing squads are not dangerous to one's health!

Jane said...

@Jesse: But what about the last part of rbh's question? What if the patient gets a new therapist, and then dates the former therapist? Is that still wrong or ill advised?

Dinah said...

In psychiatry, it's felt that it's always wrong to have a relationship with a patient or former patient. "Wrong" however, is an imprecise term...frowned upon? The hospital lawyer said at our risk management meeting that the standard is that you can date a patient 5 years after the end of the doctor-patient relationship. I think other fields may have standards as well. It seems to me that some of it would depend on the relationship that existed during treatment. Is it wrong to date a patient one saw one time 20 years ago? Is it ever okay to date a patient one saw for a on-going psychotherapy? It would be wrong to terminate a relationship so that one could date the patient.

I agree with Jesse that it's hard to say that forbidden relationships are Always harmful, but since they often are, and since there is no way of knowing at the outset who will end up feeling injured, abused, and angry, they are a bad idea.

jesse said...

@Jane: Amen to what Dinah just said.

Even in normal treatment situations, where the patient ends therapy with absolutely nothing having occurred between therapist and patient that would raise one eyebrow of criticism, the relationship between the two is loaded with feelings (transference) that would deeply affect it if they began dating.

If the patient or therapist stopped the treatment in order that the two could begin dating, then that is a serious problem, whether or not the patient then begins therapy with another therapist.

This is a general rule to which every professional, and every society and professional Board, would agree. That is not to say there cannot be exceptions to it, but they are rare. The American Psychiatric Society holds that once a psychiatrist begins to treat someone a sexual relationship between the two is never condoned.

Clearly this is an extreme position (it is easy to imagine situations in which it should not apply, but do they ever occur?), but the very fact that it needed to be taken shows the seriousness we psychiatrists think this issue deserves.

Jane said...

You know...maybe it is a good idea for patients and psychiatrists not to date each other. I can remember that movie with Richard Gere where he dates a psychiatrist he met while locked up in a mental hospital during a manic episode. And one scene that always stuck out in my mind is, after he is released and they're dating, he's in the car with her and she asks him about his bipolar disorder and how things are going along...And he can't believe she just did that. He tells her that is like her going out somewhere, she's having a good time, and then her gynecologist sees her and asks her about their last appointment and how things are going with that little problem he was treating her for. And the shrink scoffs and says, "That's not the same thing!" And Richard Gere tells her YES! It is the same thing. The sun is shining, I'm having a good time, and then you brought up this really private problem when I'm trying to enjoy myself. And then she replies, "I guess I never thought about it like that."

And I wouldn't think that would actually happen, but I was looking up the reviews for a certain GP in my area that I was thinking of going to for location reasons...and she had terrible reviews. And one that stuck out in my mind was a complaint from a teenage girl. She and her teen brother went in to get refills. They were then put in the same room together. The brother was on an antidepressant, so the doctor started asking him if he was experiencing any suicidal thoughts. And the sister's jaw just dropped cuz both she and her brother are really private people and they didn't want to be talking about that kinda stuff in front of each other. The sister needed a birth control refill so she was asked about her sexual activities and when her last period was. She and her brother were totally horrified by the experience.

But what got me was that the doctor replied to this comment, said the kids were rude, their mom should have been with them, and she put them in the same room with their mother's permission. If they wanted separate rooms then why didn't they request that? And then she said the sister didn't know what she was talking about, because there is a black box warning on antidepressants and so she had to ask him about suicidal thoughts. And then I replied...I don't think that was the point of her comment! I think she was saying the brother felt uncomfortable discussing that in front of his sister and was deeply horrified (as was the sister). Like he doesn't normally talk to her about stuff like that. Kind of like how she didn't want to talk about her period in front of him. And then the "patient complaints" dept. replies that they treat really poor people, take insurance no one else will take, and sometimes there are problems but the doctor doesn't want to give up...etc.

But they just didn't get it. They did seem to get on some level that a teenage girl would be mortified if she talked about her period with her brother in the room...but the doctor had no clue why the brother's depression would be a really personal problem that he would want to discuss privately. I think after I posted she got it a little better, but I think the Richard Gere movie might be right. There is some weird disconnect where doctors just don't get how deeply private some of these issues are. Desensitized maybe?

That would suck to date your former psychiatrist and then have him casually bring up your issues ...some things you want to keep in the doctor's/therapists office and out of the rest of your life.

LOL @ that GP who actually thought a deeply private teenage boy, who doesn't like talking about feelings was going to tell her about his suicidal thoughts with his sister present!

Anonymous said...

This counts as a relevant thread for me and my psychiatrist, there is no doubt that he thought I had a sexual dysfunction and he gladly sought it out, before I could even say no. He hypnotized me, sought out my deepest thoughts then accused me of leading him on. There was definitely an attraction from word go, which caused confusion as it grew with emotion. It broke my heart but I had to break therapy with him(for his sake pretend I was well even though I still burn myself) I felt it was getting dangerous, two people sharing their deepest fantasies you wouldn't even tell your partner is always a recipe for disaster or increasing love as the case maybe, but now its left a bitter taste, a love hate feeling that you both feel a connection that is futile. The law states we cant even be friends (what a joke I am doing a law degree) The story of my life another man that isn't to be and now he and his girlfriend just pick on me and belittle my illness as being endemic of my character and I have to be the strong one even though technically I am the most vulnerable, such is love and life. Now no one in the clinic will treat me because of the lies he has said about me to protect his interest, I don't blame him, how can he know if I will grass his up, trust is built over time (how can he know if I will tell, after all he could lose his job), shame he didn't consider my feelings the same way. but what can you do but try and not put yourself in another situation where you can get close to someone no good for you. the whole reason I went to the doctor to begin with! The lesson here is valor! sticking to your guns acting with foresight, for the best interest of everyone involved. Atleast you can congratulate yourself on being the loving kind person even thought the most hurt. The only other alternative for me (to even the odds) was a trip to the law courts again! No thanks life just ain't like that.

Dima said...

interesting information

Anonymous said...

(I'm the anon who commented Nov 27) @ Dinah, actually I didn't agree to my therapist reporting it. My therapist was mandated to report the psychiatrist (in my state that's the rule, honestly I don't know if that's the case in any other state and it may not be). However, she didn't release my name so it made the complaint pretty much useless in the beginning as the state board had nothing to go on without a patient name and probably all it did was sit in a file until I eventually agreed to talk with the state investigator.

I can see benefit in reporting even if the victim doesn't cooperate, because there's something on file. The physician isnt going to be called to appear or anything and probably the investigator wouldn't even talk to the physician, but if a victim eventually does come forward and all these complaints have stacked up it will probably help that victim's case. I don't know, I kind of see both sides on that. There are vindictive pts who make up stuff, and I do think the physician should have the right to face their accusor, so in that sense I kind of go back and forth on this.

@ Jesse, yeah I think you're right. I think probably the physician I saw was very different than the example you gave where someone recognizes they did something wrong and seeks help. My psychiatrist would never seek help or even admit he did anything wrong, other than probably wish he hadn't put some of what he did in email. He probably won't do that again.

Regarding the question some have asked about it being abuse versus falling in love. Obviously, I'm very biased about this issue because of the fallout I experienced. I think it is almost always an abusive situation when it involves a therapist/ psychiatrist and a patient. When the patient goes in and talks to a psychiatrist they're opening themselves up and being extremely vulnerable, talking about their innermost thoughts and fears. If a patient is seeking psychiatric help it's because things aren't going well to begin with. The psychiatrist or therapist is not being vulnerable at all. They aren't sharing their innermost thoughts and vulnerabilities. So, I don't know how it could ever really be love when the patient knows nothing about the therapist/psychiatrist.

I don't really understand the board's stance on it being abuse with all physicians, though. I don't think the vulerability is remotely the same with a family practice physician, for example. Going in to see the physician for the flu isn't the same kind of vulnerability as going in and spilling your guts or struggling with a mental issue. So, while it isn't professional for a family practice physician to hit on a patient, I don't see it as abuse because I think an adult patient is free to say no in that case.

jesse said...

@Anon, you are right: as far as the Board's stance related to all physicians, here is my understanding of how the Maryland Board of Physicians treats it: a physician cannot have a sexual relationship with a patient. They can be friends, they can socialize, but as soon as it becomes a dating relationship the physician should transfer the care of that patient to another physician. The reasoning behind this is to guarantee as much as possible that medical decisions will not be colored by the personal relationship, and to avoid abuse of patients as much as possible

It is only the psychiatrists who hold to a much stricter rule, as explained in the previous posts.

Andrea said...

I do agree that abusive behaviour is really bad and would have serious effects. In a therapist-patient relationship, there is trust involved and if one party abuses that trust then it'd be very harmful for the other party and should not be condoned.