Thursday, November 17, 2011

The Very Badly Behaved Health Care Practitioner

I've been asked several 'ethical dilemmas' in the past few weeks.  I'm putting them up on Shrink Rap, but please don't get hung up on the details.  These aren't my patients, but the details of the stories are being distorted to disguise those involved.  The question, in both cases, boils down to: Should the mental health professional report the patient to his professional board?

In the first case, a psychiatrist is treating a nurse who is behaving badly.  The nurse is stealing controlled substances from the hospital and giving them to friends who 'need' them.  She doesn't intend to stop, and her contact with the psychiatrist was only for an appointment or two before she ended treatment.  Should the psychiatrist contact the state's nursing board?   Is he even allowed to?

In the second case, a psychotherapist  sees a patient who is also a psychotherapist (I will call the patient here the patient/therapist).  The patient tells the therapist he having a sexual relationship with one of his own patients (the patient/victim).  This is clearly unethical, but the patient/victim is an adult and the relationship is "consensual" in that it is not forced or violent.  There is no question that if a licensing board knew of this, the patient/therapist would lose his license.  Should the treating therapist report his patient for unethical behavior?  Ah, he asked a colleague on the Board and was told that he must report this, and if he doesn't, his own license could now be at risk.  If he now reports it, as instructed, can the patient/therapist turn around and sue him for breaching his confidentiality?  After all, he was seeking help with his problem, he believed it was protected information, and now he will be sanctioned out of a livelihood.    Does it matter if the therapist is a physician (for example, a psychiatrist) as opposed to a psychologist or social worker or nurse practitioner?  I realize that all mental health professionals have confidentiality standards, but are the confidentiality laws that apply to physicians/clergy/attorneys the same as they are for other mental health professionals? 


Liz's Blog said...

In the first case, I don't think it's appropriate for the psychiatrist to breach confidentiality, unless he/she is aware that these "friends" are underage or in some way disabled. The second case, to me, is trickier, but I still do not think it is an exception to confidentiality standards. If it is known that the areas in which confidentiality can be breached become broader and more vague, the public trust of mental health practitioners will be totally undermined. This slope is just too damned slippery.

Anonymous said...

It seems that the respective codes of professional conduct would address this for psychologists/psychiatrists/social workers, etc.

In my jurisdiction, as an attorney I'm required to report a violation of the Rules of Professional Conduct committed by another attorney if the violation raises a substantial question as to the attorney's honesty, trustworthiness or fitness as a lawyer. But the reporting rule contains an exception for information that is otherwise protected by the attorney/client privilege. If it's subject to the privilege, you don't report it. Of course, the attorney/client privilege itself has a number of exceptions built in, for criminal or fraudulent conduct, for example.

The reporting rule also contains an exception for any communication concerning substance abuse that is made for the purpose of seeking treatment for oneself or another attorney. This makes sense in my jurisdiction because we have a strong program in place to identify and assist attorneys with substance abuse or other mental health issues.

Dinah said...

Liz: the friends are likely substance abusers: does that make them "disabled?"

And anon:
So you have a paying client who is an attorney and he tells you he's done something unethical (like slept with a client). I take it this is subject to privilege and you don't report it?
What if you go out socially with a friend who is an attorney and you notice he often orders more alcohol then seems reasonable to you....say he's a regular 6 drinks/dinner out kind of guy and he gets sloppy and he has few stories his drinking escapades that lead you to think he's more than a social drinker. Do you report that your friend has a problem with alcohol to the local Bar? Maybe you've seen him order a martini or two at a work lunch.... does that change it?
Or maybe you've wondered if his work has been sloppy. He's a good friend, and any insinuation that he has a problem has been met with a poo-poo, ("just having fun" or even "when did you get to be such a prude" or "you were drinking at dinner, too").
There's a line somewhere, where is it? This is your best friend, by the way, whom you love and talk to all the time, and his health is good and his wife does the driving.

Anonymous said...

Alcoholism will rarely fall under privilege because in most instances it won't be told to the attorney in the context of seeking legal advice (but it could in some instances, such as a custody case). If it's privileged, you do not disclose it. Period. (unless there's a crime fraud exception).

In my jurisdiction they want to "help" attorneys with alcoholism, drug addiction, depression, or other mental health issues, but by reporting someone, that person can lose their license forever. The legal community is not forgiving of these things. It is best to get someone help without going to the bar. Indeed, in California, a survey is sent to acquaintances of persons seeking admission to the bar, asking whether the person has a mental health issue that could interfere with their ability to practice. Presumably if one of your friends says yes, you're not getting admitted to the bar.

As to your hypo, I don't think the shrinks have any business disclosing the information because they learned it in the course of treatment.

Anonymous said...

Speaking to second scenario, there is a duty to report if someone knows a child is abused (oh no , we won't start that again) and doctors have a duty to report a patient who is or is likely a danger on the road. In both cases, the patient could have said something thinking it was confidential but the duty to report supersedes this and that is true even if the patient will lose his or ehr job as doctor, a waitress, a bar owner or a brick layer.

it should be but is often not standard practice for doctors to deal with this at the outset and inform patients that some things cannot be kept confidential. Last I checked, doctors don't keep firm suicide plans confidential.

Anonymous said...

Dinah--with regard to reporting substance abuse by attorneys, in my jurisdiction there is a Lawyer's Assistance Program ("LAP") that is funded by, but run separately from, the State Bar Association. The LAP works with both professional mental health providers and volunteer attorneys who are themselves in recovery.

If an attorney believes another attorney has a problem with alcohol or drugs, the attorney can pass that information along to the LAP. The information does not go to the State Bar.

What the LAP does with information reported by a third party varies. They can to anything from providing advice to the reporting attorney to doing a professional version of an intervention, where one or more of the volunteer attorneys in recovery pays a visit to the attorney reportedly experiencing problems. I think they try to take a pretty customized approach.

Of course, an attorney with a substance problem can also contact the LAP himself to receive assistance.

As I said, the LAP doesn't provide information to the State Bar. It's confidential by rule. However, the lawyer with the substance problem is still subject to disciplinary sanctions for any unethical behavior that comes to the Bar's attention, whether or not resulting from a substance problem and whether or not that attorney is working with the LAP, though seeking treatment may be considered as mitigating.

This program was started some years ago by a very respected attorney, who is very candid about his alcoholism and his recovery. There are now a number of respected attorneys and judges who participate openly as volunteers. They are usually the ones that do the professional interventions. From what I understand, this is a very successful program. It seems the ability to seek treatment without fear of professional sanction is a good model, at least in my jurisdiction.

Interestingly, though our LAP also bills itself as a resource for attorneys with mental illness, there is not a single volunteer attorney who openly identifies himself as having a mental illness. Stigma persists in interesting ways.

First Anon attorney

Anonymous said...

As to the question of sex with an attorney's client--subject to the privilege, don't report it.

Threat of death or bodily harm to another-not privileged, report it.

As I said, there are exceptions to the attorney/client privilege, so any analysis requires an evaluation of the facts of the particular situation.

First Anon attorney

Anonymous said...

In my state, mental health professionals have a legal duty to report sexual exploitation by other mental health care professionals. They have 30 days to report it to the DA's office and the licensing board. I guess it depends upon the laws in your state as to whether you are obligated to report it or not.

Anonymous said...

Does the APA / other therapist licensing boards not have guidelines?

I find that absurd.

Dinah said...

From the APA confidentiality guidelines:
Reporting Statutes
The responsibility that psychiatrists have to keep their patients' confidences may come into conflict with other responsibilities they have to the community at large. Over the years, society has decided that it has an overriding interest in protecting certain needs of the public, even at the risk of disclosing some information patients might wish to be kept confidential. The prototype of such laws is the reporting of contagious diseases, beginning over a century ago. More recently, statutes have been enacted requiring that psychiatrists and other physicians report cases of actual and suspected child abuse to appropriate public authorities, including cases of child sexual abuse. Now a growing number of states have begun to require the reporting of abuse of the elderly.
The intent of these laws is to protect the public from future harm. Except for child abuse, there is generally no legal requirement to report past instances of crime or misdeeds. Learning that a patient has committed a serious crime in the past, however, presents many difficulties in the therapeutic process. Because of these complexities, consultation with a senior colleague and a knowledgeable attorney is well advised in such cases.
Please note that in the case of the patient/therapist who is having an affair, the therapist is not a psychiatrist. I don't know if that makes a difference. (It was part of my question). Requirements to report sexual exploitation may not be in effect if the the professional learns of this from his own patient who is the perpetrator-seeking-help in psychotherapy. I believe reporting requirements are limited to child abuse. Even the duty to warn of an impending threat to the personal safety of another can be circumvented by hospitalizing the patient.

jesse said...

We as professionals have various sets of duties which may or may not conflict. Obviously our duty is to follow the law. I knew that various professions here in Maryland had different standards, but I did not know that in some states all mental health professional were required to report sexual exploitation of a patient by another professional. There should be people to whom we can turn to discuss complex problems. We need to consider who it is to whom we are turning, though. Most professional societies have committees, and many of us have colleagues whose experience and judgment we respect. If we ask a lawyer we need to consider his experience and whom he is representing. Asking a malpractice carrier, for instance, may get advice more tuned to the needs of the company than to us, so we need to ask.

The Tarasoff decision makes it clear that all communication is not confidential. If a patient threatens another person we may need to take action, which under Tarasoff was to warn the potential victim, call the police, or hospitalize the patient. The basic consideration is that once we conclude something our actions need to follow appropriately from that conclusion. That is why in Tarasoff once the psychologist concluded that his patient's threats against the victim were credible his response, which was to notify the campus police, were not sufficient.

Simply thinking a colleague drinks too much, is unethical in various ways, and so on does not trigger action. Here in Maryland a psychiatrist's duty to protect confidentiality is very strong. We do not report professionals who come to us for treatment if we learn from them of sexual acts with adult patients, drug use, tax evasion, and so on. If we learn they are planning to harm another person, though, action is indicated. In certain circumstances I have told people whom I am interviewing that there were limits to confidentiality.

It is not unusual to learn from our patients of colleagues who act with them in ways of which we very much disapprove; or of patients who may be doing things we totally dislike, but we need to keep our professional responsibilities in the forefront and, subject to very strict exceptions, always act in our patients' interest.

Anonymous said...

Jesse writes, "If we learn they are planning to harm another person, though, action is indicated." I think that is the reasoning behind the states who require a duty to report mental health professionals who sexually exploit their patients.

I'm not sure how many states have a duty to report in this case, but I do know Texas has one. I've seen therapists include this in the informed consent.

If curious, you can read about the duty to report sexual exploitation by mental health services providers in the Texas Civil Practice and Remedies Code, Title 4, chapter 81, sec 81.006 Duty to Report.

jesse said...

@Anon, that indeed may be the intention, but I wonder if it proves to be for the best. The cases I have heard of are not ones in which a professional is planning to become sexually involved with a patient, but ones in which a professional seeks treatment precisely because he is so upset by the fact that he had become involved. In these cases is the best course to report the professional?

That position (to report) can result in those professionals not seeking the treatment they need. So I think that the position of other states on this issue is best overall.

Anonymous said...

Jesse, I suppose the same argument could be made for people who abuse children or the elderly. If we report them, they will be less likely to seek help. I'm not sure how common it is for people to seek therapy because they are sexually abusing their patients, but for the situations I'm aware of the remorse (if they feel it at all) tends to set in when they get caught.

Anonymous said...

in the first case i think there is probably a legal duty to report - as a crime (stealing drugs) is taking place, and patients are being harmed or very likely being harmed by the nurse's act. the duty to protect the vulnerable patients seems clear, here. allegations get investigated, and often are not supported during investigation.
the second case is less clear, tho i think that what the therapist/patient is doing is morally repugnant and an abuse of the power differential inherent in a patient/treatment provider relationship. I think that the agreement the patient signs at the start of treatment is key here, as is exactly what you say if/when someone says 'can i tell you something and ask you not to tell anyone?" your professional association ought to be able to refer you to a knowledgable attorney who can help you sort out competing roles, regulations, and consequences for your state. Or perhaps your malpractice insurance carrier provides this sort of consult on a confidential basis?

jesse said...

One of the things I came to believe early on was that when a person sought out psychiatric treatment he was opening himself only because he understood it was safe to do so. His communication is privileged except in carefully spelled out situations.

I have heard of quite a number of boundary violation cases over the last few decades, and have treated some who transgressed boundaries and more who had been improperly approached by professionals. The practitioners who came into treatment voluntarily had transgressed boundaries seriously one time, and that was actually the precipitating reason for them seeking treatment. I know of no cases in which serial boundary violators sought treatment.

Certainly I know that other situations must exist, and am not saying that my own experience is the rule. Additionally, when the transgressors have come into treatment voluntarily the only information the treating therapist had came from the patient. That psychiatrist knew only what the patient told him. So what evidence does he really have? Just exactly what would be reported? The violation may have been long in the past.

I have discussed this issue with others in our psychiatric society and in the state medical society and believe that the best course is to protect the confidentiality of those who seek treatment, certainly from physicians, unless there is good reason for the doctor to believe others will be hurt. I do not know enough to have an opinion on other professions.

Anonymous said...

Dinah wrote " .the patient/victim is an adult and the relationship is "consensual" in that it is not forced or violent. There is no question that if a licensing board knew of this, the patient/therapist would lose his license."

The reason the licensing board would take this action is
because in a therapy relationship, it does not matter whether the patient was an adult or whether there was physical force or violence. if the patient were a child or if there were violence then it would qualify as a criminal act. Since it is not a criminal act, there must be some other reason that the board would strip the therapist of the license. The board is sending a statement to members that this sort of relationship warrants the loss of license. In the case written about the relationship is not in the past but is taking place in the present. The colleague on the board confirmed that he is obliged to report. If that is so then I cannot understand how the therapist could be sued for breaching confidentiality. It can't really be the case that he could both lost his own license for failing to report and also be open to a lawsuit for fulfilling his duties. i don't feel sorry for the patient/therapist but I do worry about the patient/victim (you used that word for a reason). if reported, the victim could be called on to testify and this can be very traumatizing in its own right. On the other hand, if it is not reported, the therapist can keep using patients to gratify his own needs which is why we have these boards to take away licenses.
Assume the therapist decides not to report because as Jesse said, most of the cases he knows of the person feel remorse for their actions , and as Dinah said, the patient is an adult and there was no violence. Then, fast forward a couple of years. The relationship came to an end, the patient/victim is in therapy with another therapist and she decides she does want to report that doctor. She reports and the board gives her a tough time. The offending therapist fights to defend himself and it is his word against a patient who is painted as woman with borderline personality disorder who made a pass at the doctor and is angry that she was rebuffed. Through his colleague at the board the therapist who did not report hears of what is going on (even though these things are supposed to be confidential). Now what? If does not come forward with what he knows, how do you feel about it now? if he comes forward now won't he be asked why he did not report two years earlier? It is different when a therapist hears of abuse at the hands of a doctor from a patient. In that case, it is hearsay. The patient can be encouraged to decide what action they want to take. If the doc hears of it from an offending doctor and does not act, how is he any better than people who do not act or speak up in other kinds of cases? The best case would be to encourage the doc to turn himself in. Likely? Not very.

Dinah said...

I have a form of office policies that I send to patients before the first session. It says: I do not release psychiatric information. If you wish to have me share information with your family members, other physicians, employers, insurance company, or any other agency, you must authorize the release of such information.

I make an exception to this policy if I have strong reason to believe that your behavior may present an imminent danger to yourself or others. Please also be aware that there are state-mandated reporting requirements for issues involving child abuse and endangerment.

How many patients talk in therapy about child sexual abuse? Zero. Sometimes people will talk about an incident with an unnamed other person where there is nothing to report: a date rape at 15 by another 15 year old whose name is not recalled from 50 years ago, or similar episodes where all involved were children from long ago with long forgotten identities.

Do we think that it's funny that I don't see the victims of child sexual abuse? No, I think mandatory reporting laws make it so that perpetrators can't get help even if they want it, and that victims can't get help unless they are willing to be scrutinized and possibly re-victimized by the legal system. We've created a world where you must shut up.

If the therapist reports the other therapist, the Board may question it and the therapist/patient may well deny it. "I never said that, he's lying." The therapist/patient will never return and the licensing board will have no information with which to proceed. Unless (or until) a victim comes forward with a complaint, or the therapist/patient voluntarily admits to the misbehavior, a licensing board would have very little to proceed with.

Mandatory reporting laws silence everyone in therapy and they stand in the way of getting help. As Roy will tell you in the next podcast (it's recorded) they create for some ridiculous conversations with docs and agencies: so you report. They say "thanks, there's nothing we can do with that information."

I do believe that ER docs who see child victims of sexual and physical at the time of the event should be required to report.

Anonymous said...

Dinah writes, If the therapist reports the other therapist, the Board may question it and the therapist/patient may well deny it."

That's true and if I understand the laws in my state correctly unless the victim is willing to be named the MHP has to file the complaint without the victim's name. So, of course the complaint will not be pursued by the state board. However, if the victim does later decide to come forward or another victim comes forward the complaint is already part of the shrink's file and if things sound eerily similar then it lends legitimacy to the next victim.

For example, if you have two separate complaints that mention the shrink has a weird looking mole on his right butt cheek, then the medical board is going to pay attention to that.

Anonymous said...

Dinah writes: How many patients talk in therapy about child sexual abuse? Zero."
This may be true in Dinah's practice. i am not sure whether she means how many people talk about being the abuser or how many people talk of having been abused. The practices of many psychiatrists are filled with people who are talking about child abuse, or at least trying to.

jesse said...
This comment has been removed by the author.
jesse said...

I have seen many patients who told me of being victims of child sexual abuse. So many, in fact, that I now now it is far more common than is generally supposed. It is a very serious thing, and from my work I know of many people who have suffered life scars that are exceedingly deep.

I do not think that a psychiatrist should not report because his practitioner-patient feels remorse, but because the information was imparted to him on the understanding it was confidential. It is the only reason he now has that information. I think we are correct to hold to that standard and at times it it is personally difficult to do so. There are times, unfortunately, that our patients are scoundrels. There is parallel with a lawyer's duty to protect information, but it is not completely congruent by any means.

I agree with most everything in the long Anon post (I wish Anons would choose some name because it makes dialogue much easier). It is important in most instances to ask what hat we are wearing when we hear of anything. If I hear at a party that a colleague is crossing boundaries I do not report it, I can talk about it, and I certainly can decide never to refer to that colleague. If I hear in a therapy session the same thing (this has happened) I can decide not to refer but I would not talk about it. Information imparted to me in therapy is confidential.

However, the example Anon gave of information that might either exonerate another practitioner or else help find him guilty is an excellent one. I would in such a case seek out an experienced colleague and confer with him.

Anonymous said...

No one should ever underestimate the ability of past deeds to come back to bite them in the backside. many abuse victims, whether child or adult, wait years to take action. Everyone should operate under the assumption that judgment day is coming and I do not speak of standing at the pearly gates. I have seen therapists, teachers, members of the clergy, lose the right to work in their respective fields. i have witnessed people take action and I have personally taken action. Every therapist who believes that their patient/victim will be under their sway/shit up forever, ought to take a look at the disciplinary actions of their respective boards. Dinah is only partly right that we shut up. We don't all stay silent forever.
I do not know how i would feel about someone else outing a therapist who was abusing me sexually since i could be called to testify before i was ready. i do know how I feel about the people, all of them who stayed silent in the knowledge of what was going on. it is ironic that this post follows so closely on the heels of the Penn State one.No, it is not the exact same scenario but again we have a victim and we have people who have knowledge they do not act on.

Alicia said...

Maybe a question then becomes - does a decent psychiatrist continue to see these "scoundrels?"

I'm hearing an undercurrent (from the professionals' comments here) of implied deserved sympathy with "scoundrels" of these sort that I'm just not comfortable with. I don't think that's what the original point of the post was but that's the implication I'm getting now. Perhaps indeed it was an unconscious point - how do we psychiatrists make ourselves feel better about working with these "scoundrels" rather potentially taking action to prevent future misconduct by them? Let's justify it.

jesse said...

One of the requirements of us as psychiatrists (I was trained analytically) is that we work in a non-judgmental manner, which is not to say we look away or do not confront our patients with their actions. It is important to be able to call a spade a spade. But it is obvious we work at times with people who do things of which we strongly disapprove. We are there to help them medically.

I have never said to a patient that I would not treat him because of something he has done, but even that would of course have limits. This is the problem with open-ended hypothetical musings. We can all imagine scenarios that would make for good theater, but I have been practicing a very long time and such a scene has never occurred.

Anonymous said...

@Alicia: i get that same sense and I do feel differently about a therapist who is working with a colleague who has strayed but who has already been caught or admitted the facts. than I do about one who is still involved with a patient whether or not they feel troubled by it. I have a tough time dealing with the thought of going to a therapist who stayed silent in a case like this. it is not the job of a therapist to play god or tell the government of someone cheating on his taxes but to be a therapist knowing that another is abusing a patient and it is abuse if it is an act one could lose their license over, another story.

Anonymous said...

Jesse, I have been alive a long time, have taken my kids to the zoo, but I have never seen a real live kangaroo. I know they do exist though.

jesse said...

@Alicia: if you as a physician were referred a businessman who doing something of which you disapprove, or a politician from far on the other side, or a military person who confides to you that he killed people out of uniform and who were not threatening him, or even a college student who tells you he is coercing his girlfriend in regard to an abortion, or..., what do you do? Do you not think that as a physician you treat that person's wound, or help with their cancer, and so on?

Recognizing that our patients are human allows us to help them as we can; having empathy for them does not mean we agree with all that they do.

I have found that frequently long-term therapy helps a person to have a more inclusive, sensitive relationship to others. That may not be what they indicated they were coming for, but that is frequently what happens.

The people who seek therapy voluntarily because they themselves have become involved in boundary violations are in pain and getting help with that pain does not shield them from the consequences of their actions if their Boards hear of what they did.

Sunny CA said...

I think if I were a therapist, I would err on the side of protecting patient confidentiality. When I went to my high school 40th reunion, my former H.S. best friend, whom I had not seen for over 35 years, confided that she was being bankrupted by the real estate crash, so she was declaring bankruptcy, but had figured out a "clever" scheme to divert some assets and buy a new house and start a new, smaller business in another state using the hidden funds. I was appalled, decided to not continue being friends, but I did not turn her in to law enforcement. For one thing, I did not know all the details, though both her former and new business have web presence, but I do not know the addresses of her residential properties. It was not taking the moral high ground to fail to report her. In this electronic age it would seem a miracle she could pull it off. If a friend confides cheating on their taxes do you call the IRS? There are victims of both the crime of cheating on a bankruptcy and in the crime of cheating on taxes. Am I legally obligated to report a friend hiding money during bankruptcy? I did not call the police in her area and ask them.

My sister is a retired nurse who in her early years nursing, stocked her medicine cabinet with medications obtained from the hospital. This was the early 1970's. Did hospital wards at that time stock medications, or did this mean she was taking medications from individual patients in her care? She seemed to indicate that all the nurses were doing it, and that every nurse she knew had medications from the hospital to treat just about anything. My sister self-diagnosed high blood pressure and self-prescribed presumably stolen blood pressure medications for a number of years before she admitted to her doctor that she had high blood pressure. I was a college student at the time, and no, I did not turn her in. I don't know if she continued to do this or if the hospital got more strict over time on control of medications. She stopped telling me.

I think that the obligation of the psychiatrist in these scenarios to protect patient confidentiality competes strongly against the legal obligation to tell. I am not sure what I would do if I were in those dilemmas.

jesse said...

@Sunny, exactly so, except that for a psychiatrist (except perhaps in Texas) you don't have a legal obligation to tell. You have a legal and professional obligation NOT to tell, as the information is privileged and can only be released by your patient. There are exceptions, carefully spelled out in law. One has to respond to a subpoena. But we do not have the option of protecting patient confidentiality, it is our duty.

BTW, for anyone here who has followed my blog on the Penn State Matter, there is an opinion piece in the New York Times today by author critic Daniel Mendelsohn who makes the exact same argument I did. As I said on the blog, you read it first on shrink Rap!

Anonymous said...

I'm not really sure the comparison of a non-psychiatrist telling on her sister is valid or at all relevant to the point of this ethical question.

A key point here seems to be a psychiatrist/mental health clinician treating another mental health clinician. That is completely irrelevant to telling on siblings or ex-best friends from high school. The point of the highly hypothetical question, I believe, is the obligation of the psychiatrist. Not the layperson.

Anonymous said...

If you you are talking about a psychiatrist and whether or not they should keep confidentiality or disclose the behavior of another psychiatrist, I do not understand the question when the AMA has this to say in their Principles of Ethics: II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

jesse said...

@Anon, yes, that is true, but in this instance the duty to keep information gathered from a patient confidential generally takes precedence over that. The situation is similar for an attorney, in which attorney-client privilege generally takes precedence over other considerations.

No two situations are the same, and that is why one can get only so far discussing this here, and why I think it is very wise for any physician-therapist to seek consultation.

Anonymous said...

Okay, how about a psychiatrist is treating a pediatrician patient who discloses that he has a bad habit of touching his young patients inappropriately. The shrink happens to know several members of his own inner circle take their kids to this doc.

Dinah said...

Last anon: Confidentiality trumps all with the exception of child abuse and an imminent danger to others. There is no ambiguity in your example: the psychiatrist must report a pediatrician who is sexually abusing his child patients.

jesse said...

@Anon, that is an excellent example. In the case you hypothesize the action is repetive and continuing, and involves children. That Shrink should seek consultation with an experienced colleague, his professional society and a lawyer. I think we can all imagine such situations, ones in which we would want to break confidentiality.

As I said before, I have heard of quite a few boundary violation cases over the last few decades. And I know of cases in which individuals who have committed boundary violations have sought therapy. But none of the cases in which therapy was sought contain the type of actions we might imagine would lead a physician to divulge confidential information.

The default position for a psychiatrist is to keep confidential information imparted to him. I have never come across a situation that has led me to break confidentiality, but I can certainly imagine one.

jesse said...

(Back from dinner) Before the Anons hound me out of town because I said the Shrink should seek consultation and speak with a lawyer in a situation that sounds so black and white, consider this:

There is no smoking gun. The Shrink goes immediately to the Board which charges the pediatrician, who becomes despondent and depressed. He can no longer work. The Shrink then gets slapped with a lawsuit and the pediatrician complains to the Board about the Shrink.

The pediatrician says that he had gone to the Shrink because he had thoughts about touching patients inappropriately but had never done so. Even the thought of such an act made him anxious. He was having obsessive thoughts that were never acted on. So he sought treatment from our Shrink who had acted grossly unprofessionally and caused the pediatrician significant harm.

It is always a good idea to get a consultation.

Anonymous said...

@ jesse - I quite agree with the first one, though, but would just stipulate that those consultations with an experienced colleague, lawyer, and professional board take place ASAP and not at the end of a long list of things to do.

Jane said...

"Okay, how about a psychiatrist is treating a pediatrician patient who discloses that he has a bad habit of touching his young patients inappropriately."

There may need to be a procedure about how to handle this one. Cuz he could just say later on to the board that he didn't really mean that, moment of insanity, it was a misunderstanding with the shrink, whatever. Immediately following that confession, the shrink should explain the consequences of that confession, and then ask the patient if he still stands by his confession. The patient should be asked to repeatedly makes this same confession (not just once and then he took it back the second you say you're reporting it). The reason I say that is because people say things sometimes they don't really mean, especially when they are upset. Also, shrinks "mishear" things sometimes or genuinely do misunderstand. I had a shrink think I was talking about a sexual fantasy with another woman once. Not only did what I said have NOTHING to do with sex, but I am not even a lesbian or attracted to the woman I was discussing. I think I was talking about doing stuff with her, but then he thought I said "doing her." That was awkward.

Anonymous said...

Okay, how about a psychiatrist whose patient is a football coach and he confides that he has a bad habit of doing stuff with kids, boys. girls. Dinah says go to the authorities because child abuse trumps everything. Others are not so sure, maybe they misheard, maybe ask him to repeat what he said 10 times, each time asking if he knows the ramifications of such a statement. That sure gives a guy a lot of time to say hey, uh no, that wasn't what I meant. It is like being coached to retract the statement because if it were only fantasy then the shrink is much more comfortable.
I have seen this in action before in small ways. Shrink pretty much says don't tell me stuff that you know I will have to act on.

jesse said...

@Anon, in the situation you just described (which as I said I have not seen anything like it in my practice nor know anyone who did) the Shrink could go over the confession carefully with the coach, write a note, and check again with the coach to be certain it is accurate. He could then inform the coach that the law requires him to report this, he has no option, and then discuss the ramifications with him.

It may well be that it will be relief to the coach; whether it is or is not, however, the coach is still his patient and the Shrink need to be concerned for his welfare.

Jane said...

"It is like being coached to retract the statement"

I know what you are saying. And I think there really are people in the helping professions that are like that. I've met them. But my intent isn't to be condescending to the patient (Retract! Don't make me do my job and make me report you). I've heard about false memory syndrome, where the people really believe they committed murder or some other terrible crime that they never actually committed. Or they even remember being victims of child abuse themselves. What if this child abuse confession happens under hypnosis, or is confessed by one of only many multiple personalities, or during a moment of intense distress, or during a psychotic break...I'm not an expert on the human mind, but I do think confessions like that need to be looked at very carefully. Just cuz there's so much more knowledge now about false confessions and false memories.

I guess to give an example, what about that guy who admitted to killing Jonbenet Ramsey? Obviously, we now all know he only killed her in his mind. And I'm not saying that if he admitted that to a shrink, the shrink should not have reported it...I'm just saying the shrink should be careful in handling confessions.

Dinah said...

The law says child abuse must be reported. In our state, the attorney general has stated that this includes child abuse in the past and even if the perpetrator is dead.

I didn't write this law or the interpretation of it, and my stance on is that I'm the patient's psychiatrist, my responsibility is to care for my patient. Even if they are scoundrels or have political beliefs I don't like, or behaviors I don't approve of. That's what doctors do.

I personally feel that it more often victimizes the patient who may want to have therapy to deal with past abuse, but does not want it dredged up.

I'm not a detective, when someone tells me they've been victimized, it's often long past. My job is to treat the patient, not to hassle them for names/places/details that they pretty much never offer. Psychiatrists are required to report, and when we do, it sounds pretty silly: My patient was sexually abused by an uncle 20 years ago. What's his name? I don't know. Where did this happen? She lived in Tennessee until she was 7 and then in Florida until she was 12 and then in New Mexico so it may have happened in one of those states, unless it happened where the uncle lived and I don't know where that was. Where is he now? He died of cancer sometime when she was in college. But it's been reported. The truth is that even if uncle is running a day care center, the most a psychiatrist is going to do is call protective services and give the patient's name and phone number and give them the opportunity to try to ascertain his identity and whereabouts.

The pediatrician is well aware of child reporting laws and knows this will be an issue. It's only an issue if he says he's doing it, if he says he's fantasizing, that's not a crime, and he can engage in psychotherapy.

What should we blog about next?

jesse said...

How about a blog about the use of Anon in posts? There has been issue with this in the press regarding Facebook. A Pseudonym at least allows dialogue, while "Anon" makes it much more difficult.

Why do people who might choose a pseudonym choose to use Anon?

Liz said...

confidentiality is the keystone in any kind of psychotherapy...only instances of danger and child/elder abuse can trump this most central aspect that distinguishes the sanctity of the therapy room.

Anonymous said...

I could call myself Charlie or Hortense but if another Charlie or Hortense makes a comment, it still has the potential to get confusing.
Some people feel like they are Anonymous or like to feel that they are Anonymous, not in the sense that their identity is "protected", but in the sense that they don't feel much of an identity at all.
"I'm a million different people from one day to the next"
From: Bittersweet Symphony by The Verve

Anonymous said...

I contribute to charitable organizations as Anonymous. Typically, there are several of us in the same year end booklets that get published. of course, someone in the accounting department knows who I am since I have to pay by credit card most of the time.
No matter where I go, I am Anonymous to whatever extent possible.

elder care charlotte said...

Great debate going on here! I agree that in this field confidentiality is of most importance and cannot be changed under any circumstance.

Anonymous said...

A good source for future reference :

CatLover said...

I was using anon for a long time because I didn't know how the choose an identity option worked, where you can just make up a name. I don't have a google account and because I talk about personal matters, I want to be anonymous.

Jane said...

I actually used anon for the same reason as CatLover. I don't use google, so I actually use a friend's google account (we're good friends) to talk on here. I have no clue how OpenID or the URL thing works.

Anonymous said...

Or perhaps using a psuedonym feels more false then just "anon." I'm not "Joe." I choose to be anonymous - to not give my name, not to assume a false identify.

jesse said...

The only problem with just plain Anon comes when there is a dialogue and there are several Anons (or so it seems) and one does not know how to specify what question and to whom a response is directed.

Also, at times the Anon is asking rather direct questions, or taking a somewhat personal or edgy tone. It is hard to know how to respond. It is easier to say "in response to what Fred asked above," especially when there are a series of back and forth responses.

Just a thought. i think one can be totally anonymous and still give a specific identifier, even if it is Anon1 or C3PO.

There is more to this. Would someone want to blog about it, even as an Anon?

AndreW Gonzalez said...

como Por arte de magia, Se convirtió en Graffiti

Liz's Blog said...

dinah: i struggle with whether drug addiction makes a person "disabled." i know my addicted friends seem pretty "disabled" to me, but it still FEELS different than if they had down syndrome or cerebral palsy or something like that. i would also still be concerned about the quality of care that nurse is providing during this time. still, i believe the helper's first focus should be on his or her client. ideally, in this sort of situation, there would be a continuing relationship, and these sorts of issues could be addressed.

Liz's Blog said...

dinah-- you wrote about how sex offenders can't get help even if they want it... my mother and i had this conversation recently; her step-dad was sexually abusive. this abuse was made all the more confusing because in many ways, he treated her kindly; he helped her with homework, for example, in an encouraging, kind way. his behavior was evil, and there is no excuse for it. however, i know that he was abused as a child, as well, and i wish there had been a way, back then, for him to address these issues and feelings before he committed such awful crimes. or even that there was a way for him to get the help he needed once this behavior began to occur. there isn't ANY good way for a person who has this psychopathology to get assistance BEFORE they commit an atrocious behavior, ruining the lives of children and their own life. it's a damned shame.

Sarebear said...
This comment has been removed by the author.
Michael Ricksecker said...

Fighting against therapist abuse!

Links and resources about this type of horrific exploitation: