The prevention of psychotherapist sexual misconduct: avoiding the slippery slope.

Therapist sexual misconduct has its genesis in the therapeutic relationship. The mental health professions have long recognized the delicacy with which the therapist must handle the therapeutic relationship, with its power imbalance, inherent vulnerability of the patient, and transference and countertransference reactions. The prevention of sexual contact starts with the careful attention to boundary violations, which, though themselves perhaps not harmful, may escalate into sexualized behavior. Methods of preventing this behavior include the establishment of clear guidelines for practitioners and the expansion of the educational process for therapists, therapists' employers, patients, and other professionals. Last resorts lie in the legal and quasi-legal proceedings available to victims, such as civil suits for damages, criminal complaints, board of licensing complaints, and actions before professional associations. The best method of preventing sexual contact with patients involves respecting the boundaries of the professional relationship and avoidance of the slippery slope.     

Treating the patient who has been sexually exploited by a previous therapist

Patients who have experienced sexual exploitation by a previous therapist constitute an increasingly recognized clinical population. Although some of these patients were transiently overwhelmed or mildly disturbed when exploited, the majority were severely symptomatic and the victims of incest or other previous abuse. Many demonstrate a constellation of four factors that predisposes them to revictimization or the sitting duck syndrome: severe symptoms, idiosyncratic dynamics, atypical socialization that discourages self-care, and cognitive difficulties. The experience of such exploitation is not benign, although the sequelae vary considerably. The treatment of such patients is facilitated by arranging the therapy in a way that maximizes safety and clear communication. The importance of hearing the patient' own reconstructions, pacing the treatment to the patient's tolerance, and respecting the patient's agenda cannot be overemphasized. A cluster of issues that appear central to the treatment of such patients includes addressing their helplessness, their ambivalence about the exploitive therapist, their difficulties with trust, their guilt, their depression and pressures toward self-harm, their confusion over sexuality, their post-traumatic and dissociative features, their severe symptoms and the diagnostic confusion this involves, and the countertransference pressures upon the therapist.     

Research and laws regarding therapist-patient sexual involvement: implications for therapists

Therapist-patient sexual intimacy has emerged as a major issue. This article discusses the legal and ethical prohibitions, the accumulation of research regarding the prevalence and consequences of therapist-patient sex, and the implications for therapists, particularly those treating patients who have been sexually intimate with a previous therapist.     

Role conflict and role ambiguity among creative arts therapists

Creative arts therapists, as professionals, have progressed from their nascent position in developing training programs and defining skills and competencies for qualified art, dance/movement and music therapists in particular. It appears, however, that we Mill may he in a nascent position in defining our role with relationship to other mental health professionals in the work setting.Cashell, an an therapist and Miner, a dance/movement therapist, present a provocative survey and discussion of this issue, identify some problems and suggest we have much to do to clarify our role as members of the mental health profession with specific skills that are valuable and valued.We invite our readers to contribute their thoughts about this issue, either in the form of letters to the Editor or as articles on the subject.     

Using telephone reminders to increase attendance at psychiatric appointments: findings of a pilot study in rural Appalachia

OBJECTIVE: This study examined whether phone reminders increased attendance at intake and therapy appointments in an Appalachian community mental health center and whether it mattered who (therapist or staff) made the call. METHODS: One of three conditions (no reminder calls, therapist made calls, or staff made calls) was assigned to each week of the nine-week study. During the study period, 451 appointments were scheduled (310 for therapy and 141 for intake). Mixed-effects logistic regression was used to analyze the data. RESULTS: Phone reminders were effective for intake appointments when therapists made direct contact with patients (43% for no contact and 94% for direct therapist contact). The other conditions did not significantly increase appointment keeping. As a result of these findings, therapists were asked to place reminder calls to patients scheduled for intake appointments for a ten-week period. Findings from the second pilot study replicated findings from the first, with direct contact resulting in significantly more kept appointments. CONCLUSIONS: Direct contact with therapists before initial appointments may increase appointment keeping by patients.     

The role of music therapy in paediatric rehabilitation

Meeting the needs of the child in rehabilitation requires an interdisciplinary approach, whereby a variety of health care professionals are called upon to work together in planning and coordinating each patient's programme. The Registered music therapist is one of the allied health professionals who plays an integral role in this team approach. Music therapy is a recognized allied health profession, which is becoming acknowledged in the expanding world of health care as a therapy able to meet the expansive needs of the patient in rehabilitation. This article will present a literature review which advocates the role of music therapy in rehabilitation, with particular focus on the needs of the paediatric patient. Case vignettes will be used as further evidence to support the role of music therapy in this context, together with considerations for future research.     

Response to tanner and gerstenberger

Abstract

More and more health care professionals are wondering what they can do for the brain injured. This interest stems from several sources: modern medicine is able to increase the survival rates of those who sustain head traumas and strokes, thus more and more individuals are seeking rehabilitation; cognitive interventions with the brain injured, be they performed by a speech pathologist, neuropsychologist or occupational therapist are becoming recognized as a useful addition to the armamentarium of therapies available to rehabilitation workers; and affective disorders are becoming recognized as one of the most frequent and debilitating of the deficits which are secondary to brain injury regardless of etiology, side of the brain that has been damaged or the length oftime since the onset of the injury. This interest has resulted in increased demand by therapists for new and easy to use material for patients and has resulted in a myriad of articles describing theories and new approaches to intervention that have had neither the benefit of sufficient critical review nor adequate clinical testing.     

Sexual minority reflections on their psychotherapy experiences

Objective: Sexual minority (lesbian, gay, bisexual, queer) individuals are regular consumers of psychotherapy, and are more likely to utilize psychotherapy than heterosexually identified individuals. However, there is scant research on sexual minority clients examining their perceptions of therapists’ efforts to work successfully with them. Method: We examined the experiences reported by sexual minority individuals in psychotherapy (N?=?77), utilizing an Internet-based survey that asked open-ended questions such as, “How did your therapist address your sexual orientation?” Result: Using directed content analysis, we derived 19 repeating ideas, which we categorized into five major themes and two overarching concepts, including: (a) participants reported appreciating general person-centered psychotherapy competencies (e.g., active listening, validation, Socratic questioning) and (b) participants reported that various aspects of sexual orientation (e.g., therapist sexual identity, therapist knowledge about sexual minority populations) are relevant to their experiences in therapy and should be addressed directly by therapists. Conclusions: Results indicated that clients want generally competent therapists who understand that a sexual minority identity is only one part of a client's overall identity and not a defining characteristic or psychopathological. We explicate themes and representative quotes, and provide preliminary recommendations for therapists working with sexual minority clients.     

Racial and sexual bias in psychiatric diagnosis: psychiatrists and other mental health professionals compared by race, sex, and discipline.

In a study designed to test for sex- and race-related bias in psychiatric diagnosis, the responses of 173 mental health professionals to four hypothetical patient profiles were analyzed. Minimal racial bias was observed. In some instances, therapists appeared more likely to make judgments biased against patients who were of the same race and sex as themselves. The results support the contention that hysterical and antisocial personality disorders are sex-biased diagnoses. The race of the therapist strongly influenced diagnosis. It is argued that this finding reflects resistance of nonwhite therapists to a majority-group-dominated diagnostic theory. Professional discipline rarely affected diagnosis with the exception that psychiatrists were more prone to diagnose psychosis.     

Sexual abuse of patients by therapists: strategies for offender management and rehabilitation

Many therapists are unsure of how to respond to reports of sexual abuse of patients by previous therapists. The results of strategies developed in Minnesota and other jurisdictions suggest ways to handle the reporting, management, and rehabilitation of offenders in therapist-patient sexual abuse cases.     

Who Initiates Emergency Commitments?

Florida’s Mental Health Act was amended in 2005 and 2006 to include licensed mental health counselors and licensed marriage and family therapists, respectively, to the list of professionals authorized to initiate emergency commitments. The present study evaluates the volume of involuntary emergency commitments by type of initiator for a 5 year period. The results indicate that allowing licensed mental health counselors and licensed marriage and family therapist to initiate emergency commitments has not been related to increased numbers of emergency commitments or a higher proportion of emergency commitments being initiated by mental health professionals. Potential policy and fiscal implications, as well as future directions for research, are discussed.     

The psychiatrist's image in commercially available American movies

OBJECTIVE: To explore quantitatively how American movies portray psychiatrists/therapist. METHOD: A total of 106 movies were reviewed regarding how psychiatrists/therapists were portrayed. The psychiatrist's or therapist's sex, age, clinical competence and knowledge, boundary violations, attitude toward the patient, influence in the movie's events, treatment modality or modalities used, intervention's outcome, and therapeutic setting. RESULTS: The psychiatrists/therapists tended to be males (71.2%), and (regardless of sex) middle-aged (50.8%). Despite the general view of the psychiatrists/therapists as friendly (63.6%), there was an over-representation of boundary violations. The percentage of total boundary violations was 44.9% of the cases portrayed and sexual violations accounted for 23.7%, while non-sexual violations accounted for 30.5% (with 9.3% overlap). The appearance of clinical incompetence was 47.5%. CONCLUSION: The image of psychiatrists/therapists in commercially available movies is not flattering: close to one out of two violated boundaries, close to one out of four committed a sexual boundary violation, and the psychiatrist/therapist was as likely to be incompetent as competent. The bright point is that psychiatrists/therapists were depicted as more likely to be friendly.     

Nonphysician psychotherapist-physician pharmacotherapist: a new model for concurrent treatment

In the last century the mental health field has vacillated between a biologic versus a psychologic model of the mind. Only in the last two decades have proponents of both views calmly discussed their virtues and limitations. As a result, clinicians have begun to promulgate the concept of an integrated, concurrent psychotherapy and pharmacotherapy. While this debate has raged in the psychiatric field there has been a parallel proliferation of nonphysician mental health professionals. Most of these mental health clinicians come from training programs steeped in the traditions of a psychodynamically based treatment that occurs within the interpersonal context. Today more and more of these clinicians compete for the increasing population of those seeking relief. The result of these two movements has been the introduction of a unique form of treatment in which a patient sees two therapists. In this triangular treatment, the pharmacotherapist prescribes medications and the psychotherapist provides the interpersonal therapy. In order for all practitioners to participate in this form of triadic treatment they must appraise themselves of not only the historical debates preceding this therapeutic concordance but of the transference and countertransference potentials. Some patients can have idealizing, magical, and nurturing transferences toward either therapist in the triangular relationship. Other patients can be narcissitically wounded, with a negative devaluing response toward either therapist. Paralleling the patient's transference distortions are the therapists' countertransference reactions. These can run from the omnipotent identification with the patient's idealization to the devalued, distancing response toward oneself or the patient. If these distortions are not checked they can intrude on the treatment, acting out the patient's internal split self-object representations and ultimately sabotaging treatment. Successful attention to transference and countertransference phenomena can lead to an enhanced treatment in which the biologic and psychologic treatments have a synergistic effect. Only then will we be capable of fully evaluating and researching the positive and negative effects of combined psychotherapy and pharmacotherapy with two different therapists. The outgrowth of this research will be improved patient care by enhancing our capacity to identify those patients and therapists who are good candidates for this triangular treatment relationship.     

Psychiatric residents' sexual contact with educators and patients: results of a national survey

In a national survey of PGY-4 psychiatric residents, 4.9% of the 548 respondents indicated that they had been sexually involved with psychiatric educators and 0.9% reported that they had been sexually involved with patients. Most residents reported no or minimal instruction in their residency programs about educator-resident and resident-patient sexual contact. The authors compare these results with those from previous surveys of psychologists. They discuss the need for expanding training curricula to include specific education on sexual exploitation.     

Multidimensional characterization of sexual minority adolescents' sexual safety strategies

Young adults have high rates of sexually transmitted infections (STIs). Sexual minority youths' risk for STIs, including HIV, is as high as or higher than sexual majority peers'. Sexual safety, while often treated as a single behavior such as condom use, can be best conceptualized as the result of multiple factors. We used latent class analysis to identify profiles based on ever-used sexual safety strategies and lifetime number of partners among 425 self-identified LGBTQ youth aged 14–19. Data collection took place anonymously online. We identified four specific subgroup profiles for males and three for females, with each subgroup representing a different level and type of sexual safety. Profiles differed from each other in terms of age and outness for males, and in outness, personal homonegativity, and amount of education received about sexual/romantic relationships for females. Youths' sexual safety profiles have practice implications for sexuality educators, health care professionals, and parents.     

Child and Family Therapy Process: Concordance of Therapist and Observational Perspectives

The objective of this study is to examine the characteristics of outpatient mental health services delivered in community-based outpatient clinics, comparing information obtained from two different sources, therapists serving children and families, and observational coders viewing tapes of the same treatment sessions. Videotaped therapy sessions were rated by therapists and independent coders regarding goals and strategies pursued during each session. Sixty-three sessions were taped of outpatient care provided to 18 children and their caregivers by 11 therapists. Children were 4–13 years old and families were receiving services at least in part due to reported child behavior problems, confirmed by ratings from the Child Behavior Checklist and Conners Parent Rating Scale—Revised. Analyses assessed the frequency, type, and intensity of goals and strategies pursued in therapy sessions from both therapist and observational coders’ perspectives. Reliability of observer ratings and correspondence between therapist and observer reports were also examined. The reliability of observational coding of goals and strategies was moderate to good, with 76% of 39 codes having ICCs of .5 or greater. Therapists reported pursuing 2.5 times more goals and strategies per session, on average, than identified by observational coders. Correspondence between therapists and coders about the occurrence of specific goals and strategies in treatment sessions was low, with 20.5% of codes having a Kappa of .4 or higher. Substantial differences exist in what therapists and independent coders report as occurring in outpatient treatment sessions. Both perspectives suggest major differences between the content of services provided in community-based outpatient clinics and the structure of evidence-based programs, which emphasize intense pursuit of a small number of goals and strategies in each treatment session. Implications of the findings for quality improvement efforts in community-based mental health care settings are discussed.     

The ParkinsonNet concept: Development,implementation and initial experience

The quality and efficiency of allied health care in Parkinson's disease (PD) must be improved. We have developed the ParkinsonNet concept: a professional regional network within the catchment area of hospitals. ParkinsonNet aims to: (1) improve PD‐specific expertise among allied health personnel, by training a selected number of therapists according to evidence‐based guidelines; (2) enhance the accuracy of referrals by neurologists; (3) boost patient volumes per therapist, by stimulating preferred referral to ParkinsonNet therapists; and (4) stimulate collaboration between therapists, neurologists, and patients. We describe the procedures for developing a ParkinsonNet network. Our initial experience with this new concept is promising, showing an increase in PD‐specific and a steady rise in the patient volume of individual therapists. © 2010 Movement Disorder Society     

Differences between behavior therapists and psychotherapists.

Patient-therapist interaction patterns of three experienced behavior therapists and three matched analytically oriented therapists were compared. Each therapist saw ten patients in short-term individual therapy. The more active behavior therapists dominated the conversation in terms of speech time, more frequently offered explicit advice and instructions, gave more direct information, presented their own value judgments, and exerted greater control over the content of the interaction than did psychotherapists. Although both groups provided a warm and accepting atmosphere, behavior therapists showed higher levels of accurate empathy, interpersonal contact, and therapist self-congruence. Patients viewed behavior therapists as more authoritarian and believed that psychotherapists encourage greater independence. It was concluded that the two therapy approaches to patients were consistent with theoretical models of each.     

Sexual Surrogate Partner Therapy: Legal and Ethical Issues

The Ben Lewin film The Sessions has drawn attention again to the potential role for sexual surrogate partners and sex workers in enabling persons with disabilities and impairments to give expression to their sexual needs and desires. However, away from the big screen, the ethics of registered health practitioners in themselves engaging in such therapies are highly problematic. Difficult too is the role of such practitioners in being ‘the therapist’ responsible for enabling or brokering sexual contact between their patients and those offering such services for financial reward. In some jurisdictions, arrangements involving sexual surrogate therapy (especially where the therapist benefits from it financially) may not be lawful. Further, in spite of many assertions one way and the other, there are no data enabling evaluation of the success rates of the interventions of sexual surrogates or sex workers. Whether positive outcomes to such interactions are likely in most circumstances, given that the provision of services is predicated upon idealised attachments, is questionable. It is also unclear whether sexual surrogates’ adherence to an ethical code effectively ameliorates the potential for counter-therapeutic consequences from the commodification of intimacy, and it is far from straightforward to identify what steps should be taken by the referring health practitioner to select a suitable provider of sexual services to their patient or client, and then to monitor whether the arrangement is achieving its objectives.     

Behandling af traumatiserede flygtninge med følger efter seksuel tortur: Et biopsykosocialt perspektiv

Many of the political refugees who have arrived in Denmark during the past decade have psychosomatic symptoms related to experiences of sexual torture during imprisonment. On the basis of clinical experience from treatment of traumatized refugees, the authors suggest a biopsychosocial approach to symptoms. This implies that therapists respect the symptoms presented by the refugees as a prerequisite for establishing contact and alliance, wherein also the ideology of both therapist and refugee plays an important part. In this context a re-framing of the symptoms can begin. It is demonstrated how sexual torture can affect the refugee by creating strong feelings of guilt and shame, which implies that the prisoner has experienced the torture as an individual act of humiliation. In the refraining of these traumatic experiences the ideologic consciousness of the refugee is an important element enabling the therapist to establish a frame of reference in which the sexual torture can be seen as a political weapon aimed at hitting the prisoner's weakest points. In the treatment sexologic techniques and couple therapy can be used in a transcultural setting. The methods of Culture Exchange and Giving Testimony are introduced as examples of transcultural therapeutic tools.