Psychologist Seeks Return of License

By Colman Herman

CommonWealth

June 22, 2011

A female psychologist is asking the state's Supreme Judicial Court for her license back even though she violated one of the cardinal rules of her profession by having sex with a former patient.

The standard punishment for someone in the medical and related professions who has sex with a patient or former patient is permanent revocation of his or her license. Officials at several of the boards that oversee health professionals said they couldn’t recall an instance where a practitioner who had sex with a patient failed to lose his or her license.

But Brookline psychologist Mary O'Neill says she deserves another chance. She acknowledges beginning a sexual relationship with her patient, Eric MacLeish, just weeks after his therapy sessions ended, yet says her license shouldn’t be permanently revoked because her lapse in judgment was caused by a marriage that had collapsed.

O’Neill petitioned a single justice of the Supreme Judicial Court to review her license revocation by the Board of Registration in Psychology.  Subsequently, she and the board jointly asked the full court to hear the case, which it agreed to do. Oral arguments are scheduled for this fall.

O’Neill is arguing that the psychology board “arbitrarily and capriciously” refused to consider the mitigating evidence she presented. Rather than revoking her license, she says the board should have suspended her license for a year and then allowed her to resume work on a probationary basis for a year. She says she would continue to receive personal psychotherapy and have her work supervised by a peer. O’Neill also says she would do 100 hours of community service.

The psychology board’s regulations adopt the code of conduct of the American Psychology Association. The code states that “psychologists do not engage in sexual intimacies with current therapy clients/patients” nor with “former clients for at least two years after cessation of therapy.” Beyond two years, sex between a psychologist and patient is permitted only if the therapist can prove there has been no exploitation. The regulations also say it is not a defense to say the patient consented. The regulations were crafted to prevent psychologists from exploiting the tremendous power they often have over their patients and former patients.

In its April 2010 decision, the psychology board held that O’Neill’s marriage crisis “no doubt exacted a significant emotional toll” on her and that her “marriage crisis can be understood to have ‘clouded’ her judgment.” But the board nonetheless revoked her license, saying her care was the “antithesis of treatment” and her “conduct abrogates a basic tenet of the psychology profession: trust.”

The entire article can be found here.

Thanks to Ken Pope for this story.

Colleague Assistance

A recent article in the Monitor on Psychology by Rebecca Clay highlights several important points about colleague assistance and your ethical responsibilities as a psychologist.  The article features our own Sam Knapp.

The article, When A Colleague is Impaired, can be found here.  A portion of it is reproduced below.

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A psychologist friend of yours is undergoing a divorce so wrenching, you sense she can barely get up in the morning, let alone provide effective therapy.

A colleague in your building stumbles as he walks down the hall, and you smell alcohol on his breath.

You’ve heard that an older colleague has become forgetful, sometimes seems confused and has even fallen asleep during a session.

How do you ethically handle such scenarios?

APA’s Code of Ethics requires psychologists to recognize when their own personal problems might interfere with their effectiveness and take action. But when it’s someone else who has the problem, knowing what to do can be difficult.

“On the one hand, people want to do something; on the other, they don’t want to get someone in trouble where they might lose their license,” says Michael O. Ranney, executive director of the Ohio Psychological Association. “For many people, it’s a difficult ethical dilemma — what to do and how to do it.”

The approach Ranney and other experts recommend? Step in early and take advantage of a colleague assistance program or other forms of help offered by your state, provincial or territorial psychological association (SPTA). Reporting someone to the state licensing board should be a last resort, they emphasize.

Preventing problems

Getting other psychologists the help they need is an ethical duty just like getting help for yourself, says Stephen Behnke, JD, PhD, director of APA’s Ethics Office.

“All of our training, all of our experience is to promote health and well-being, and that should begin in our own community of psychologists,” he says. “It absolutely should be an ethical responsibility that we take on as psychologists to be that supportive community to our colleagues in distress.”

Stopping problems before they escalate is key, Behnke and others agree.

One way to do that is to develop and maintain a network of social relations with other psychologists, says Sam Knapp, EdD, director of professional affairs at the Pennsylvania Psychological Association. Work on meeting your colleagues and reach out to them in good times and bad.

“If you find out that a colleague has just had a death in the family or a divorce or some kind of event like that, send them a card or call them up and express condolences,” says Knapp. “Ninety-nine percent of the time they’re not going to slip into impairment, but they’re going to appreciate it and feel that they can confide in you about other things.”

It’s not just personal issues that can cause problems, he adds. A patient’s suicide, for example, could plunge a psychologist into depression.

Once other psychologists become comfortable with you, says Knapp, they might ask for a referral for therapy or substance abuse treatment. They might seek consultation on a case they’re having trouble with. Or they might just want someone to talk to.

What Should I Wear to Work?

by Sam Knapp, EdD, ABPP

Director of Professional Affairs

What should psychologists wear to their offices? Should I wear formal attire, casual attire, or business formal? As with the use of names and titles, the standards for dress vary according to context, such as the services being provided, the clientele being seen, the preferences of the psychologist, local customs, and other factors. For example, when going to court, formal attire is mandatory and doctoral level psychologists would generally refer to themselves as “doctor” in court. Generally, psychologists who provide services to upscale clients will dress differently from those who provide services to lower income patients. Problems can occur if psychologists who work with upscale clients dress too informally, in that the patients may not consider them professional enough. On the other hand, psychologists who work with lower income patients may appear “uppity” or out of touch if they dress too formally.

Women have to be careful because some men may misinterpret clothing perceived as too attractive, especially in combination with the use of first names, as an invitation to a boundary crossing. Psychologists who treat children often wear more casual clothing, especially if they do play therapy or other therapies requiring movement or getting on the floor. Also, some children view adults in formal attire as authoritarian and might be less likely to open up. Psychologists who work in hospitals or other institutions often wear softer and more comfortable shoes to accommodate the walking that they have to do as part of their jobs.

Local customs also influence dress choices. Other parts of the United States tend to be more informal in their dress, as are some rural parts of Pennsylvania. In Key West, Florida, Dr. Stephen Ragusea, a Florida psychologist transplanted from Pennsylvania, says he is the only psychologist (or professional) he knows who wears a shirt and tie, and health care professionals commonly wear Hawaiian shirts there. One younger psychologist from Hawaii resisted wearing skirts because she had a tattoo on her ankle. Although tattoos and body piercing are common among Hawaiians and many younger persons even on the Mainland, some older persons in Pennsylvania view them as disreputable. Although teenage clients might think it is cool to have a therapist with body piercing, their parents often feel quite differently.

The Ethics Committee: Part 3

This is the third and final installment of what we do as the Ethics Committee. 

We hope that these three blog posts give PPA’s membership a better idea of what we do.  The hope is also that other state associations learn from what we are doing.  If there are Ethics Committees in other state associations that engage in some creative activities, we would certainly enjoy hearing about them.

Consultation

·    PPA staff will respond to requests from members for consultation on ethical issues and often supplement their telephone or email consultations by referencing articles on the PPA Web site.

·    Ethics Committee members often respond to ethical issues that PPA members post on the PPA listserv, which has more than 700 subscribers.

·    For a fee PPA members may receive up to 3 hours per year of legal consultation from psychologist/attorneys through a legal consultation plan.

Resources for Ethics Educators

·    The Ethics Committee hosts an annual one-day workshop for Pennsylvania psychologists who teach ethics. For purposes of this conference, an ethics educator is defined broadly to include those who teach ethics in graduate school, teach ethics continuing education programs, supervise interns, belong to the ethics committees of local psychological associations, or who otherwise express an interest in teaching ethics. Topics include in-depth presentations on ethics as well as teaching strategies.

·    The Ethics Committee gives the annual Patricia M. Bricklin Award consisting of $500 to a Pennsylvania graduate student who submits the best work product (such as a paper) on ethics.

·    The Ethics Committee gives an annual award to a Pennsylvania psychologist who has made an outstanding contribution to ethics education.

·    Ethics Educators may use vignettes created by the Ethics Committee. For several years, the Ethics Committee posted an ethical dilemma on the PPA Bulletin Board. This allowed psychologists to comment on the dilemma, read the comments of other psychologists, and comment on the comments if they so choose. Several of these vignettes have had several thousand hits. We now post ethical vignettes on our Ethics Blog.

As a final thought on this theme, I invite those who are interested to visit our wikispace.  We stay organized via our wiki.  As a non-member, you can see the wiki, but not edit it.

Does your office appearance matter?

From research.news.osu

People may judge the quality and qualifications of psychotherapists simply by what their offices look like, a new study suggests.

After only viewing photos of offices, study participants gave higher marks to psychotherapists whose offices were neat and orderly, decorated with soft touches like pillows and throw rugs, and which featured personal touches like diplomas and framed photos.

"People seem to agree on what the office of a good therapist would look like and, especially, what it wouldn't look like," said Jack Nasar, co-author of the study and professor of city and regional planning at Ohio State University.

"Whether it is through cultural learning or something else, people think they can judge therapists just based on their office environment."

Nasar conducted the study with Ann Sloan Devlin, professor of psychology at Connecticut College.

Their study appears online in the Journal of Counseling Psychology and will appear in a future print edition.

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The entire press release can be found here.

British Psychological Society Critiques DSM-5



The British Psychological Society


The British Psychological Society responds to the new DSM-5.   A prior blog post looked at some criticism of the DSM-5.  The British Psychological Association offers a more formal, 26-page critique.  The entire document can be found here.  The first part of the critique is posted for your review.

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The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.

We therefore do welcome the proposal to include a profile of rating the severity of different symptoms over the preceding month. This is attractive, not only because it focuses on specific problems (see below), but because it introduces the concept of variability more fully into the system. That said, we have more concerns than plaudits.

The putative diagnoses presented in DSM-V are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgments, with little confirmatory physical 'signs' or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity.

Diagnostic categories do not predict response to medication or other interventions whereas more specific formulations or symptom clusters might (Moncrieff, 2007).

Finally, disorders categorised as ‘not otherwise specified’ are huge (running at 30% of all personality disorder diagnoses for example).

Personality disorder and psychoses are particularly troublesome as they are not adequately normed on the general population, where community surveys regularly report much higher prevalence and incidence than would be expected. This problem – as well as threatening the validity of the approach – has significant implications. If community samples show high levels of ‘prevalence’, social factors are minimised, and the continuum with normality is ignored. Then many of the people who describe normal forms of distress like feeling bereaved after three months, or traumatised by military conflict for more than a month, will meet diagnostic criteria.

In this context, we have significant concerns over consideration of inclusion of both “at-risk mental state” (prodrome) and “attenuated psychosis syndrome”. We recognise that the first proposal has now been dropped – and we welcome this. But the concept of “attenuated psychosis system” appears very worrying; it could be seen as an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis

Diagnostic systems such as these therefore fall short of the criteria for legitimate medical diagnoses. They certainly identify troubling or troubled people, but do not meet the criteria for categorisation demanded for a field of science or medicine (with a very few exceptions such as dementia.) We are also concerned that systems such as this are based on identifying problems as located within individuals.  This misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our wellbeing and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives.

Blogging from the Convention

John Gavazzi & Rick Small

Today, Rick Small and John Gavazzi presented an advanced ethics workshop on ethical decision-making.  The workshop addressed relational ethics: a blend of positive ethics, psychological culture, and patient-focused care.  They used the Acculturation Model (Gottlieb, Handelsman, and Knapp) as a means to introduce how relationships with the community of psychologists is an important factor in understanding the ethical culture of psychology.  Bridging from that model, they highlighted how ethical decisions can be understood within that framework. 

Rick and John also described the differences between remedial ethics and positive ethics.  They also touched upon principle-based ethics as a means to identify competing ethical principles that are sometimes found in ethical conflicts.  Since there is no ethical decision-making strategy within APA's Code, they explained how knowledge of ethics, emotional factors, cognitive biases and situational factors combine to make the best decision possible.  Simultaneously, the outcomes of these decisions are ambiguous at the time the decisions are made, which can lead to anxiety and uncertainty.

Relational ethics accentuates that ethical decisions play out within the psychologist's relationship to the patient.  Relational ethics includes a commitment to both the relationship and high quality of care.  Relational ethics combines psychologist factors with the clinical features of the patient.

Rick and John finished the lecture portion of the presentation with quality enhancing strategies related to documentation and redundant protections.

Finally, Rick and John provided participants with several ethical dilemmas.  The workshop participants discussed the vignettes, focusing on the following questions.

What factors make the dilemma difficult for the psychologist?

What would his/her emotional reactions be to the content of the scenario?

What types of redundant protections and documentation issues would be helpful for the dilemma?

Feedback from workshop participants was uniformly positive.

For a copy of the slides, please email John.

A 12-year-old Models Advocacy

Sometimes, psychologists do not recognize the many ways in which we can advocate for our patients.  In this case, a 12-year-old started a petition for the Boston Red Sox to become involved in an anti-bullying, anti-suicide video for the project "It Gets Better."

In the recent past, psychologists won a major victory for access to psychological services. We achieved mental health parity, but there is much work to do.

Join with APA and your state psychological organization.  No one else will advocate for psychology and our patients.  It is up to you to join, volunteer, and participate in advocacy for the profession and our patients. If a 12-year-old can do it, then certainly others can.

APA calls for psychologists inclusion in ACOs

Part of a psychologist's aspirational ethic is to urge government agencies to help our patients access appropriate psychological care.  This form of advocacy also advances our profession.  Here is a press release from the American Psychological Association that illustrates an important part of our collective professional responsibility.

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June 9, 2011—This week, APA sent a comment letter (PDF, 265KB) to the Department of Health and Human Services (HHS) regarding a draft proposal to establish Accountable Care Organizations (ACOs) in Medicare. Section 3022 of the Affordable Care Act requires the establishment of the Medicare Shared Saving Program, which is intended to encourage the development of ACOs.

ACOs, one of the reforms included in the Affordable Care Act, will allow hospitals, physicians and other Medicare providers and suppliers of services to establish a network that emphasizes primary and coordinated care. Medicare beneficiaries will enroll in an ACO as an alternative to fee-for-service delivery, where the ACO will coordinate their care in an effort to improve quality and contain cost increases. Medicare beneficiaries may still see providers of their choice but their care will be more carefully coordinated by the ACO.

The letter from APA Chief Executive Officer Norman B. Anderson, PhD, and APA Executive Director for Professional Practice Katherine C. Nordal, PhD, to HHS Secretary Kathleen Sebelius, dated June 6, 2011, addresses a specific portion of the proposal regarding health care professionals who may participate in ACOs.

In the letter, Drs. Nordal and Anderson urge inclusion of clinical psychologists as participants in ACOs, therefore ensuring better access of Medicare beneficiaries to mental health, substance use disorder and behavioral health services. The letter is a recent example of APA’s ongoing advocacy to promote psychologists as key players in primary care as it develops.

Among Anderson and Nordal’s comments:

- APA agrees with Sebelius’ decision to expand the list of providers eligible to

  participate in ACOs to include clinical psychologists and other providers not

  specifically named in the statute. 

- Clinical psychologists should be incentivized to provide care as part of the ACO

  primary care team. 

- Including clinical psychologists in ACOs ensures the integration of mental,

  substance use disorder and behavioral health with physical health and a more

  comprehensive integrated care system.

APA is asking HHS to retain and implement this provision in the proposed rule in the final draft. We anticipate that HHS will finalize the rule in the coming months.

APA and the APA Practice Organization will continue to evaluate and provide input on proposed rules of interest to practicing psychologists. 

For more information, contact the Government Relations department by email or at (202) 336-5870.