Abstract
The setting of an appropriate, considered, informed frame around doctor–patient interactions is increasingly recognized as a key issue in medical and particularly in psychiatric practice [1–4] Boundary transgressions, especially those involving sexual misconduct have emerged as a serious cause for concern and a major reason for complaint, litigation, and deregistration worldwide. In North America [5], [6], and in Australia [7], it is estimated that between 7 and 10% of male therapists, and around 1–3% of female therapists sexually abuse their patients. Within the educational frame too, trainees in Australia report inappropriate, disrespectful and even frankly abusive treatment from their supervisors as a serious issue [8], [9] This has also been reported overseas [10].
While all these studies must be viewed as less than definitive, relying as they do on questionnaire methodology [4], they certainly underline that the problem is one that must be confronted. Furthermore, there can no longer be any doubt about the harmful impact of such transgressions. A number of studies have clearly and repeatedly documented the destructive effects [11].
Such misconduct almost invariably begins in an apparently minor way. Small slips and boundary crossings, if not recognized and dealt with, can proceed inexorably from the harmless to the major violation with all its devastating effects [4], [12]. This progression has become widely known as ‘the slippery slope’ [3].
In response to the problem, it is often argued that penalties must be harsher, regulations more stringent, and offending colleagues should be evicted from the profession [13], [14]. Yet studies of transgressing therapists suggest that most of these people are not a group apart from the rest of the profession, but rather more like than unlike the rest of us [15]. Somewhere in the complex interaction between psychiatrist and patient, a series of events has unfolded which has led to the abuse. Unfortunately, it appears that all psychiatrists need to be mindful of the possibility of becoming a player in such a drama.
The ability to monitor behaviour, and particularly one's personal feelings and responses, is thus one of the important tasks facing registrars in training [4],[9–11],[15–17]. Yet the issue is not routinely addressed in most curricula.
Surveys in North America until recently found an overall absence of courses directly addressing this topic [18], [19].
In Australia, no such course exists to the author's knowledge, despite several highly publicized accounts over the last few years regarding severe sexual misconduct on the part of high-profile psychiatrists and other medical practitioners here and in New Zealand.
Drawing heavily on previously devised courses from the USA [17], [18],[20–22], a course was devised to address these issues. Modifications were made to accommodate
Australian and New Zealand culture in general, and to address the specific difficulties of a smaller community in particular.
Objectives
The objectives were to pilot a course for psychiatry trainees and to: Evaluate the feasibility of engaging a registrar cohort in sessions focusing on professional boundary maintenance, feelings generated in psychiatric practice and awareness of the balance between over- and underinvolvement with patients; Evaluate the acceptability of the format in which the programme was delivered; Evaluate any changes in attitudes achieved by such a programme; and Attempt to plan ahead for further teaching in this area.
Method
All trainees currently enrolled in postgraduate training in the Newcastle and Central Coast Psychiatry Training Programme were invited to participate in a three-session course scheduled in normal didactic training time. Each session ran for approximately 2 h and the sessions were at weekly intervals.
Course description
Presenters
The author (female) acted as the anchor person for each session and used three separate co-presenters. Each was male to preserve a gender balance. The chosen co-leaders were:
Session 1: a newly qualified psychiatrist working primarily in private practice;
Session 2: a psychiatrist from outside the area who was a recent member of the New South Wales Medical Board Impaired Practitioner Programme; and
Session 3: a consultant psychiatrist working within the local Mental Health Service.
Material
Session 1: overall rules for the conduct of the sessions including openness, sensitivity, support, confidentiality; and basic definitions and discussion of concepts including boundaries, the fiduciary relationship; transference, countertransference.
Session 2: the establishment and maintenance of appropriate boundaries with attention to the need for flexibility and limit setting; typologies of therapists who exploit their patients and of patients who may be vulnerable to exploitation; medicolegal issues.
Session 3: feelings evoked in therapy including affection, dislike, anger, sexual attraction, guidelines for managing such feelings, use of supervision.
Presentation methods
A wide variety of methods was deliberately used: Examples and anecdotes of personal experience of the presenters; Handouts of useful reference material [1], [3], [7], [16], [23]; Questionnaires evaluating knowledge of the literature in the area and personal attitudes; Video vignettes of troubling confrontations [21] and commercial film material; Newspaper articles describing local cases of misconduct and how they were treated by the courts; and Role-play: using presenters to play out a hypothetical interview between the Director of Training and a registrar involved in a worrying boundary transgression.
Evaluation
Vignettes were distributed prior to the first (vignette 1) and after the final (vignette 2) sessions. The vignettes are included in Table 1; they were chosen from a selection included by Pope et al. [24] to generate reflection and to contain unusual but feasible situations which have no ‘right or wrong’ solutions. Registrars were instructed to list issues arising from each, and possible ways to manage them.
Vignettes
In addition, trainees completed an evaluation questionnaire at the end of the final session rating the choice of presenters, the modes of presentation, the number of sessions and the main topics presented. Questionnaires were anonymous and were collected immediately after the third session.
Finally, questionnaires were sent out to the supervisors of the involved trainees to ascertain their awareness/involvement in the process.
Results
Of a total of 19 trainee psychiatrists enrolled in the lecture programme, the sessions were attended by 79%, 79% and 89%, respectively.
Since two trainees were absent on leave for all three sessions almost all trainees able to attend did so. Anxiety was particularly marked in the first session, with few contributions from the trainees; these increased slightly but remained largely in the domain of question and observation with little self-revelation. The most common issue raised was the perceived difficulty with creating professionally appropriate distance without seeming uncaring or rude. This led to discussion of self-revelation and how much was appropriate. There was also considerable discussion about the problems experienced trying to preserve privacy in small communities. The issue of personal distress coming either from the workplace or from outside, and the sense of being unsupported was, frequently raised particularly in relation to patient suicide. However, despite recent highly publicized cases of misconduct involving professionals from the area and further afield, the registrars did not appear to have considered such an occurrence as a personal risk. There was no discussion relating to difficulties encountered by trainees, and the role-play which alluded to such transgression led to vigorous defence of the ‘registrar’ and a discussion on perceived lack of support.
All trainees completed responses to the vignettes as asked. The responses to the vignettes were categorized into themes. In vignette 1, the most common theme to emerge related to a sense of invasion of privacy and attempts to control this. This was expressed both as an issue (having one's private life exposed, being intruded upon) and as a way to manage (move seats, close eyes, leave psychiatry!). In a similar vein, around one-third of respondents felt that the incident would mean that therapy would need to be terminated. In total, this theme appeared in around 60% of answers. The next most commonly noted issue was the need to explore the meaning for the patient; this was described in terms of ‘consideration of the transference’, and also as the feelings of the patient needing to be explored and discussed in subsequent therapy sessions. Another group of responses may be described as ‘telling’ rather than exploring; in these, patients were informed that they needed to remember that this was a therapeutic and not a personal encounter, or were greeted and acknowledged without any need to check or understand. Finally, one-third of all respondents said they would discuss the situation in supervision to obtain guidance.
By contrast, responses to vignette 2 were somewhat different. They were more concise and mentioned the word ‘boundary’ or the phrase ‘slippery slope’ frequently. The notion of invasion of privacy and escape from the situation again did appear, but was mentioned less frequently: only in 20% of answers. Needing to terminate therapy forthwith came up only once this time. The idea of exploration and understanding was by far the most common theme this time, being mentioned in every single response. A more didactic ‘telling’ or ‘explaining’ response appeared but again less commonly than in the earlier set of responses. Finally, supervision was again mentioned only by one-third of the trainees. A summary of the responses arranged in general themes is included in Table 2.
Vignette responses – themes and frequency
Overall, satisfaction with the course was high. All participants rated the course as either very important (94%) or fairly important (6%).
Most felt that they had definitely got what they had wanted from the course (53%); 73% said they would definitely recommend the course to other registrars. The use of varied facilitators was unanimously endorsed. Most (60%) endorsed the number of sessions, 33% wanted the number increased, 7% wanted them decreased.
Ratings given regarding the relevance of some of the topics presented were all high, with the more general topics: ‘nature of boundaries’, ‘transference and countertransference’ and ‘powerful feelings in therapy’ being rated as the most important; ‘current professional guidelines’, ‘general legal issues’, and ‘perpetrators and victims of boundary violations’ were seen as somewhat less important.
Additional comments added varied from a stated desire to have more freedom to discuss personal material, to a concern that such sensitive issues could be more freely discussed if the groups were segregated by gender.
The questionnaire for supervisors was mailed out to the 15 principal supervisors whose trainees had participated; the return rate was 73%. Of these, 64% answered that they had been aware that there was a programme on professional boundaries being conducted and 46% that their registrar had discussed the lectures with them. Supervisors were evenly distributed among those who felt that issues related to boundaries had arisen a little more frequently over the month and those who felt that there had been no change. None had observed a major change. All agreed that the topic was a useful part of training and 81% felt that more training was needed on the topic for supervisors themselves.
Discussion
The importance of focusing on professional conduct and misconduct before problems arise has been increasingly accepted. Attention has been drawn to these issues in the local literature [7], [25] as well as in recent RANZCP reports. The revision of the RANZCP code of ethics [26] emphasizes the ‘power differential in the psychiatrist– patient relationship’ and directly addresses the issue of sexual exploitation. The review of training and education currently well underway [27] recommends a continuous self-directed approach to maintenance of professional standards and stresses the need for supervision to emphasize continuous self-reflection and peer review.
This paper describes a pilot of one possible method to address these issues during training.
The course drew heavily from similar programmes in North America [21], [22] both in the format and the didactic material chosen [3], [5], [11], [12], [16], [28], [29]. However, some differences were deliberately built in to adapt to what were perceived as local needs.
The most important difference was in the emphasis of the course. It was decided that while sexual feelings and sexual boundary maintenance should be a crucial part of the teaching, it was important to focus on other strong feelings and professional issues. These were frequently raised by participants, and included the impact of patient suicide, the relationship between trainees, the relationship between trainee and supervisor, the issue of selfdisclosure to patients and the difference between psychotherapeutic and non-psychotherapeutic work. While it was recognized that moving away from the issue of sexual and loving feelings might constitute avoidance, nevertheless these other issues are a crucial part of professional practice and taking them seriously accords with the ‘slippery slope’ theory of boundary violations [3]. Registrar evaluation tended to rate these more general issues more highly than those related specifically to sexual misconduct. This may represent avoidance or a valid expression of preference.
It has been suggested that despite increasing recognition of the problems of professional misconduct, the conditions under which registrars now train may in fact increase the risk of these occurring [10], [25], [30], [31]. With the reduction in emphasis on training and experience in psychotherapy, some of the concepts traditionally taught in that context may have been overlooked. The most relevant of these is the ability to recognize and manage countertransference, not just in the setting of psychotherapy, but in all areas of practice [28], [31]. Furthermore, even where active psychotherapy programmes do exist, the issue of sexual attraction to patients and its proper management is a difficult and sensitive subject, and is frequently simply ignored [31], [32]. This was borne out in this cohort. The registrar group did not appear to have had any opportunity to discuss the topic of sexual feelings towards patients in any other forum, and in only a minority of cases did they respond either in discussion or in response to the vignettes that they could obtain help in supervision.
The responses to the vignettes at the beginning and at the end of the course suggested that some changes had occurred over the sessions, presumably as a result of the chance to discuss and reflect. In particular, there seemed to be less tendency to escape or avoid at the end of the course. There were also more responses suggesting a willingness to explore and discuss feelings, rather than to set limits unilaterally. On the other hand, there was no increase in the use of supervision.
No attempt was made to measure general knowledge about the issues before and after the course as has been done elsewhere [21], [22]. It was felt that this would inappropriately imply that change in attitudes and behaviour are based on an increase in theoretical knowledge whereas the course was designed to promote openness to thought and discussion.
On the whole, an atmosphere of freedom and honesty was achieved. Perhaps predictably, the most self-revealing anecdotes were told by presenters, and no trainee ventured an experience that might have been criticised by others in the group. In other words, some self-censorship almost certainly remained. Similarly, the ubiquity of sexual feelings in therapy and indeed in doctor–patient relationships in general was talked about more freely by the presenters with no self-disclosure by the trainees. It is thus entirely possible that ongoing, current undesirable behaviour in the group was kept silent. There is no way of knowing whether discussion might have had an impact even so, although this may be overly optimistic.
However, the basic concepts of boundary creation and maintenance, and the importance of ongoing selfmonitoring, supervision and discussion did seem to be welcomed and carefully considered by the group. In this regard, the excellent attendance provides some optimism for the ability to continue this process throughout training, and to encourage a further course next year and perhaps every year thereafter.
The main change suggested by the pilot experience would be towards discussion of a greater range of difficult feelings and situations encountered in working situations and more strenuous efforts to involve registrars in some discussion of personal experience.
Footnotes
Acknowledgements
The author thanks the co-presenters Drs Slowiaczek, Diamond and Hornabrook, and the trainees of the Newcastle and Central Coast Psychiatry Training Programme who kindly and generously participated in the project and contributed openly and sensitively.