Thomas G. Gutheil, MD

Addressing Challenging Moments in Psychotherapy: Clinical Wisdom for Working with Individuals, Groups and Couples

by Jerome S. Gans, MD; Routledge, September 30, 2021

There are many useful books on beginning and continuing 

, but I sincerely doubt there are many as enjoyable to read as this one. Using a wealth of telling examples from psychotherapy and supervision, including candid examples of his own work and countertransference processing, Jerome S. Gans, MD, addresses matters that speak first to the primary concern of novice therapists: “What do I say?”; and to the concerns of more advanced therapists: “How do I get this therapy unstuck?” The importance of an exploratory approach above all is appropriately stressed; the context might best be described as psychodynamic, but with interpersonal and participant observation elements as well.

Gans brings nearly a half-century of experience in individual, group, couples, and consultation-liaison psychiatry (full disclosure: he is a long-time colleague). He can legitimately claim to offer clinical wisdom, although his tone here is often self-effacing. The text positively bristles with clinical examples from both his private practice and his extensive supervisory role. With laudable candor, like all great teachers, he often imparts his own personal countertransference difficulties and their resolutions to illustrate a point. The net effect is that this book will provide a kind of short-cut to the depth of his experience in a readily accessible form. The writing is clear and vivid and will remind clinicians of every stripe of their actual practices.

Two of the divisions in the text are observations of human nature and clinical pearls. The former represent the kind of assessments of behavior patterns, character pathology, and interpersonal dynamics that would most likely be of interest to a wide audience. The pearls are helpful phrases that encourage, or even force, introspection and challenge those fixed attitudes and habitual interactions of which the individual patient or therapy group are unaware.

An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future

Science Over Stigma: Education and Advocacy for Mental Health

Kings, Conquerors, Psychopaths: From Alexander to Hitler to the Corporation

The book consists of 11 chapters of general observations from his years of practice and 10 chapters of clinical pearls, each of the latter based on 2 examples each of carefully constructed comments that promote therapeutic progress, resolve dilemmas, or confront defenses. The focus here on “what do you actually say” will be of enormous help to therapists in general, especially beginners. Here are some brief examples of what a pearl looks like may be helpful in grasping this approach.

Many natural reactions are not helpful and many helpful reactions do not come naturally.

Isn’t it fortunate that all the objectionable people reside outside of our group?

How did such a kind, caring woman like you happen to choose a man like

What is it like coming every week to a therapist who doesn’t answer your questions, repeatedly misses the mark with her comments, and isn’t helping you?

The mechanisms by which these feats are accomplished are not usually to be found in textbooks of 

Gans explores the uses of humor, irony, paradox, counterprojective statements, and gentle management of defenses in individual and group therapy, with careful attention to timing, dosage, and potential pitfalls. Core value is placed on the state of the 

: some interventions work well at late stages of therapy but are inappropriate before the alliance is firmly established.

In the present popularity of cognitive behavioral therapy, dialectical behavioral therapy, and psychopharmacology, effective psychodynamic therapy sometimes seems to take a back seat. This book reassures those of us who practice the last category that this modality can be carefully and thoughtfully studied, improved, and used, all to the benefit of our patients.

has been faculty and staff at the Massachusetts Mental Health Center in Boston for half a century and is Professor of Psychiatry at Harvard Medical School.

Articles

Candid examples from psychotherapy and supervision makes this book by Jerome S. Gans, MD, a useful and enjoyable book for mental health professionals. 

6 Things to Remember When Practicing Telemedicine

Slideshows

What 6 things are important to keep telemedicine practice running smoothly? 

During the present COVID-19 pandemic, mental-health practitioners of all disciplines are becoming accustomed to a variety of telemedicine-enabled modalities for treatment and evaluation. A growing variety of telemedicine platforms are now in use. This development has produced an explosion of articles and other documents describing theoretical advantages and disadvantages of teletherapy in psychiatry and how it can best be carried out.

 For more than a decade we have practiced with the assistance of telecommunication technology for patient and examinee accessibility. Based on our own and our colleagues experience with clinical and forensic telepsychiatry, what follows are some practical pointers and potential pitfalls for clinical and forensic practitioners.

Over the past several decades, rural health care delivery, the courts, and prisons have increasingly relied on 

 to accomplish their work. This modality has increased access to examinations and improved care by medical professionals in remote geographic communities. However, it took the pandemic of 2020—and the suspension of some governmental regulations until an emergency no longer exists—to increase significantly the use of telemedicine. In forensic settings, telelinks are now used even by judges conducting trials, as well as in forensic competency evaluations, independent medical examinations, and tribunal hearings for evaluating claims of physician liability.

It is clear by now that telelink-enabled clinical and forensic evaluations are here to stay, given their evident convenience and cost savings. This is especially true in the forensic context, where the examiner and examinee, having no ongoing local treatment relationship, may be located in different regions of the country, or the examinee may be incarcerated or otherwise immobile. Moreover, elimination of the costs of travel allows for more frequent (virtual) meetings with patients, who can more easily maintain attention and concentration in shorter sessions. These may include persons suffering from psychosis, severe anxiety, depression, dissociation, fatigue, and/or lack of self-integration. Such meetings may routinely be preferred because the absence of travel, parking, and security requirements allows for more flexible scheduling and time- and cost-effectiveness.

Nonetheless, the authors believe that insufficient attention has been paid to concrete structural and behavioral details of this form of psychiatric work. There are practical issues to keep in mind that can increase the efficacy of clinical and forensic telepsychiatry, and steer clear of common pitfalls. (Except where otherwise specified, the term “interview” is meant to apply to both clinical and forensic interactions.)

It is important to establish appropriate video and audio platforms and to allow time to ensure that the preparatory technological setup for the interviews is working adequately. (When the interview is on the court premises, the setting and technical apparatus are predetermined.) As to what technological complaints need to be addressed, some evaluators have noted that poor lighting is a concern. Dark shadows, for example, can interfere with clarity of the visual image. In addition, disruptions in the video feed may interfere with accurate evaluation of the patient for abnormal involuntary movements (the AIMS test) used to monitor long-term effects of neuroleptics. On another sensory dimension, the sense of smell obviously cannot be utilized on video calls. For example, the odor of alcohol may go undetected—a significant potential omission. This limitation may necessitate alternative means of gathering otherwise olfactory-dependent data.

In the current COVID-19 emergency, free video platform setups, which have received HIPPA-compliant waivers from the federal government, may be used. However, the manufacturers may set time limits for the sessions that can compromise the needed length of an interview. Additionally, technical difficulties such as bandwidth and the absence of timely technical assistance may interrupt the flow of the interview. Such interruptions, if not adequately prepared for, may compromise the interview and affect the process of therapy or the findings of a forensic examination.

In forensic evaluations, problems may arise with connectivity for the attorney and/or the judge. The greater the number of persons on the video link, the greater the opportunities for technical interruptions, particularly when trying to connect with WIFI and cell phones. Allow time at the beginning of sessions to test and correct any audio or visual problems and plan for augmented bandwidth.

For a clinical interview, all participants have a role in establishing the appropriate guidelines. To begin with, it is important to establish who will schedule the sessions and provide the formal invitation. Some parties may prefer to originate the telecall interview to feel more in control of the session process. Generally, it is the party that initiates the link that is responsible for whether or not that link is HIPAA-compliant. Some patients who initiate telecommunication will wish to waive any applicable HIPAA-compliance requirement for the comfort of using a more familiar telecommunication pathway of their choice.

The visual environments of both parties can be expected to influence the dynamics of the interaction. While many interviewers practice in home offices, those are usually curated to some degree, with attention paid to the furnishings according to some concept of a professional space.

 By contrast, when practitioners who have not already set up home offices find themselves unexpectedly working from home in the pandemic, they may be working in their lived-in home. Both information and misinformation may emerge from this reality.

For this reason, some clinicians and evaluators, especially those who are novices to home office practice, prefer a blank screen that will not show personal effects in the office space or provide any indications of the geographic area of the assessment. Such details may expose clues to the whereabouts of secure locations needed in domestic violence or custody cases. Other practitioners use a virtual background, which, while reflecting an aspiration to neutrality, may also contribute to an aura of unreality. An inauthentic background can reinforce an interviewee’s predisposition to view Shakespeare’s metaphor of “All the world is a stage” (in “As You Like It”) in concrete terms. By contrast, appropriate objects visible in the office, such as works of art, can prompt helpful associations in psychotherapy or psychodynamically informed forensic examination. Regardless of the distinctive features of an interviewer’s office, it is often better that the background be the interviewer’s own authentic office.

The visual field of online practice has a number of potentially limiting factors. Awareness of these potential pitfalls is a vital step in increasing the efficacy of such practice.

For example, while video makes it easy to observe facial expressions and register tone of voice, the lower body, sometimes from the neck down, often is not visible. Some body language and aspects of dress are thus unavailable. This potential limitation may be particularly problematic in custody evaluations, where full body choreography in family evaluations is sometimes essential. The presence of the family can be a positive part of an online evaluation.

 However, if the interviewee is told to place him/herself far enough from the lens to permit such full viewing, facial expressions may be harder to see and the voice harder to hear. Varying the patient’s distance from the camera in the course of the interview is a potential remedial option when necessary. 

Telepsychiatry may not be the ideal or exclusive modality for young children, especially when they are overactive to the extent it is difficult to keep their attention or capture their interactions within the screen. However, evaluations for attention deficit disorders may be successfully accomplished using telehealth.

 The mindful observer may need to pay closer attention to information that may be more telepsychiatry-accessible, such as variation in eye movement, facial expression, and speech rhythm or tone, as well as to integrate this information into analysis of corroborative data.

In one such custody evaluation, a child being interviewed was noted to look away from the screen at times. It became clear that the parent, initially excused from the room, had returned, unnoticed by the interviewer, and witnessed (and perhaps influenced) the interview.

 screenings, it may help to visually take in the entire clinical gestalt of the family. Without an additional party running the cameras, many camera settings do not permit a full view of all parties at the same time. In such instances, more attention needs to be paid to the rhythm, timing, and tone of the family speech patterns. The visual gestalt may need to be further complemented by the auditory gestalt and corroborative data (eg, medical and school records, structured interviews, and psychological testing). 

Time may also be a relevant consideration, especially if clinician and patient are in different time zones. Some patients, uncertain about their appointment time, may be confused if placed in a digital waiting area until the doctor is available. Because of the recognized intensity of such meetings and the need for particular focus and attention, the session may need to be divided into 2 or more such meetings to allow breaks for either party.

In working with developmentally disabled individuals, some evaluators find that the lag in digital savvy can be a major holdup in the evaluation process, particularly with a deficit in WIFI and the staff’s inability to correct deficiencies. At times, the video feedback may be so distorted that the evaluator cannot get enough of the expressive language clues to understand the problem. This is made even more difficult when the staff is new and unfamiliar with the parties being assessed. The collegial relationship and teamwork between staff and evaluator are critical factors deciding the quality of the examination, particularly in agencies with increased staff turnover. With these patients, it is best to have a team in place, including a behavioral clinician, a nurse, and family members. However, be aware that some family members will not agree to participate in video sessions.

Some of the problems that emerge from online observations can be grouped under the rubric of potential distractions for both interviewer and interviewee.

Recording the session, as well as providing a record of the interview, may increase performance anxiety and attempts to manage one’s impression, especially in forensic examinations or adversarial proceedings, in which the examinee and others (family, attorney) have a stake in the outcome. The same applies to having a third party (such as an attorney) present. The distorting effect of recording or third-party presence in both the clinical and forensic contexts has been well studied.

 If such distortion is unavoidable (eg, by court order), special consideration needs to be given to minimizing it. In some states, such as Massachusetts, the recording of clinical interviews without permission of all parties is prohibited by law.

Some patients of all ages are more comfortable with audio transmission alone, as they are then less distracted by the close-up of the therapist’s face as well as their own. As in all therapy and evaluation, being aware and respectful of the wide range of individual variability, as well as of one’s own countertransference, is vital.

By contrast, the absence of the interviewer’s picture or the substitution of a photo for a live image may be experienced by some interviewees as inattentiveness or lack of interest on the part of the interviewer, much like analytic patients who cannot tolerate being unable to see the analyst. When an interviewer is aware of such a risk, asking the interviewee to describe their experience of the interview can be helpful. 

The picture-in-picture effect may have several valences, pro and con. For some interviewees it is a potent distraction. For others it may convey the reassuring presence of the examiner and/or an intrusive pressure to influence behavior. Not using picture-in-picture, especially in forensic contexts, may decrease some interviewees’ less authentic tendency to play to an audience. Clinicians and forensic examiners likewise may be distracted by their own faces or facial reactions, splitting attention from the interviewee. Alternatively, some interviewers find it helpful to see themselves as the process evolves, perhaps detecting their own countertransference reactions (eg, blind spots) and distractions. An interviewer’s awareness of these effects can help support the therapeutic alliance or the validity of a forensic examination.

How Therapeutic Issues Can Manifest in Telepsychiatry

Sometimes it is difficult to distinguish between interruptions or distractions attributable to technical imperfections or mishaps and those that have a deeper dynamic origin.

The session started on time, but when the questions moved into more affect-laden material, the examinee complained that they could no longer hear the examiner. After several attempts to resolve the difficulty, the interview was rescheduled. This change resulted in lost time for all parties. In this case, one might conclude that telepsychiatry was no longer time efficient. On the other hand, the ostensible technical breakdown might serve as an opening for exploration of sensitive material.

Awareness of a potential distraction can turn a potential video call pitfall into a therapeutic insight. Exploring the meaning of telelink-enabled communications in the course of treatment can be helpful not only for avoiding telelink-related pitfalls, but also for furthering the therapeutic process itself.

A patient who is a childhood survivor of the Shoah invariably kept her eyes glued to her therapist’s face on telelink. At one point she noted less cyberspace traffic than usual as background noise. Her associations to the changed transmission noise included the bombing she heard as a very young child in hiding. This exploration opened the path for a safer cyberspace discussion. Having less need to keep her eyes on the therapist’s face, she spoke more freely and with great insight into how her experience of social isolation as a hidden child at times shadowed her experience of danger and social isolation during the pandemic.

In telelink-enabled psychotherapy with an adolescent patient who had early issues around separation anxiety due to the father’s medical problems and a mother who felt the need to be immersed in work, processing the feelings of both being there and not being there opened up an avenue for more effective use of teletherapy.

When the patient is present in one’s office, one always knows what local emergency services to call in, which is not the case when the individual is a distance away. In virtual sessions, it is still sometimes necessary to have an appropriate emergency support network and backup plan at the patient’s site. In the rush to adapt to telehealth, there is a risk of omitting this step. Thus, for new patients, for some ongoing patients when indicated, and in high-risk populations of forensic examinees, a risk assessment should be completed at the beginning of every session, along with the standard brief technical check-in (“How’s the WIFI? Can you see me, hear me okay?”). Since interviews may occur at some distance from the practitioner’s location, and may even cross state lines, the practitioner should obtain phone numbers of local emergency services, police, family members, or significant others to assist in times of crisis. When indicated, the availability of such resources should be assessed and documented. 

During a teletherapy session, the patient became distressed and threw a chair at the monitor. A limit was set on this behavior, as it would have been had the patient and therapist shared the same physical space. The behavior was then explored for its meaning for the patient and the relationship.

, interviewers should know whether other parties are in the home or within earshot, and whether the session is being recorded. The use of HIPAA-compliant or -noncompliant telecommunications should also be identified. It is important to establish behavior limits, ensuring that the meeting is a safe time for communication without domination, bullying, or intimidation.

Many students are now spending much more time in the family home. One recalled that he had to go to a local coffeeshop or sit in the car to get needed WIFI for his session via cellphone and to be out of the hearing of family members. Obviously, a public setting poses its own privacy issues.

In one session a patient was discussing a sensitive marital issue when the spouse walked into the room.

Clearly, family privacy rules need to be set early in treatment. The patient may wish to bring others into the session; ideally, this would be discussed in advance. However, since the patient is already there, the opportunity for this step may be missed or scanted.

In addition, telepsychiatry poses some questions that the clinician or examiner needs to reflect upon, since a single size does not fit all patients or examinees; nor is telepsychiatry any more of a rote diagnostic-checklist exercise than in-person psychiatry. How does the new remote distancing process affect people of diverse cultures? How is rapport established between parties to encourage truthful disclosure? These are questions that need to be considered early in the process. Clinicians should inquire about the patient’s or examinee’s comfort during the process. 

Whenever possible, encourage patients to decide how and where the virtual interview will occur and proceed only with their agreement. They may have concerns about allowing someone into their home space; for example, an interviewee may be self-conscious about the appearance of their home environment. Inquire about what other options may be available for the interview: is there private space in a library or other accessible public building? For individuals needing an interpreter, how is this use accounted for in the responses to questions? How does this affect the 

It is essential to maintain a professional environment when working from home while connecting with the interviewee’s home space. Doing so requires an appropriate setting and attire, even if one is not fully visible to the patient. For example, interviewing from a bedroom or while wearing pajama bottoms is unwise.

It is the authors’ view that in some instances the casualness of the setting does present potential obstacles for maintaining appropriate boundaries, even when online. A messy environment in either the clinician’s or patient’s room may generate an atmosphere of laxity about the clinical work, leading to a loss of focus. On the other hand, with increased self-awareness and experience, a casual atmosphere can have the advantage of freeing all concerned from rigid formulations or habitual preconceptions.

The patient was interviewed at home. During the course of the session, the patient was suddenly lost from view. The patient had decided to take the therapist on a tour of the home and yard and was not aware that the WIFI did not extend outdoors.

A clinician reported that a patient partially disrobed in the session and had to be reminded of her state of undress and of the expected appropriate decorum.

 is not the same as in-person visits. Some patients feel that some things have been lost, such as empathy and respect. The shift to a virtual environment has shocked some patients, and some claim that physicians are seemingly less available and less empathic about patients’ concerns. One person complained that physicians seemed to be keeping their distance—even when the office was back up and running with appropriate personal protective equipment. Another patient, who had undergone major surgery for cancer, recalled that when they arrived for a follow-up visit, the treating physician spoke from the doorway and never came into the examining room

Has the patient-physician relationship suffered from this imposed distancing? Historically, it has been recognized that an emotionally vital and mutually respectful professional relationship between physician and patient offers some protection from lawsuits. The physician’s commitment to caring for the patient, even within the safe distancing of this pandemic, must be maintained.

When meeting patients online, mental-health practitioners must confront a host of issues. 

Telepsychiatry: Practical Pointers and Potential Pitfalls



Gutheil TG, Brodsky A. Preventing Boundary Violations in Clinical Practice. New York: Guilford Press; 2008.

Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice: theoretical and risk-management dimensions. Am J Psychiatry. 1993;150:188-196.

Gutheil TG, Gabbard GO. Misuses and misunderstandings of boundary theory in clinical and regulatory settings. Am J Psychiatry. 1998;155:409-414.

Gutheil TG, Simon RI. Non-sexual boundary crossings and boundary violations: the ethical dimension. Psychiatr Clin North Am. 2002;25:585-592.

Norris DM, Gutheil TG, Strasburger LH. This couldn’t happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatr Serv. 2003;54:517-522.
 

The points summarized in this pocket guide-drawn from actual cases-recur repeatedly as problems for practitioners.

9 Tips to Maintain Boundaries in Clinical Practice

Cases that come to our attention as malpractice claims, ethics claims, or Board of Registration complaints raise the question: why did the treating clinician not terminate the treatment before things got so out of hand?

The answers to this question embrace a wide range of issues, including rescue fantasies; beginners’ errors; transference/countertransference impasses; the drive or need to complete a task once begun; power issues; conflicts around abandonment; and narcissistic, sadistic, or erotic dynamics in the therapist and/or the patient. Often these difficulties play themselves out through boundary violations. Moreover, patients may, in some cases, employ a variety of strategies aimed at resisting termination, including threats of suicide, violence, or litigation and other forms of complaint.

Termination is the appropriate ending of therapy, but also it challenges the emotions of both parties in the dyad.

 We focus here on the therapist’s problem, recognizing that the particular chemistry of the dyad may be the wellspring of the issues leading to the impasse. Therefore, although patients may have difficulty in leaving treatment, this analysis addresses the matter from the therapist’s side.

 although it is difficult to achieve in today’s environment. The point is that treatment at impasse may be 

 prolonged under certain conditions-conditions that may lead to various forms of medicolegal trouble.

The case presented here is a composite of actual cases encountered by the authors. Although the case features a patient who has a personality disorder, termination problems can occur with a broad spectrum of conditions.

The italicized sections in the case are intended to indicate those ideas and postures that were pivotal tothe bad outcome, but the issues, of course, spread far wider than this one example.

Ms J is a 42-year-old married woman with recurring and persistent depression. She tells her psychiatrist, Dr S, that she terminated treatment with her 2 previous therapists out of frustration because they did not give her enough support and did not understand her depression adequately. She refuses to give Dr S permission to contact any previous treater, anxious lest those records “poison” this treatment. 

Dr S feels there is no patient he cannot treat, records or not, and decides to rescue her from her current depressed state that has apparently been mishandled by previous treaters. 

He agrees to treat her in his private home office, accessed by a separate entrance in his house. Ms J frequently passes, and interacts with, Dr S’s children as sheuses this entrance.

Early in the therapy, Ms J tells Dr S he is a miracle worker who, she hopes and prays, will never abandon her.

 Dr S, willingly accepting this description of himself, repeatedly reassures Ms J that he would never think of abandoning her.

Over time, Ms J demands that Dr S run over sessions if she is late, switch her session time to late in the day, and come to her house for a session-later, for every other session. 

After refusing all these requests at first, Dr S ultimately agrees to all of them, wishing not to be the disappointing therapist like her previous treaters. 

On one visit, she offers him wine, which he first refuses, then accepts. When she invites him to swim in her pool, he decides he should leave. 

He considers ending the therapy but feels that he should see it through, especially because of his patient’s obvious sensitivity to abandonment.

Invited in a demanding manner to visit again on a later occasion, he refuses on ethical grounds. The patient, enraged and arguing that she can only be treated in her home environment, states that, after all, he did come over before and if he really cares, he will come over again. When he does not do so, she leaves multiple messages stating that if he does not immediately call back, she will take her own life. 

Dr S rejects the idea of consultation because he perceives it as a sign of weakness. 

When he calls, she denies that she meant her threats and states she is “testing his loyalty.” She reminds him pointedly of all the sessions that ended with mutual hugs and of all the letters and e-mails signed “Love,” as though to say, 

Dr S decides to consult his insurer’s attorney.

Dr S writes the patient a letter indicating that because her calls and harassment have made the therapy unworkable, he believes it will be in her best interest to move on with another therapist. He offers 3 termination sessions and a 30-day supply of medication. The patient’s return letter is filled with recriminations, threats, reports of consultations with other therapists and plaintiffs’ attorneys, and reminders of his promise never to abandon her. Not so subtly, she threatens him with Board of Registration complaints, civil suits, and claims of ethics violations.

 She begs him to continue treatment, promising changed behavior according to his rules; 

if he refuses, he can discharge his obligations by a letter of apology and a full refund.

No specialized training is required to recognize how soon the situation in the case presented here spiraled out of control. Clearly, when the decision to terminate comes very late in the game, it often fails to “take.” We repeatedly encounter factors that delay the decision to terminate-even when that response is the only remaining appropriate one.

Clinicians enter the health field to help others and derive satisfaction from so doing. They have a sense of their own helpfulness and competence. However, these laudable attitudes may go astray into 

 and rescue fantasies. Informed consent represents the core of therapeutic work and should stand clearly at the outset.

The patient in the case refused to permit her previous records to enter into the treatment. A patient’s refusal to grant permission to obtain past records (or, at a minimum, to speak to the previous treater) should trigger active discussion of this matter. It may ultimately be a deal breaker to continuation of treatment, especially when the patient calls attention to problems in previous treatment. Many ominous pitfalls and therapeutic errors or impasses may be revealed by the records of, or remarks about, even failed previous treatments. Of course, great difficulty may attend locating previous treaters and obtaining records, assuming they kept records.

Grandiose and possibly counterphobic attitudes led Dr S to go ahead with treatment, despite being unable to obtain the patient’s past records. The expressed rescue fantasy (“I will save this patient”) and competitive strivings with devalued past treaters (“they failed, I will not”) also played a role in the decision. The narcissistic view that “I can treat anyone” is as erroneous as “anyone can be treated.”

 was met with reciprocal self-idealization by the therapist. This reciprocity may create the so-called magic bubble,

 a conceptual sphere that begins with a mutual admiration society containing super-patient and wonder-doctor. The doctor then becomes impervious to consultation, supervision, good judgment, and common sense.

We can infer some dynamic conflict around countertransference-derived sadistic feelings in Dr S, who bends over backward, as it were, to avoid abandonment-even when responsible termination and referral would have avoided that form of malpractice, although that was not the patient’s subjective feeling about it. Consultee therapists often report fearing the anger of the patient if they were to suggest termination. The unneutralized rage of individuals with personality disorder has the apparent ability to intimidate even seasoned therapists.

In addition to aggression, libido may play a role in delaying termination; gratifying erotic feelings and fantasies may account for the prolongation of some therapies beyond the appropriate point. A patient’s idealization of the therapist may have an erotic force.

A common precipitant to transference/countertransference problems is a personal crisis in the life of the therapist-for example, serious illness, divorce, or death of a loved one. Such stressors can easily weaken the therapist’s objectivity and ability to set limits early.

 . . Some features in the case presented above are commonly encountered and merit particular focus. One is the “you’ve already gone this far . . .” approach, in which the patient points out that some boundaries have already been crossed and thus further transgressions are required or demanded. In this situation, therapist guilt about past boundary transgressions may be the driving force behind agreeing to continue. Conversely, threats of complaint about early boundary issues may frighten or coerce the treater into continuing or expanding the crossings.

Consultee clinicians encountering “you’ve gone this far” report a complementary reaction of “it’s too late to change.” In reality, it is never too late to change one’s approach and terminate and refer as indicated, although in fact that response may not avert unfortunate consequences. The distance gone “too far” all too often leads to very undesirable results.

. The ability to say “No” to a patient’s demands, knowing that this response will frustrate, anger, or hurt the feelings of the patient, requires that the treater be comfortable with sadistic feelings, since one will be causing pain to another. We suggest that the widely acknowledged decline in awareness and teaching of dynamic theory has left many therapists unfamiliar and uncomfortable with this common yet problematic countertransference response.

Issues of power and control may also explain difficulty in terminating. Some therapists may be reluctant to give up a position of power over the patient and thus continue to hold on.

 A significant number of cases on which we have consulted reveal a highly disturbing unwillingness of the treater to obtain consultation, thus violating a sovereign principle of risk management, “never worry alone.” This reluctance empirically stems from 3 main sources: feelings of shame and guilt at what has already happened in the therapy; fear of reporting consequences (to Board or ethics committees) if the details are revealed; and, more regrettably, fear that the consultant will tell the therapist to get out of the relationship.

 While flexibility and willingness to negotiate are hallmarks of good therapy, a necessary and indicated termination should be sustained, even against psychological and other pressures from the patient to retract it, replete with promises to change, as in the case example. Some patients may attempt to exert pressure on the present therapist by refusing to see subsequent therapists, although that is the patient’s choice. Consultation may be helpful in strengthening the treater’s resolve.

 Appropriate documentation is extremely important in the charged situations described, but our experience is that the record can cut two ways. Recording inappropriate behavior by the patient, and the patient’s failure to be able to remedy such behavior after ample time and assistance, can be extremely helpful in refuting claims of negligence or abandonment. Inclusion in the record of all letters and e-mails to and from the patient avoids the appearance of concealing potentially damaging materials. However, e-mails and letters from the therapist that display an inappropriate tone, excessive informality, hints of intimacy, and expressions of endearment are damaging rather than protective.

 Even those therapists who are not highly compulsive may express an understandable wish to finish what they started: they resist the idea of terminating before the therapy is “completed.” This view acts as a strong deterrent to necessary termination.

 Efforts should always be made first, in the service of informed consent, to negotiate an alliance-based, boundary-respecting therapeutic relationship. Clear explanations of professional limits should be freely given. Barring physical attack or serious threat by the patient, which may require abrupt cessation of therapy, most terminations should be discussed in advance, negotiated, and enacted in a professional process. A responsible termination with appropriate referral does not constitute abandonment.

Given the complexity of the therapist-patient relationship, this brief review can only point to particular known trouble spots; it cannot cover the entire issue comprehensively. However, the ubiquity of this problem in leading to trouble for therapists requires at least a warning.

All of us who strive to be good therapists want to be helpful, to stick with the patient through the rough times, to finish a job once begun, and to assist the patient in meeting his or her clinical needs. But we cannot help everyone, and in some cases, we may need to stop. Breaking up is, in fact, hard to do, especially in a field that is largely based on sustained relationships. At certain points, however, it is necessary. Not everyone can treat everyone; not everyone can be treated. Awareness of the issues noted here may be helpful to clinicians struggling with essentially irreconcilable differences with their patients. Section 6 of the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry states

A physician shall, in the provision of appropriate care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide care.

Similar provisions are contained in other behavioral health specialties.

One approach has the therapist describe a treatment plan at the outset of therapy that requires such basics as on-time sessions, limited phone calls for emergencies, release of prior records, and a boundary-respecting approach going forward. The patient’s consent to this plan is sought (and usually given). If the plan is violated, the therapist explains that the patient is violating the agreed-on treatment plan, and the therapist cannot continue to provide treatment under those conditions. Such an approach makes informed consent the heart of the contract, as it should be.

The avoidance of consultation is a particular problem. We all have some hesitation in exposing our work to scrutiny, but the importance and clear value of consultation, not only as advice but also as protection, should be stressed for trainees and encouraged for peers among practitioners. Whether or not one consults through fear, one should never fear to consult. A patient who refuses to consult should be strongly urged to follow that advice. (Comparably, a patient should consider terminating with a clinician who refuses to consult.)

A point sometimes lost sight of by clinicians in crisis is this: if you realize you are practicing, by whatever means, below your 

 standard of care, you cannot defend your practice as being above the needed standard of care. No matter how far you fear you have gone astray, it is never too late to change your ways in the service of the patient’s welfare.

Few things are as valuable in the situations described as advice from an experienced health law attorney-preferably one who is familiar with psychiatric issues. In addition to valuable advice, an attorney can write termination letters to patients and intervene if the patient refuses to stop, threatens, calls excessively, or fills up your answering machine to a degree constituting harassment or other criminal acts.

In sum, clinicians must realize that in some cases, the best therapy is letting go.

 Levinson H. Termination of psychotherapy: some salient issues. 

 Hynan DJ. Client reasons and experiences in treatment that influence termination of psychotherapy.

 Hiatt H. The problem of termination of psychotherapy. 

 Martin ES, Schurtman R. Termination anxiety asit affects the therapist. 

 Dewald PA. The termination of psychotherapy. 

Preventing Boundary Violations in Clinical Practice.

 Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice: theoretical and risk-management dimensions. 

 Gutheil TG. Medicolegal pitfalls in the treatmentof borderline patients. 

 Norris DM, Gutheil TG, Strasburger LH. This couldn’t happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. 

The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.

 Arlington, VA: American Psychiatric Publishing; 2010.

Breaking Up Is Hard to Do: Terminating Therapy Before Things Get Out of Hand

The Yale School of Medicine Department of Psychiatry was host to Dr Thomas Gutheil, Professor of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School in Boston.
 
 Among Dr Gutheil’s key points: 
 • When there is a boundary issue, the therapist is culpable, even though both the therapist and patient may be responsible.  
 • Ultimately, the therapist has “fiduciary” power and-from a risk management perspective-the clinician must act in a manner in which misconduct cannot be inferred.
 • There are 2 types of boundary breaches: 
     – Boundary crossings
     – Boundary violations 
 • Some preventative measures against boundary violations:
     – Psychodynamic education
     – Alerting to “exceptions”
     – Didactic teaching explicitly on clinical and  legal pitfalls
     – Teaching on patient management
     – Presenting case of erotized transference  to supervisor

Psychotherapists have fiduciary power and-from a risk management perspective-the clinician must act in a manner in which misconduct cannot be inferred. In terms of boundary violations, some preventative measures (like psychodynamic education) can be taken.

Grand Rounds-Boundary Issues in Clinical Practice

Careful medical documentation is a primary factor in patient care, risk management, and liability prevention.

 Such documentation represents a contemporary record of the flow of patient care; thus, it can be extremely helpful to the practicing clinician and can be an important factor in error prevention.

Unfortunately, although a number of forms of documentation may simulate valid recordkeeping, in actuality these are hollow shells of verbiage rather than appropriate chart content. Here we address some of these problems of meaningless phrasing, empty shells, and template-distorted recording in an attempt to improve clinical documentation for both clinical care and risk management.

It is important to face the grim realities that underlie the issue of documentation: documentation is hard, boring, time-consuming, and unloved by almost all practitioners. In the here and now hurly-burly of clinical activity, it is hard to appreciate the value and long-term benefits of a solid, useful chart. Thus, it is easy to understand the seductive lure of any shortcut (eg, abbreviations) that promises-no matter how speciously-to lighten the load. While some abbreviations may be well understood and quite useful (MMPI-III is much more convenient than the full title written out), the examples below reveal abbreviations that do not accomplish a valid clinical purpose.

The lure is especially seductive given the striking (perhaps appalling) strictures on the time that doctors are currently allocated to spend with patients; under managed care in the modern era, the 5-minute medication check is not uncommon. The temptation also to compress the note taking can become extremely strong.

Modern documentation occurs in a novel electronic context. The electronic health record (EHR) was promised by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 to “save 100,000 lives a year and $77 billion annually.” In reality, 

 and medical errors have not been reduced nor have lives been saved; indeed, errors have been added.

 Moreover, since the EHR infrastructure is fundamentally insecure, 513 separate data breaches from 2005 to 2011 have affected more than 20 million patient records-and this number is limited to those actually reported.

One of the most common documentation shortcuts that offers an illusion of appropriate mental health assessment is the famous triad: no SI/HI/CFS. This, of course, stands for “no suicidal ideation, no homicidal ideation, contract for safety.” Although these abbreviations suggest that at least some questions were asked, this handful of letters does not represent an adequate suicide or homicide risk assessment of the patient, especially in an evaluation in which these particular concerns arise. These 7 letters are so deeply ingrained in clinicians that in a recent chart review, we found the statement “continuing suicidal ideation” in the history section but noted, in complete contradiction, “no SI/HI” in the mental status segment.

Another shorthand expression is WNL, “within normal limits.” While this abbreviation might be adequate for narrow aspects of a physical examination or certain highly specific laboratory values, it is difficult to attribute any meaning to this acronym when applied to mental status issues that require at least some elaboration. What does it mean to say one’s fund of information is within normal limits? How could any clinician possibly identify what is “normal” about particular mental status entries without more specific content? If one could identify “normal,” what would it mean? Two variants on this latter topic include “NML,” meaning normal, and “unremarkable,” perhaps the vaguest of them all.

Life’s but . . . full of sound and fury, signifying nothing.

“Pt. left AMA” without further content fails to offer subsequent treatment providers a clue as to the reason: disagreement with the treatment plan, rage at treatment providers, inability to pay, lack of insight into illness? Each of these precipitants and others not listed would be quite important for appropriate responses by subsequent clinicians.

Yet another shortcut is NKDA, “no known drug allergies.” Although it may be reassuring to indicate that no allergies are known, this acronym does not answer the question of whether the issue was actually raised by the interviewing clinician or whether it is merely a statement of that clinician’s ignorance of a potentially important clinical factor.

Another regrettably generic phrase is “by history.” This phrase is often used to refer to past significant events of a clinically relevant nature, such as past suicide attempts, incarcerations, and involuntary hospitalizations. Because it lacks any reference to a particular source, it is often unclear whether “by history” refers to the history that the patient is providing by self-report or whether the datum is recorded in some medical documents; if the latter, what are those documents?

According to DSM, the abbreviation NOS, “not otherwise specified,” represents a presumably appropriate inclusive attempt to describe a patient whose complex and idiosyncratic presentation offers a diagnostic pattern that simply fails to fit into the convenient pigeonholes provided by the diagnostic manual. In some charts, the abbreviation suggests that the writer of the entry cannot be bothered to be specific or to commit to a particular diagnosis. We have heard a story of a forensic psychiatrist who when testifying as an expert witness in an insanity context, refers to the diagnosis of all his examinees as “psychosis NOS” in order to forestall being cross-examined on the listing of necessary diagnostic features from the manual.

A puzzling entry often seen in the nursing notes in assessments in psychiatric inpatient charts is the comment: “skin warm and dry.” Neither the psychiatric nor mental status significance of this entry is clear, but it may merely suggest that the nurse in question has just transferred from a medical-surgical setting and has internalized this rote phrase from frequent usage in that earlier context.

“Patient pleasant on approach” begins a number of nursing notes that we have seen. “Pleasant” is sufficiently vague to embrace everything from cooperativeness to frank hypomania; but does “approach” mean seeking out the patient for an evaluation or pass-ing within the patient’s social orbit in a random encounter? Or does it refer to the patient approaching staff?

“Non-contributory,” as in “family history non-contributory,” gives the illusion of performing some kind of “rule-out” function but is sufficiently generic not to be useful. Can one seriously maintain that a patient’s family history does not contribute in any way to the patient’s condition, symptoms, or psychological makeup? Here again, the value judgment inherent in that term should have been replaced by a narrative about what the history actually revealed.

Note that the expression “rule out,” which indicates a task to be done in the future, is often misinterpreted by attorneys as a statement about the past, namely “that diagnosis has been ruled out.” Some clinicians suggest using “consider” as a preferable alternative (R. Sadoff, MD, personal communication, October 5, 2011).

Finally, in addition to empty words, one can find a chart with no ending: even after years of treatment notes, the record simply stops-blank. Did anyone notice that the patient was no longer coming, or was this an agreed-on (although completely undocumented) termination? If the former, were any efforts made to reach the patient? Was the patient transferred? Did the patient die?

Psychiatric records depend on narratives to provide a living and comprehensive picture of the patient. This goal is thwarted by the increasing use of checklists and simplistic templates that leave record notes stripped of personal meaning and context. Some authors suggest that the very appearance of this template-driven recoding is influenced by the DSM itself, which promotes a 

Such devices are a mixed blessing: on the one hand, they may act as prompts to ensure that certain questions will be asked and certain topics considered; on the other hand, in the common form of a chart page teeming with many, many tiny checkboxes, such devices completely obscure any narrative picture of the patient. In addition, a box or two may be unnoticed, and thus a number of important areas of inquiry are overlooked. Furthermore, the template designer may not be a clinician, and therefore a clinically important area may simply have been omitted. If some element is omitted, the computer blindly responds and fills in the blanks, often redundantly, as seen in the following true example: PSYCHIATRIC HISTORY: History of depression, history of anxiety. History of anxiety, history of depression. No psychiatric history.

Another major fault of some computer-generated templates is their tendency toward redundancy, repeating some or all previous entries. For example, a note on the fifth hospital day is preceded by all the notes of the previous 4 days and the sixth day’s note has the previous 5. Keeping pace with the evolution of the clinical case becomes increasingly daunting; simultaneously, the redundancy fails to allow the clinician to obtain an evolutionary picture of the patient as a person undergoing changes.

Other forms of redundancy also appear: Social history: Denies alcohol abuse, denies tobacco abuse, denies drug abuse: patient smoked tobacco but quit at least 10 years ago. Patient consumes alcohol socially; lives at home with family. Denies alcohol abuse, denies tobacco abuse, denies drug abuse. Patient smoked tobacco but quit at least 10 years ago. Patient consumes alcohol socially; lives at home with family.

Documentation remains very important, but practitioners should avoid deluding themselves into thinking that checking off forms and boxes (although sometimes necessary) constitutes adequate and sufficient documentation. This caution should be heeded by all clinicians and taught to trainees in all the relevant disciplines.

The core risk management issue is the fact that stock entries usually suggest that the proper assessment or intervention was not done, especially when unaccompanied by narrative that supplies the necessary context. It is too easy for a fact-finder or subsequent decision maker-be it in a liability claim, a board of registration complaint, or an ethics complaint-to see the stock phrases as indices of a rote mentality that fails to take into account the individual clinical needs of the particular patient in question.

One of the most important risk management functions of documentation is capturing the use of clinical judgment: exercise of clinical judgment is an antithesis of negligence. But judgment cannot be captured through a host of checkboxes, especially when the checklists are designed primarily for recording individual symptoms or signs rather than complex mental processes.

If writing abbreviated notes is such a bad idea, is there really a need for documentation? Lawyers sometimes take the position that “bad documentation is worse than no documentation.” While one can understand the lawyers’ perspective and their concerns about what to bring to court, clinicians need to remind themselves that documentation is not primarily for lawyers: the main concern is always the direct effect on patient care. If the clinical picture of the whole patient is absent or blurred, care suffers.

At least 1 hospital has eschewed the use of an electronic medical record for psychiatric emergency admissions. In part, this move is justified by the fact that the existing data entry system allows only a few computer characters to record historical information. For psychiatric patients arriving at the emergency department, there was simply not enough space for narrative entries. A new version of the entry system allows narrative to be included for these patients.

Historically, psychiatric material has been presented in narrative form. Similarly, patients tell us their histories in the same format-their narratives provide the chronology of their experiences as persons. Moreover, the vocabulary, syntax, grammar, and associative connections in the patients’ own stories tell us far more about them as persons than a simple listing of the facts and events that mark their life experiences.

While today the definition of a formulation has taken various forms, an old version popular in Boston was the triad of premorbid personality, external precipitating stress, and type of reaction. Although this model leaned heavily on an event-based theory of the emergence of psychopathology, it contained a narrative vision of what the patient experienced and afforded a holistic view of the patient.

A narrative framework is still needed to capture and convey what a patient is all about. This model should be taught as part of clinical training in all disciplines. Since writing clinically relevant narratives is not an inborn skill, and since all narratives are not uniformly useful in providing a valid picture of a patient, composing clinically meaningful narratives ought to be a seminal component of all training programs.

http://shakespeare.mit.edu/macbeth/full.html

 Gutheil TG. Paranoia and progress notes: a guide to forensically informed psychiatric recordkeeping. 

 Gutheil TG. Documentation and sexual response. 

 Gutheil TG. Fundamentals of medical record documentation. 

 Simon RI. Suicide risk assessment forms: form over substance? 

 Simon RI, Shuman DW. Therapeutic risk management of clinical-legal dilemmas: should it be a core competency? 

 Blackwell T. Electronic prescriptions do not reduce errors: study. 

http://www.nationalpost.com/Electronic+prescriptions+reduce+errors+study/4524330/story.html.

 Spruiell GL. Keeping tabs on tabulators: patient identification transformation. 

 Gopal AA, Bursztajn HJ. DSM biases evident in clinical training and courtroom testimony. 

http://www.psychiatricannalsonline.com/showPdf.asp?rID=23800

Here we address some of these problems of meaningless phrasing, empty shells, and template-distorted recording in an attempt to improve clinical documentation for both clinical care and risk management.

Empty Words in Psychiatric Records: Where Has Clinical Narrative Gone?

“Although a number of forms of medical record documentation may simulate valid recordkeeping, in reality these are hollow shells of verbiage rather than appropriate chart content."

So say Drs Thomas Gutheil and Robert Simon in their article published in the December 2011 issue of 

" In that article, the authors address problems of “meaningless phrasings, empty shells, and template-distorted records.”

Dr Gutheil has chosen that article-and the issues it addresses-as a top paper of the year and a key challenge facing psychiatrists. Here, he offers tips that may help you manage your medical records to optimize patient care, to manage risks, and to prevent liability.

Dr Gutheil is professor of psychiatry at Beth Israel Deaconess Medical Center of Harvard Medical School in Boston, and a new member of the editorial board of 

 Dr. Gutheil mentions the MMPI-III in his podcast: he meant to cite the MMPI-II.]

Podcasts

In this podcast, Dr Thomas Gutheil talks about a key challenge facing psychiatrists. . . valid medical record keeping. Here: important tips from an expert based on an article he coathored with Dr Robert Simon. 

Podcast: Psychiatric Records-Careful of Those Empty Words

In serving as an expert or consulting witness throughout the United States in more than 250 cases of boundary violations, up to and including sexual misconduct, I have observed some common pitfalls into which clinicians fall with distressing frequency. There are a variety of reasons for boundary problems; some may stem from the practitioner’s ignorance or exploitative character, others from moral weakness or emotional vulnerability, and so on. But what makes the matter even more distressing is the fact that some of the pitfalls I repeatedly observe, that often result in litigation or board complaints, could have been avoided with relative ease.

Here is a “pocket guide” for clinicians drawn from actual cases. With some modification, the list could become a patient information sheet or office policy.