Thomas G. Gutheil, MD



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.
 

Slideshows

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.

Articles

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

[[{"type":"media","view_mode":"media_crop","fid":"32298","attributes":{"alt":"","class":"media-image","height":"154","id":"media_crop_8360510518551","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3418","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":"","typeof":"foaf:Image","width":"104"}}]]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.

I have written extensively about this problem, but books and articles take time to read and grasp and are not always available when you need them. To aid the practitioners confronting these pitfalls, a handy short list is offered-a kind of conceptual wallet card-of extremely simple but effective risk management tips to aid in staying out of trouble. Consider this list a highly distilled summary of a spectrum of potential boundary problems. Note that there may well be context-driven exceptions to each of these points (eg, in some forms of behavior therapy), but that does not preclude keeping these points in the forefront of one’s clinical work.

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

When invited to do something unusual, ask yourself: “Is this what a therapist/psychiatrist does?” Also ask yourself: “Is this for me or for the patient?” An amazing number of treatments go forward without a contract (ie, an agreement by both parties as to what they are there for or what they will work on and how). Not having a contract is a very bad idea. Requests by patients to stray from the therapeutic contract (hold hands, sit on lap, take trips, etc) should be explored and almost always resisted.

 As a rule, do not take patients outside the office. There are exceptions to the rule: Some programs do use chaperoned home visits, and there are behavior therapy protocols that include outings; however, these must always be within standard practice (eg, treatment of agoraphobia).

 Consult with a colleague, supervisor, or mentor before questionable actions can occur or after something questionable has occurred. Always remember to document your consultation sessions about patients.

 You may be emotionally present (but not unconditionally) when in session, barring ordinary human distractions. But do not promise to “always be there” for the patient; it is not a promise that you can keep. Someday your treatment of the patient will come to an end, either by mutual agreement or because of unforeseen circumstances (eg, you may fall ill or you may have a family emergency)-all of which will seem to some patients and, later, to some decision-making bodies, like a betrayal and an abandonment.

Do not avoid personal questions from the patient.

 As a rule, explore therapeutically a patient’s personal questions about you rather than either giving the requested information or responding in a rejecting or punitive manner.

Know the protocol for gift giving and receiving.

 Treat a patient’s gift as an opportunity to explore. Document your reasoning for accepting or not accepting a gift, and discuss the reasoning with the patient. Avoid giving gifts to adult patients. Boards of registration and licensure often practice “concrete thinking” about gifts and other boundary issues and equally often ignore context; they seem to operate out of a “list of forbidden acts” schema rather than a model based on context, clinical variability, and discretion.

 You have to supply the context in your notes. If you give a patient a relevant book or article, write it down with your reasons.

When communicating with patients, be cordial and polite.

 Do not sign letters, cards, or e-mails “Love,” even if you do so with everyone else in your life. It is, of course, a standard, common, supposedly harmless and perhaps mildly hypocritical closing, but the very patients who are most likely to misconstrue it are the very ones to whom you should not be writing it.

Communicate your caring and concern by always keeping your focus on the patient’s needs and issues first. Do not tell a patient that you love him or her, even if you do. You may mean divine, abstract love, but the patient may hear (and the board may assume you meant) eros.

 Thoroughly document the incidents that seem questionable to you regarding boundaries; not to do so suggests a cover up. Use the 3 D’s: demeanor, documentation, and debriefing. If you give a patient a ride to the bus station in a blizzard, for example, keep a professional demeanor in the car; document the situation and your reasoning; and debrief it with the patient at his or her next session.

Such a concentrated summary as this pocket guide cannot be comprehensive, but the points summarized here recur repeatedly as problems for practitioners. For further analysis and discussion, see “Additional Reading,” below. Thoughtful, knowledgeable practice is always best for patients and the best avoidance of trouble for clinicians.

Preventing Boundary Violations in Clinical Practice

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

. 1993;150:188-196.
Gutheil TG, Gabbard GO. Misuses and misunderstandings of boundary theory in clinical and regulatory settings. 

. 1998;155:409-414.
Gutheil TG, Simon RI. Non-sexual boundary crossings and boundary violations: the ethical dimension. 

 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. 

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.

A “Pocket Guide” to Avoiding the Most Common Boundary Pitfalls

To the APA Leadership and Membership Committee:

This letter constitutes my formal resignation from the American Psychiatric Association. Although my feeling that the APA does not have its members' interests at heart has been growing for many years, the precipitant for this action is, first, the selection of Archbishop Desmond Tutu as recipient of one of APA's highest honors, the role of convocation speaker and second (and more important), the complete indifference and non-responsiveness of the leadership when his despicable record of anti-semitism and anti-Israel communications was explicitly pointed out by actual cites and quotations. The leadership's refusal not only to dis-invite him but even to respond to members' concerns was, for me, the final straw.

I will, of course, also be boycotting the Hawaii meeting and urging all I communicate with to do the same.

Thomas G. Gutheil, MD
Distinguished Life Fellow (resigned)
 

a copy of his letter. Interested readers can learn more about this controversy by reading 

"Boycotts and Protests to Meet APA Keynote Speaker, Desmond Tutu."]

This letter constitutes my formal resignation from the American Psychiatric Association.

A Letter To the APA Leadership and Membership Committee

The issue of self-disclosure in psychotherapy is one of complexity and some evolution.

 Most discussions about the practice refer to boundary questions because self-disclosure by the therapist to the patient is a boundary issue. Self-disclosure has, of course, a number of dimensions, including clinical, therapeutic, technical and-in some cases-legal or regulatory. Despite the rich and interesting clinical issues relating to self-disclosure (outlined in Gutheil and Brodsky

), the focus of this article is on the ethical aspects of self-disclosure.

Of necessity, the discussion centers on the more exploratory forms of psychotherapy, such as dynamic therapy, rather than on behavioral therapies, co-counseling, substance abuse treatment, or pharmacological treatment.

In considering ethical aspects of self-disclosure, we should identify the most relevant principles, which are:

• Beneficence (doing good for the patient)

• The fiduciary relationship between clinician and patient, where the interests and welfare of the patient always predominate

These 3 principles share the purpose of undertaking therapeutic interventions to benefit the patient, not the therapist. Indeed, respecting the dignity of the patient is the sovereign ethical principle that guides all the others. Compassion, neutrality, altruism, autonomy, and abstinence from personal gratification may also be invoked in resolving dilemmas regarding self-disclosure.

In contradistinction to the ethical principles above, we may identify a number of potentially unethical motivations for self-disclosure. Therapists can violate the above principles through self-disclosure that is ex-cessive, seductive, exploitative, or narcissistic/exhibitionistic. Unethical self-disclosure may also occur because the therapist wishes solely to unburden himself or herself of some concern, with no foreseeable benefit to the patient.

 outlines how ethical principles may be correlated with boundary violations (the latter defined in more detail below).

Self-disclosure manifests itself in 3 major forms in actual clinical practice. One form is inevitable self-disclosures. A number of self-disclosures occur with no possibility of avoiding them (

). These may or may not be problematic but may well enter into the therapeutic discourse. Therapists, as it were, are broadcasting on the international social awareness frequency at every moment of the relationship, and patients have receivers of variable bandwidth. Some of these disclosures may be unconscious:

The well-known psychoanalyst Ralph Greenson in 1967 admitted that his patient actually figured out that Dr Greenson was a liberal Democrat. Greenson, who thought he was practicing anonymity, asked, “How is that?” The patient explained that when he mentioned anything positive about Roosevelt, Greenson was silent. If the patient said anything negative about Roosevelt, Greenson asked for his associations, implying that not liking Roosevelt was an infantile feeling. . . . Greenson’s response to being discovered was both chagrin and the realization that pure anonymity was impossible.

Accidental self-disclosures are extratherapeutic encounters, slips of the tongue, public notices of lectures, obituaries, and so on. Personal aspects of the therapist’s life come to light because the therapist calls a patient by another patient’s name, a newspaper prints an obituary of the therapist’s spouse, or the therapist is seen entering a place of worship.

• The 3 principles most relevant to ethical aspects of self-disclosure are beneficence; nonmaleficence; and the fiduciary relationship between clinician and patient, where the interests and welfare of the patient always predominate.

• Intentional self-disclosures may be clinically based and therapeutic, supportive and alliance-building; or they may be seductive, exhibitionistic, care-seeking, and the like.

• Patients may be ambivalent about having personal questions answered: the therapist’s task is to explore and determine whether the patient truly needs to hear the answer to prevent a therapeutic impasse. 

Intentional self-disclosures occur during the session. They may be clinically based and therapeutic, supportive and alliance-building; or they may be seductive, exhibitionistic, care-seeking, and the like. Modern social networking systems (eg, Facebook, MySpace) exemplify intentional self-disclosure without a particular patient focus. In contrast, Internet search engines (eg, Google, LexisNexis) may allow unintended disclosure of personal details of the therapist’s life.

A therapist told a patient that he had to postpone their next session because of illness in his family; another postponement followed when the therapist’s relative died. After each of these absences the patient said, “I’m not going to ask you anything about this, but are you all right?” That was an appropriate thing for the patient to say, but in retrospect the therapist felt that he had burdened the patient unnecessarily by sharing his personal misfortune with the patient. It shifted the focus of need and care from the patient to the therapist.

Distinctions are often drawn between intra- and extra-session disclosure. The former appears to provoke fewer ethical conflicts than when the therapist brings in personal material from “outside.” For example, saying to a patient, “I feel as though you are shutting me out today; why might that be?” proffers a disclosure of the therapist’s personal feelings in a way that encourages clinical exploration. In contrast, comments along the generic lines of “A funny thing happened to me the other day” merit some doubt about their clinical value and utility.

Everything a therapist does or does not say is a disclosure, but not necessarily an inappropriate one.

In this area as in all matters involving possible boundary problems, 

 is the most important determinant in assessing the appropriateness and ethical valence of self-disclosure.

 First, different schools of therapeutic practice may have different teachings about self-disclosure; classical psychoanalysis, client-centered therapy, existential therapy, and reality therapy may place different weights on the therapist’s transparency. Second, different patients with different diagnoses, as well as the same patients at different stages of therapy, may require different decision making about self-disclosure. Third, the therapist’s motivation and intent are critical factors in weighing the ethical force of self-disclosure, particularly whether the goal of such disclosure is primarily for the patient’s benefit.

As noted elsewhere, boundary issues like self-disclosure may be divided into 2 categories with ethical implications.

 Boundary crossings represent departures from usual therapeutic practice that do not harm the patient or the therapeutic work (the principle of nonmaleficence). Boundary violations, in contrast, depart from usual practice but have the effect of harming the patient, often (but not always) in the form of exploitation of the patient. For example, a therapist who states, “I am having such intense sexual feelings for you I can barely stay in my chair” is clearly being seductive while intruding personal issues into the therapy. Although context is still determinative, in most cases the therapist’s disclosure of sexual feelings usually burdens, alienates, inflames, frightens, or intimidates the patient.

Furthermore, the fiduciary obligations of the therapist require that he take responsibility for setting and maintaining the boundaries, even against pressure from the patient to transgress them.

It is important to consider that self-disclosure may have specific benefits in context, when clearly done for the particular patient’s benefit. Some of these benefits are listed in 

Nondisclosure, or refusal to disclose when asked, is also a disclosure, eg, of a posture toward the patient, of a distant or ungiving persona, of a theoretical orientation, or of withholding. Moreover, the patient’s ability to tolerate and use nondisclosure for therapeutic advantage may depend heavily on how the therapist couches the refusal to disclose on request. It is one thing to turn the patients’ queries perpetually back on themselves (“Where do 

 think I am going on vacation?”) and another to use tact, restraint, and a nonrejecting manner in responding. Epstein

I’d like to hear about your interest in this and to know more about it and any other questions you have, but I prefer not to reveal information about my personal life to you. Doing so could alter my special professional role with you, which is for me to listen to your thoughts and feelings rather than for me to burden you with mine.

This example brings out the fact that self-disclosure may burden the patient. It also hints that patients may be ambivalent about having a personal question answered. Maroda

 suggests that the therapist’s task is to explore and determine whether the patient truly needs to hear the an-swer to prevent a therapeutic impasse. Patients who are curious but who do not need to hear the answer tend to let the matter drop. Those who do need an answer become stuck on the issue, which should lead to consideration about the necessity of self-disclosure.

Therapists are well advised to think through their own views on the ethics of self-disclosure in advance. When an unforeseen opportunity arises, or when a patient requests disclosure, the response-though also spontaneous-will be neither thoughtless nor impulsive. Indeed, the opportunity for the therapist to reflect, and to explore the matter with the patient should not be neglected in favor of a prompt answer, such as is often sought in the doorway of the office as the patient is leaving.

 A respectful temporizing response is useful, such as, “That sounds like something we might want to explore more thoroughly in our next session.”

As always, the twin standbys of documentation and consultation should not be neglected in this complex area. Visualizing about having to document a particular disclosure may aid in guiding the therapist on its appropriateness.

Both disclosure and nondisclosure may foster or impair the therapeutic alliance. Critical contextual issues include the timing of disclosure, the condition of the patient, and the contract for the therapy. The patient may well be entitled, in the name of informed consent, to some disclosures about the therapist’s training and orientation, as well as the modality of therapy used and what to expect from the therapy; in some areas such disclosures are required by local statutes. For completeness, note also that the therapist’s comfort level, personal needs, and wishes for privacy also enter into the decision of whether and what to disclose.

 Caudill B Jr. Malpractice and licensing pitfalls for therapists: a defense attorney’s list. 

. 2005;24:31-46. doi:10.1525/jung.1.2005.24.2.31.


 Zur O, Williams MH, Lehavot K, Knapp S. Psychotherapist self-disclosure and transparency in the Internet age. 

 Zur O. Self-disclosure and transparency in psychotherapy and counseling: to disclose or not to disclose, this is the question. 2010. 

http://www.zurinstitute.com/selfdisclosure1.html

 Psychopathology Committee of the Group for the Advancement of Psychiatry. Reexamination of therapist self-disclosure. 

The issue of self-disclosure in psychotherapy is one of complexity and some evolution.1-16 Most discussions about the practice refer to boundary questions because self-disclosure by the therapist to the patient is a boundary issue. Self-disclosure has, of course, a number of dimensions, including clinical, therapeutic, technical and-in some cases-legal or regulatory. Despite the rich and interesting clinical issues relating to self-disclosure (outlined in Gutheil and Brodsky1), the focus of this article is on the ethical aspects of self-disclosure.1,15,16 Of necessity, the discussion centers on the more exploratory forms of psychotherapy, such as dynamic therapy, rather than on behavioral therapies, co-counseling, substance abuse treatment, or pharmacological treatment.

Author | Thomas G. Gutheil, MD

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