"Risk ManagementAn FAQ Approach Philip J. Kinsler Ph.D"
Risk Management: An FAQ Approach Philip J. Kinsler, Ph.D. Anyone who uses the web will be familiar with the practice of posting frequently asked iso u k nw r sr cm n uso s T i o m wla t cy ’ questions on web-se t qi lase ue so mo qetn. h cl n it e i s u lk that approach to some of the questions of risk management in our work with traumatized and dissociative persons. 1. How can I avoid ever having to deal with the dreaded complaint letter? h sotnw roh it yu a’ P o l a ad o u ec o e,l i a t T e h rase ttsshto cn. ep cn n d se ah t rf e h i e ethical complaints to licensing boards, bring malpractice cases, for their own internal reasons all the time. The population we work with is often a high demand-high risk population. Relationships and relationship management are complicated and sometimes tricky. Those who work with complex cases can, and do, get suits or complaints. Those with names and reputations, who take public stands about issues such as the tremendous exposure to trauma of children and women, also sometimes become targets. You can reduce but not eliminate risk. 2. What are the most frequent sources of complaints or malpractice suits? The three top sources of complaints are sexual contact with patients, complaints arising r hd ut y okadb t a ’rb rli si aae et T i o l o a ep f m ci cs d w r,n ‘ dhr yo ‘ d e tnh m ngm n ’ ha ao p . s was so when I was Chair of the Licensing Board in NH, and appears to continue to be true from recent literature. lI ee d ay i e awt ptn s I n h l r i t ld hg x h i , m e e ,g ? 3. We,’nvr o ntn s ul i a aet o ’ it c a rh Not so fast. By its nature, therapy with seriously traumatized individuals invites deep e i s n ae e fl ee . o smeme k o oe b uyu ptns en n o s f lgad s s o c sns Y u o t s n wm r ao tor aet i i ’ feelings than you do those of your spouse or partner. You share the best and worst of times. Close feelings can be sexy; we are biological animals designed that way. Ken Pope, in his wonderful book Sexual Feelings in Psychotherapyi, points out that these feelings are very common and are virtually ignored in therapist training. As Board Chair, I sometimes came upon persons who started out well intentioned but slid down h l eT ee o sso r s i s e u’ oe t t u dn u ad i eo n i a un d t s p. h ‘ d fes n es r gi h gm vd oh sd e t n n k s e r s n s o… cus ts in t apno vr e rn vrcs T e e eh l ad o n Ofor , iwl o hp e t eeyn o ieey a . h bs o e t e ne gi t iiako l e n o o e ep eelings, and the continual use of e n h df s aa stss cn wegmet f n’de f d s professional consultation/mutual supervision with experienced colleagues. I am also a strong advocate of the grandmother rule. If you would be ashamed to discuss the eai yu e o r o ’ ot esprs n t . bhv ro ’ pulled towards with your grandmother, d n d i G tu evi io instead. d n ee d cs d ea ao s t o ui 4. What about this child custody issue? I o ’ vn o ut y vl tn… For those of us who do work even sometimes in family courts— even those of us called this as witnesses as treating therapists— is a high risk area and the second most frequent source of suits and professional misconduct complaints. This is especially so where there is a question about whether one parent or the other may have abused the child sexually. The area is fraught with questions of the validity or malleability of memory, whether the practitioner has been fair to both parties, who has the right to control a hd o t t i rf s nl ad h tmpt a t r i h a f ls a h e i s et ci’cn cwt po so a,n t ae t t mo e wt t t o o r hs h eg p et aeao s rm . h o l e b the a a i i n ’ s d l ‘ rn llntn ydo e T icu w l e subject of an entire column or article. Some things everyone should know: a. In a legal sense, if it is not written down, it did not happen. Get in the habit f r r g ‘ eo h i t ou eto t t i a e ,o r pi o el oe o pean an ttt f ’ d cm n cn c wt l yr cut as h w s es nl A ’ t o , , c. pr n e G Lse Document what you did and did not agree to do. b. Stay current with the science. Witnesses sometimes make overly broad te n h cn o bc thut e n cm ln ‘hde am s a s t ett ta cme ako ant m ia o p i.C irn h at l ee l b usc tns ‘ . os oft poi f e i . nvriao tuh h g’MrXd e n t t e rf o a sex ih le fn e ’Me oys x e e f . r y lal n cirn r i l o edr ‘ m riet m lmaeb ad hde a h h l e l e gy ugsb . T e s o uh h g s nn r t moy fhd tl’ e i sge ie ‘hr in sc tn aa i orcme ro ci c e l bs. aue ’ c. Read the guidelines. The American Psychological Association has guidelines for the conduct of child custody evaluations and for best practices when a professional is involved in child protective actions. There is a thoughtful set of ethical specialty guidelines from the American Academy of Forensic Psychology. Familiarity with these is important. d. Consult your own attorney. You do not have to comply with a subpoena. These can be contested in court and you can wait for a judge to decide what information must and must not be provided. It is generally not considered appropriate to be both the treating therapist and the expert witness for a ln h sen s x g no e i ’vl t rl i ni o e, i . s i b cv cetT iise amin a ‘ j teea a ro wt a ‘vl d uo e h n v e o j tet a ro . s t a s yu r ht ae af t s ei r e e e pt l s b cv’ et rl A ahr i,o a w aicld ‘c e s l a ie .Y u a tk buyu t a , htor o said ns l ep wt s’ o cn a ao to rhr yw ayu n t s on such e and such a date, your treatment plan and diagnosis, etc. You should not get into issues such as false memory or parental alienation syndrome here. You should try to be explicit with attorneys calling you about what you can and cannot do. Stick closely to your data. 5. What do you mean bad therapy? Again, an answer that can and has filled books. Generally, the kinds of bad therapies h hv l o o p isnh at r xe ec hv i l d o r aae n a d at i h s t t aee tcm ln its u o’epr ne aeno e p o m ngmet i vv of complex relationships, dual relationships, or relatively new therapists failing to read the literature on the type of client they are treating and therefore, in a well-intentioned way, repeating mistakes well known to those with more experience. a. The most important variable in whether a complaint is likely to be filed, in h at r xe ec, li aot e e tnh n w at cet i h s i s at h li p ts u o’epr neic ry b ut r ao siad ht e ln h i can and cannot expect. This does not mean only the written information you are required to hand out by HIPPA; I wonder how much of this any client absorbs. This means: i. Being clear about how much contact a client can have and how emergencies will be handled. ii. Carefully monitoring the trajectory of the therapy. If the functioning level of the person is going up, you are probably all right. If the functioning level is going down except briefly, perhaps for a few days or week after a powerful abreaction or EMDR processing, you need to stop and ask why. iii. Monitoring whether you and the client are building an artificial world where your relationship is the central thing in their life and you are not attending to how they are developing external relationships. iv. Thinking that your closeness to the client makes it OK to use their cleaning service, rent them the room over your garage, loan them money etc. v. Closeness and boundaries are not incompatible, and in fact both are required for safety in treatment. vi. Not taking everything your client says as gospel. Trauma clients are subject to the same distortions, wish fulfillments, confabulations, transference power struggles, vacillations between dependency and ia eads wn o h w h fty o gt yuaeey sn h g e l d t c,n ‘ o i yu o t ye b d i io o ’s vr n t other psychotherapy client. Your stance is as a safe and kind refuge, not as a cheerleader. b. If the relationship is going well, the therapy is not becoming crisis o i e t cet fntn g vrl n n p a l ead o ad h i ’ i n ls d m nt , e lnsu co i oea io a u w r s p,n b t do h you and the client can visualize them needing less and less of you over time, then the likelihood of a complaint is significantly decreased. z In a future column, I will touch on the most common mistakes therapists make when e o d go o p isf m h me cl , ’j tedn les oh I s n at r e p ’ lu r p n i t cm ln , o t ‘ a u a Il ssn imyi net t ‘m a c ’ e’ ao ay n w s l,o a o … i l ha ntnl ko n co rh wdr yu ’ e Philip J. Kinsler, Ph.D. i Pope, K., Sonne, J., Holroynd, J., Sexual Feelings in Psychotherapy: Explorations for Therapists and Therapists-In-Training, 1993, American Psychological Association, 1993, Washington DC.