Protecting patients from clinician-patient sexual contact.
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Female↗
Biomedical subjects
T G Gutheil
Publications and source records attributed to T G Gutheil.
Obstacles to the dynamic understanding of therapist-patient sexual relations.
Several dynamic resistances appear to interfere with rational and empirically based discourse about therapist-patient sexual misconduct. These resistances include the lure of reductionism and a longing for simplicity; wishes for "political correctness"; gender bias; and confusion about the nature of the trauma in sexual misconduct. We conclude that (1) empirical study may produce unpleasant results; (2) "politically incorrect" models of misconduct merit study with care equal to "politically correct" ones; and (3) those reenactments we call transference-countertransference should be viewed in all their human complexity. Only then will our increased understanding of misconduct offer hope of prevention.
Ethics, Professional↗
Risk management in the practice of behavior therapy: boundaries and behavior.
Behavior therapy represents a treatment modality widely utilized by clinicians but to date insufficiently examined from the risk-management standpoint. Given that the determination of negligence is dependent on the role of the therapist as proximate cause of the adverse outcome and on the availability of an accepted standard of care from which deviations can be specified, a number of general characteristics of behavior therapy may render its practitioners potentially vulnerable to litigation. These may include its directiveness, its replicability, and its methodologic rigor. Similarly, certain specific behavioral techniques may carry some medicolegal risks, including the use of aversion methods, utilization of family members or other lay cotherapists, response cost, and exposure therapies. In addition, therapeutic boundaries in behavioral treatment may be different from those in psychoanalytic therapy, allowing for therapist practices that might otherwise be considered unusual or in themselves negligent, but the therapist may have a heavier burden of justification in such cases. The authors suggest that recognition of the possibility of adverse results, ongoing and competent informed consent, adequate documentation, willingness to consult, and careful monitoring of treatment outcome may help mitigate the medicolegal risks of these procedures.
Behavior Therapy↗
False sexual-abuse allegations by children and adolescents: contextual factors and clinical subtypes.
The authors review the empirical literature concerning the frequency of false allegations of sexual abuse as well as the case report literature that describes individual episodes of false allegations in detail. The authors then construct a clinical typology that is derived from the literature and their own clinical experience with similar cases. The specific subtypes of the typology are: (1) False allegation in the context of a custody dispute, (2) false allegations resulting from psychological disturbance on the part of the accuser, (3) false allegation as a conscious manipulation by the child or adolescent and, (4) false allegations based on iatrogenic factors. Clinical examples of each subtype are presented. The case material presented and reviewed indicates the importance of attending to the contextual factors surrounding the allegation and pursuing a detailed comprehensive evaluation that is as free of bias as possible.
Adolescent↗
Professionals' attitudes towards sex between institutionalized patients.
Sexual activity among institutionalized patients has always been an issue of concern to institutions. Despite this fact, there has been little consensus about how patient sexuality should be dealt with. Nor have clinical insights with respect to patient sexuality been empirically tested. Given the diversity of beliefs and policies in this area, guidelines concerning sexual activity among hospitalized mental patients seem to be badly needed. We examined the following six factors that we thought might influence staff decisions: (1) the competence of a patient to engage in sexual activity, (2) the degree of consent, (3) the nature of sexual activity (e.g., hugging vs. genital relations), (4) the location of sexual activity (e.g., in bedroom vs. on grounds), (5) the sex of the initiating patient (6) the sex of the other patients. We hypothesized that mental health professionals, both as members of the community at large and as professionals, would have conventional moral views (as defined by Kohlberg) towards sexual activity. Supporting this hypothesis, of the six factors listed above, only location of the sexual activity and form of the sexual activity affected judgements on sexual activity significantly. The professionals interviewed appeared to be most condemning of homosexual acts, and least condemning of hugging. Although we had hypothesized that profession norms of consent and competence would be significant factors, they were not. The core implication of our study is that mental health professionals need training on competence assessment and its use in decision making and must reexamine their own prejudices (e.g., homophobia) to clarify their decision making about institutional policies.
Adult↗
Two generations of sun gazers: questions of competence and shared psychosis.
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Adult↗
Micro-effects of language on risk perception in drug prescribing behavior.
The decision to prescribe neuroleptics for the treatment of psychosis involves a potentially tragic choice between, on the one hand, a probability of psychosis and a probability of side effects, such as tardive dyskinesia, on the other. In an experimental paradigm, we examined this decision process. We hypothesized that linguistic factors considered irrelevant under classical formulations of individual choice behavior would have a significant effect on this decision. All subjects were presented with a case vignette involving a potentially psychotic patient. Subjects were then asked what probability of tardive dyskinesia they would either "accept" or "risk" in order to prevent psychotic decompensation. In addition this factor was crossed with a contextual factor that varied the patient's age. The effect of "risk" versus "accept" language was evident in significantly different patterns of decision making across age groups. The data have important implications for clinical decision making, the elicitation of informed consent, and the directions that the courts have taken in malpractice and patient's rights cases.
Adult↗
Approaches to forensic assessment of false claims of sexual misconduct by therapists.
The author offers systematic approaches to evaluation of claims of therapist-patient sexual misconduct, together with their rationales. False accusations should be considered in all such cases in order to maintain the balanced forensic perspective and to probe for malingering, as in all evaluations. Practical techniques are offered and the underlying reasoning described.
Ethics, Professional↗
The psychiatrist as informed consent technician: a problem for the professions.
Psychiatric consultation in general medical settings is a valuable corollary to the work of other health care professionals. In various contexts, such consultation can be debased, however, to the point that the psychiatrist is serving as a technician rather than as a consultant in relation to several aspects of the informed consent process. The authors identify five inappropriate models of psychiatric consultation and review the proper approach to obtaining true informed consent.
Brain Diseases↗
"Therapist-patient sex syndrome": the perils of nomenclature for the forensic psychiatrist.
The escalating problem of sexual misconduct has heightened clinicians' awareness of the consequences of therapist-patient sexual relations. One consciousness-raising device, the definition of "therapist-patient sex syndrome," may pose more problems than remedies in the forensic, rather than clinical context. The author reviews the conceptual, diagnostic, and teleological dimensions of this addition to diagnostic nomenclature.
Expert Testimony↗
Hypomania and elation: a diagnostic dilemma.
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Adult↗
Bruxism and sexual abuse: a possible association?
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Bruxism↗
Medical and judicial perceptions of the risks associated with use of antipsychotic medication.
To determine whether occupational perspective influences the decision to prescribe antipsychotic medications, we presented a group of psychiatrists and judges with a hypothetical case involving a potentially psychotic patient. The subjects were asked what probability of drug-induced tardive dyskinesia they would accept in order to prevent psychotic decompensation. The subjects were then asked to estimate the actual probability that tardive dyskinesia would occur if the patient received antipsychotic medications. From the responses to these questions we inferred their treatment decisions. Although the psychiatrists and judges agreed on an acceptable level of risk, they differed significantly in their estimates of the actual risk involved and, by inference, their decisions concerning treatment. Our findings have several implications for adjudication of cases involving treatment decisions and the right to refuse treatment.
Antipsychotic Agents↗
Beyond cognition: the role of disordered affective states in impairing competence to consent to treatment.
Most of the criteria for competence in current use emphasize cognitive rather than affective dimensions. Our clinical experience indicates that affective disorders may impair competence in a detectable and identifiable way. In particular, patients with major affective disorders can retain the cognitive capacity to understand the risks and benefits of a medication, yet fail to appreciate its benefits. A case study of a pathologic grief reaction is introduced to illustrate how cognitive and affective impairments may coexist and require separate remedial strategies for restoration. Further empirical work on the role of affective disorder in impairing competence is warranted and planned.
Aged↗
A prospective, multicenter study of patients' refusal of antipsychotic medication.
Refusal of treatment with antipsychotic medication was studied prospectively in a sample of 1434 psychiatric patients admitted to four acute inpatient units in state-operated mental health facilities in Massachusetts during a 6-month period. Compared with a control group of patients who accepted prescribed antipsychotic treatment, the 103 patients who refused were older, of a higher social class, and less likely to have been prescribed antiparkinsonian medications. On admission, prior to refusal of medication, patients who refused were found to have significantly higher Brief Psychiatric Rating Scale scores than compliant patients and more negative attitudes regarding their hospitalization and past, present, and future treatment. Treatment refusal had negative effects on the hospital milieu and on the patient; refusers were more likely to require seclusion or restraint and had longer hospitalizations than treatment acceptors. Most refusal episodes ended with voluntary acceptance of treatment. In 23% of cases medications were discontinued. Only 18% of the sample reached formal, judicial review, and in every case that did, involuntary treatment was ordered. The policy implications of these findings are discussed.
Adult↗
Neuroleptics: effects on neuropsychological function in chronic schizophrenic patients.
We have reviewed the literature from the 1950's to the present on the effects of neuroleptics on perceptual and neuropsychological function in chronic schizophrenic patients. In contrast to previous reviews, we have delineated the acute and chronic effects of neuroleptics on individual cognitive and motor tasks by drug, dose, and length of administration. To date, studies have shown that acute administration of neuroleptics impairs performance on some, but not all, tasks requiring vigilance and attention, and on some tasks requiring motor behavior. Chronic administration of neuroleptics, however, improves performance on some tasks requiring sustained attention and visuomotor problem-solving skills depending on dose and length of administration. Moreover, there is consistent evidence to suggest that chronic administration of neuroleptics in this patient population does not impair neuropsychological function independent of motor function. These findings have direct implications regarding the risk/benefit ratio and legal ramifications for the use of neuroleptics in chronic schizophrenic patients.
Antipsychotic Agents↗
Aftermath of the Rogers decision: assessing the costs.
The Massachusetts Supreme Judicial Court's decision in Rogers v. Commissioner is generally regarded as an important right to refuse treatment decision requiring maximum judicial involvement in the treatment of nonconsenting patients. Since courts and legislators in other jurisdictions have looked to Rogers for guidance on right to refuse treatment issues, and since some have adopted it as a model, it is essential for lawmakers to understand the economic realities of the Massachusetts experience and the commitment of resources required by this model. The authors review these realities, suggesting that there are distinct reasons for considering this particular model "cost ineffective" in preserving patients' rights.
Cost-Benefit Analysis↗