Psychiatric residents' sexual contact with educators and patients: results of a national survey

Fifty Years of Change: A Shared Journey

The author shares a personal account of 50 years of experience practicing psychodynamic psychiatry and psychoanalysis after migrating from Argentina to the United States. Her career developed in parallel as a clinician and as an academic psychiatrist, with leadership roles in the American Psychiatric Association, the Association of Women Psychiatrists, and the American Academy of Psychodynamic Psychiatry and Psychoanalysis. After describing what constitutes the essence, substance, and form of psychoanalysis, she reviews the historic shift within psychoanalysis in the United States from intrapsychic dyadic practice with selected patients to the application of psychodynamic concepts to everyday psychiatric care of patients with complex morbidities in multiple clinical settings.

Psychotherapy Supervisor Ethical Practices

The overall purpose of this article is to present a review of the literature that identifies the salient ethical guidelines related to the practice of supervision and to discuss the results of a study that examined supervisor ethical practices. In terms of our investigation, we examined supervisee perceptions of their supervisors’ adherence to ethical guidelines, supervisee reactions to ethical violations, and the relationships among supervisor ethical behaviors, the supervisory working alliance, and supervisee satisfaction. The results indicated that 51% of the 151 beginning to intern-level supervisees sampled reported at least one ethical violation by their supervisors. The most frequently violated guidelines involved adequate performance evaluation, confidentiality issues relevant to supervision, and ability to work with alternative perspectives. Greater nonadherence to ethical guidelines was significantly related to a weaker supervisory alliance and lower supervisee satisfaction. Limitations and implications for psychotherapy supervision theory, research, and practice are addressed.

The ethics of psychiatric education

Evidence-based medicine and the professional virtues of integrity, compassion, self-effacement, and self-sacrifice constitute the cornerstones of an ethics of psychiatric education. As informed by the pioneering work of John Gregory, psychiatric educators must promote evidence-based and ethically justified behaviors in learners and practicing physicians through example and by formal teaching. These processes together will enable patients to trust the competence of psychiatrists and that psychiatrists will serve the interests of patients first.

The concept of appropriate professional boundaries in psychiatric practice: a pilot training course

OBJECTIVE

The aim was to design and run a three-session training module for psychiatric registrars on professional practice with particular emphasis on boundary setting. This included the concept of boundary transgression, an understanding of how it occurs and how it may be avoided.

METHOD

Drawing on North American experience a curriculum was designed and trialed for trainees at all levels. A variety of media were employed to present a range of common clinical and professional issues. Evaluated were trainee satisfaction, trainee responses to target vignettes at the beginning and at the end of the course, and supervisor awareness and involvement in the process.

RESULTS

High attendance and high satisfaction ratings in most areas confirmed that a course such as this is attractive and relevant for psychiatric trainees. Vignette responses suggested some change may have occurred by the end of the course, with a more limited tendency to avoid potentially challenging situations and a higher capacity to explore them. Supervisor involvement remains largely unaddressed despite interest and enthusiasm.

CONCLUSION

The area of interpersonal relatedness in psychiatry, including the issue of sexual attraction and the possibility of sexual misconduct, can be introduced as a training package in a way which is acceptable to trainees and their supervisors in an Australian setting. The impact of the training module on actual registrar behaviour is uncertain.

Narcissism, eroticism, and envy in the supervisory relationship

Supervision takes place in a framework of time, place, and duration agreed upon by teacher and student. But beyond the formal arrangements of supervision lie a host of behaviors that express conscious and unconscious fears and wishes that are aroused in student and teacher by their meetings. This paper focuses on supervisors' motivations for teaching, and the ways in which their narcissistic vulnerabilities and their feelings for their students may influence the frame of supervision and its outcome.

Shoestring science

ABSTRACT Nanette K. Gartrell, MD, is a psychiatrist, teacher and researcher who has served on the faculties of Harvard Medical School and the University of California, San Francisco. For the past thirty years, without relying on major grants, she has been gathering data to depathologize lesbianism. Her earliest investigations contributed to the effort to remove "homosexuality" from the list of mental disorders. More recently, Dr. Gartrell has been conducting a national, longitudinal study of lesbian families. In this overview of her research career, Dr. Gartrell discusses the strategies that she has used successfully for pursuing scientific investigations on a shoestring budget.

Sex, lies and training programs: the ethics of consensual sexual relationships between psychiatrists and trainee psychiatrists

OBJECTIVE

The aim of this paper is to chart the ethical territory surrounding the issue of consensual sexual relationships between psychiatrists and doctors training in psychiatry.

METHOD

The arguments for and against the prohibition of such relationships are critically examined both in general and in a number of specific circumstances.

RESULTS

There should not be a general prohibition against such relationships, but a prohibition should apply in certain special circumstances. Such circumstances include occasions when the psychiatrist is currently supervising the trainee, when a particular psychiatrist has repeated sexual relationships with trainees and when a group of psychiatrists voluntarily pledge to abstain from such relationships.

CONCLUSIONS

Institutions involved in psychiatric training should develop guidelines for dealing with such relationships, adopting a generally permissive attitude toward them with clear exceptions in special cases.

Adverse experiences in psychiatric training. Part 2

OBJECTIVE

To examine the perceptions of New South Wales (NSW) psychiatric trainees in relation to their training, the adverse events they experienced and the role and quality of the consultant-registrar relationship.

METHOD

A self-report questionnaire was developed to probe trainee perceptions of the consultant-trainee relationship and adverse events during training in all those who had completed at least 1 year of training in psychiatry (n = 138) in NSW, as well as all consultants who had completed their training in the last 5 years (n = 95). All subjects were asked to rate the frequency and relative impact of 20 adverse experiences with the opportunity to proffer adversities not listed. They were also asked to rate their experience of their consultants in relation to the adversity.

RESULTS

The results from The Training Impact Study exploring adverse events experienced by NSW trainees are presented. Assault by a patient and suicide of a patient are identified as the most stressfull adversities of training in psychiatry. However, more general concerns such as educational and emotional neglect by supervisors, observing consultant maltreatment of patients, exam failure and conflict between consultants were also identified and discussed.

CONCLUSIONS

The high response rate of both trainees and consultants gives these results a level of representative validity. Recommendations in relation to future training and research are put forward. Specific training in the management of potentially assaultive patients and facilitating trainee recovery from assault or threat of assault should be a priority of the Royal Australian and New Zealand College of Psychiatrists. Support and education in relation to patient suicide is also important. Training and recognition of teachers within the College should be encouraged.

Evaluation of sexual misconduct complaints: the Oregon Board of Medical Examiners, 1991 to 1995

OBJECTIVE

In 1991 the Oregon Board of Medical Examiners initiated a separate category for the complaint of sexual misconduct. Investigated complaints of sexual misconduct brought to the Oregon Board of Medical Examiners were analyzed for the years 1991 to 1995 to serve as a baseline. Comparison was made to the Federation of State Medical Boards sexual misconduct data for 1991 and 1992.

STUDY DESIGN

One hundred complaints brought against 80 licensees were evaluated by practitioner's degree, age group, sex, specialty, and disposition of complaints for the years 1991 to 1995. The allegations were classified into behavior categories of sexual impropriety, sexual transgression, and sexual violations.

RESULTS

Sexual misconduct was the allegation in 5.9% of the complaints investigated for the study period. Oregon had more sexual misconduct complaints than the average reported to the Federation of State Medical Boards for the years 1991 and 1992. Most (72%) complaints came from the patients or their families. Two female physicians (2.4%) had sexual boundary complaints. Sexual misconduct complaints increased by a risk ratio of 1.44 with advancing age by decades. Allegations classified into behavior categories according to severity revealed 39% sexual impropriety, 31% sexual transgression, and 30% sexual violation. Reportable disciplinary actions occurred only with multiple allegations of sexual impropriety (6.5%) and for sexual transgression (27%) whereas sexual violation allegations often had one complainant but there were 54% reportable disciplinary actions. Family practice, obstetrics and gynecology, and psychiatry had the highest incidence of sexual misconduct complaints whereas psychiatry and obstetrics and gynecology had the highest incidence of reportable disciplinary actions. Twenty-five percent of the closed cases resulted in reportable disciplinary actions. This analysis is discussed in relationship to legal and ethical issues and the goal of zero tolerance.

CONCLUSIONS

Oregon has a higher percentage of sexual misconduct complaints than the average for 42 states reporting to the Federation of State Medical Boards for the years 1991 and 1992. Analysis of the Oregon Board's experience for the study years will provide a baseline for future evaluation and as an educational resource for the Oregon Board of Medical Examiners and professional and specialty societies. Ethical standards, the reporting and investigative processes, and the legal framework are in place and lessen the incidence of sexual misconduct and work toward zero tolerance.

Fifteen years of teaching psychiatric law and ethics to residents

In 1978, the authors, a psychiatrist and a lawyer, began a course in law and ethics for postgraduate year A psychiatry residents that continues today. The authors review the course in terms of its evolution, effect on residents and faculty during the course, evaluation by residents immediately after the course and since graduation, and future prospects of such a course being started at other institutions.

A pilot course for residents on sexual feelings and boundary maintenance in treatment

Surveys indicate that between 6% and 10% of psychiatrists report sexual contact with patients. Surveys also indicate that only a small minority of psychiatrists feel that they have received adequate teaching about this unethical behavior. Educational efforts aimed at reducing sexual exploitation of patients would be of value to trainees, patients, academic programs, and the profession. The authors report their experience with a pilot 6-session course for residents, and a longer model course is outlined. Such education should be mandatory in U.S. residencies. Mandated instruction would be consistent with both the high priority training directors have reported placing on the subject of sexual misconduct in ethics teaching, and with the widespread calls for increased education on this important subject.

Medical students' attitudes on specialist physicians' social and sexual contact with patients

To assess medical students' attitudes toward social and sexual contact with patients by physicians from three medical specialties (internal medicine, obstetrics-gynecology, and psychiatry), 326 students were surveyed at one medical school and 239 students responded (response rate = 73.3%). Most students perceived that arranging to date and/or dating and genital sexual contact were not appropriate either during a patient visit or concurrent with ongoing treatment. However, as many as 20% of the male students and 3.5% of the female students said that genital sexual contact with patients concurrent with treatment was (sometimes or usually) appropriate, depending on the specialty. Significant gender differences were found in attitudes about physician-patient sexual contact. Genital sexual contact was also significantly less likely to be perceived as appropriate for psychiatrists, as might be expected, than for obstetrician-gynecologists and internal medicine specialists. These results are discussed in relation to current codes of ethics.

Psychiatrist-patient sexual relationships: the ethical dilemmas

Sexual relationships between psychiatrists and their patients raise a number of important ethical issues. The power inequality, transference and dependence which often occur in a therapeutic relationship render patients vulnerable to exploitation. Psychiatrists informed by a patient of sexual contact with a previous psychiatrist face a complex ethical dilemma. Attempts at regulation by professional organisations, or by the legal system, may create conflicts between the rights of the persons involved. The role of the psychiatric profession in confronting the problem of sexual exploitation of patients is discussed.

Sexual harassment in medical training

BACKGROUND

Sexual harassment has become a national concern and one that is increasingly recognized in the field of medicine. Although there are reports of the sexual harassment of medical trainees, there is little information on the prevalence of this problem and whether it is adequately addressed by training institutions.

METHODS

Surveys with descriptions and examples of sexual harassment were mailed to 133 internal medicine residents in a university training program. The residents were asked to report anonymously whether they had encountered sexual harassment during medical school or residency, the frequency and type of harassment, its effect on them, whether they chose to report it to a person in authority, and the factors that influenced this decision.

RESULTS

Surveys were returned by 82 residents (response rate, 62 percent), 33 women and 49 men. Twenty-four women (73 percent) and 11 men (22 percent) reported that they had been sexually harassed at least once during their training. The women were more likely than the men to have been physically harassed, and the women's harassers were of higher professional status. Among those harassed, 19 of the women (79 percent) and 5 of the men (45 percent) thought that the experience created a hostile environment or interfered with their performance at work, but only 2 women and no men reported their experiences to an authority. The women cited a lack of confidence that they would be helped as the main reason for not reporting the experience, whereas men most commonly said that they had dealt with the problem without the need for outside assistance.

CONCLUSIONS

Many medical trainees encounter what they believe to be sexual harassment during medical school or residency, and this often creates a hostile learning and work environment. Training institutions need to address the adverse effects this may have on medical education and patient care.

Are we teaching psychiatrists to be ethical?

The authors conducted a nationwide survey of ethics education during psychiatry residency. Of the 136 program directors and 95 chief residents responding, nearly all agreed that ethics should be a part of the core curriculum. Program directors reported that most programs (60%) did offer a formal seminar series or course. However, 26 programs (19%) had no planned discussion of ethics in any seminar and fewer than 30% of all programs held seminars on the issues considered most worthy of formal attention, including psychiatrist-patient sexual contact, confidentiality, and forced treatment. The discrepancy between what program directors and chief residents believe should be taught and what is actually being taught indicates a need to focus attention on the teaching of psychiatric ethics.

Sex and the teacher--learner relationship in medicine

As the numbers of women medical students, residents, and faculty increase, sexuality in teacher-learner relationships will present challenges for individuals and institutions. Ethical and legal guidelines regarding sexual harassment and contact already exist for many medical schools, hospitals, and professional organizations, as well as state and federal law. Individuals and institutions can begin to address these issues through policy development and educational sessions addressing human sexuality, communication skills, and the process of becoming a physician.

The prevention of sexual exploitation of patients: educational issues

The following guidelines were approved by the Board of Directors of the Canadian Psychiatric Association on April 12, 1992.

Medical students' attitudes toward sexual contact with patients and supervisors

We surveyed 297 medical students regarding their attitudes toward sexual relations between physicians and patients and between physician supervisors and junior colleagues. Significantly more female than male medical students would intervene in a situation involving sexual contact between a physician and a patient, and male students would intercede significantly more often in the circumstance of sexual contact between a colleague and physician supervisor. Four percent of the students considered it acceptable to have sexual relations with patients. Forty-two percent felt that sexual contact would be acceptable immediately after the professional relationship ended; 80% approved of sexual contact with ex-patients after two years. The responses of both sexes indicated a naive understanding of the unequal power dynamics inherent in these types of relationships. We recommend specific discussions with medical students about the dynamics of unequal relationships and sexual exploitation to help prepare them for some of the difficult ethical issues in medical training and practice.

Under Wraps: Prevalence of Staff-Patient Sexual Interactions on Inpatient Units

1. Fifty-seven percent of the hospitals with inpatient psychiatric units responded to the survey. 2. Out of these hospitals, 23% reported suspicions, 43% allegations, and 23% occurrences of staff-patient sexual interactions within the previous 2 years. 3. Neither the existence of staff educational programs, hospital size, nor ownership status were significant predictors of the number of events. 4. Patient abuse predictors must be identified.

Fatal attraction: the ethical and clinical dilemma of patient-therapist sex

This article reviews the existing literature on the subject of patient-therapist sexual contact. Seven point one percent to 10.9% of male therapists and 1.9% to 3.5% of female therapists admit to engaging in intimate contact with patients. Offenders tend to justify their behaviour as being at least innocuous if not beneficial for the patients. The consequences to the patients include increased psychological and psychosomatic complaints, greater mistrust and anger towards men, hospitalization and suicide. Transference and countertransference issues which account for this behaviour are explored as is the issue of post-termination involvement. Education of physicians and residents concerning the temptations and dangers of this type of contact is strongly recommended.